Every finding on record at Platte Care Center

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and record review, the provider failed to ensure one of one certified nursing assistant (CNA) (E) followed one of one resident (1) care plan when she left the resident alone in his room in his wheelchair. Resident 1 transferred himself to the toilet, fell, and experienced increased pain in his right leg. This citation is considered past noncompliance based on a review of the corrective actions the provider implemented following the incident. Findings include:1. Review of the SD DOH FRI revealed that on 1/16/26 at around 11:42 a.m., resident 1 was left alone in his room in his wheelchair after an activity. Activities CNA E wheeled resident 1 back to his room and left him sitting in his wheelchair with his call light within reach. The FRI indicated that CNA E did not read pocket care planner [a document that identifies a resident's care needs and interventions] which states Cannot be left alone in wheelchair in room. Resident 1 was found in his bathroom sitting on his wheelchair pedals. Resident 1 reported that he was trying to adjust his pants when his right leg gave out and he slid down his wheelchair and onto the foot pedals. He pulled the bathroom call light for assistance. He denied hitting his head. He was assisted off the floor and reported increased pain in his right leg. He could not bear weight on his right leg. He reported a 10 out of 10 pain rating and was sent to the emergency department. Resident 1 returned from the emergency department with no acute findings from the X-ray of his right thigh and pelvis, meaning there were no fractures. CNA E was interviewed regarding why she left [resident 1] in room unattended in wheelchair. [CNA E] stated she was not aware of [resident 1's] care plan. [CNA E] did have [the] pocket care planner on her per facility protocol and got it out and read it with [director of nursing services] and it did state in bold print that [resident 1] is not to be left alone. CNA E was re-educated about following the care plan since she was a newer employee at the time and does not work [CNA] Shifts, meaning she was primarily scheduled in the activities department versus as a direct care CNA. Resident 1 was ordered new pain control medications to help with any discomfort he is having following his fall. No changes were made to his care plan. Education was added to the daily taped report recording regarding resident 1's fall and to remind staff to follow the pocket care planner. 2. Interview on 2/3/26 at 3:26 p.m. with CNAs E and H revealed that they were full-time activity assistants, but they were also CNAs. They performed CNA duties like assisting residents with getting up and dressing in the mornings and helping residents to the bathroom. They were both aware of the pocket care plans and each had a copy with them. They learned of resident care plan updates, falls, and education each morning when they listened to the recorded nurse report. 3. Interview on 2/3/26 at 3:40 p.m. with resident 1 revealed he remembered falling a couple of weeks ago, but he could not remember what happened. He remembered feeling pain in his right leg. He confirmed he was not experiencing any more pain in his right leg from the fall. 4. Interviews with other residents (2, 3, and 4) throughout the survey from 2/3/26 to 2/4/26 who experienced recent falls revealed they had no concerns with the care they were receiving at the facility. 5. Interview on 2/4/26 at 9:55 a.m. with CNA E and activity assistant K revealed that they were aware of resident 1's fall that happened on 1/16/26. CNA E said, it was my fault. She explained that she is a new CNA and just passed her CNA test in December 2025. She worked full time in the activity department and did not usually work CNA shifts. She did not realize resident 1 was not supposed to be left alone in his room in his wheelchair. She had just taken him back to his room after an activity, and lunch was supposed to have been served soon so she thought that was a short enough time for him to sit in his wheelchair until someone could get him for lunch. She was provided with verbal education on using and following the pocket care plans after resident 1 fell on 1/16/26. 6. Interviews with other staff (CNAs F, G, and I, and activity assistant K) throughout the survey from 2/3/26 to 2/4/26 revealed they were all aware of resident 1's fall, they knew of his fall prevention interventions, they all had a copy of the pocket care plan with them, and they all listened to the recorded nurse's report at the start of each shift. 7. Interview on 2/4/26 at 10:29 a.m. with licensed practical nurse (LPN) C revealed that there was a voice recording device located in the nurse's station and a report binder that the charge nurses use to record updates. Staff were responsible for listening to the recorded report and reviewing the report binder at the start of each shift. Review of the report recording from the evening of 1/16/26 and 1/17/26 confirmed that resident 1's fall was talked about, and staff were reminded to have the pocket care plan with them, and to review the care plan if they had questions. Review of the report binder confirmed the same information was included for several days about resident 1's fall and about the pocket care plans. 8. Interview on 2/6/26 at 10:49 a.m. with director of nursing services (DNS) B revealed that audits on safe resident transfers and use of the pocket care plans had already been in place and were ongoing as a result of the provider's previous recertification survey. Audits consisted of observing nursing staff performing transfers on each resident at least once per month, ensuring that staff were following the resident's care plan, and ensuring that each nursing staff member had a copy of the pocket care plan with them. She explained that the pocket care plans were updated by the ward clerk any time a resident had a change in their electronic care plan. 9. Review of resident 1's electronic medical record (EMR) revealed that additional pain control medications were ordered after he returned from the emergency department on 1/16/26. His acetaminophen order remained the same. He had an order for Acetaminophen 650 mg [milligrams] PO [by mouth] 4XD [four times per day] PRN [as needed]. The acetaminophen was administered on 1/16/26 at 11:50 a.m., 1/16/26 at 2:45 p.m., 1/17/26 at 11:42 a.m., 1/17/26 at 1:38 p.m., 1/31/26 at 12:45 a.m., and 1/31/26 at 1:45 a.m. He had an order for Diclofenac 1% gel 2gm [gram] TOPICAL TID [three times a day] PRN [as needed] that was added on 1/16/26. Resident 1 had not yet used that pain control topical gel. He had an order for Lidocaine HCl 4% patch, 1 patch, apply to right thigh at 0600 [6:00 a.m.] and remove at 1800 [6:00 p.m.] that was ordered on 1/16/26. The patch did not start until 1/17/26 as there were no lidocaine patches on hand on 1/16/26. Resident 1 used the patch every day until it was discontinued on 1/21/26 at the resident's request. 10. Review of the 1/30/26 updated pocket care plan revealed that resident 1's section read, in bold letters, DO NOT LEAVE ALONE IN WHEELCHAIR IN HIS ROOM!!!!! 11. Review of the provider's 10/2024 Fall Risk Policy revealed that residents will be assessed for fall risk at regular intervals. Resident and Patient specific interventions will be implemented according to the results of the Fall Risk Assessment. The procedure included, Interventions will be resident and patient specific and appropriate for each situation. Resident Specific interventions will be documented in the [resident's] care plan. 12. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 2/4/26 after record review revealed the facility had followed their quality assurance process, education was provided to all staff regarding resident 1's fall and about following the resident's care plan, interviews revealed that all staff were aware of resident fall interventions, and safe resident transfer audits were ongoing from the provider's previous survey. Based on the above information, noncompliance at F689 occurred on 1/16/26, and based on the provider's 1/16/26 implemented corrective actions for the deficient practice confirmed on 2/4/26, the noncompliance is considered past noncompliance.

Based on record review, interview, and policy review, the provider failed to ensure informed consent was signed by one of three sampled resident (10) or a responsible party before administering a psychotropic (drug that affects brain activities associated with mental processes and behavior) medication.Findings include: 1. Review of resident 10's electronic medical record (EMR) revealed:*A diagnoses of hallucinations due to late onset dementia.*His daughter, who was his power of attorney, requested a medication to address the resident's increasing behaviors.*An order dated 8/7/25 to be given Quetiapine Fumarate (Seroquel) 25 milligrams by mouth at bedtime.*His care plan dated 10/22/25 indicated:-I will have no side effects of my psych [psychotropic] med [medication] noted.-My psychotropic med use will be reviewed per schedule and PRN [as needed] need.-Meds are reviewed by pharmacy/DON monthly, recommendations made to dr [doctor] as needed, review of meds at quarterly care conferences.-Psych med tracking done monthly by DON or selected nurse.-Mood observations every shift.-Family is informed of risks/benefits of treatment/potential of side effects of psych med.-Evaluated monthly vial pharmacy/DON review.*The EMR had no documentation that informed consent for the use of a psychoactive medication was provided to the resident or his daughter/POA. 2. Interview on 11/5/25 at 10:50 a.m. with social worker D revealed:*She was responsible for monitoring residents' psychotropic medications.*The provider received new informed consent forms that include the education of risks/benefits to use on 11/4/25. *Resident 10's daughter/POA requested the use of the Seroquel on 8/7/25.*Social Worker D verbally educated resident 10's daughter about the risks and benefits of psychotropic medication at that time. *There was a form used for informed consent before the new forms arrived that resident 10's daughter could have reviewed and signed.*She agreed there was no signed form for the informed consent for the use of the medication that was started on 8/7/25. 3. Interview on 11/5/2025 at 11:20 a.m. with director of nursing (DON) B revealed:*Social worker D tracked the documentation for psychotropic medications and consent forms that needed to be signed.*She knew there was a new form that was coming out soon.*She confirmed they had a form in place that residents/family should sign when a psychotropic medication was started.*She expected all residents on psychotropic medications to have signed consent documentation. 4. Interview on 11/5/2025 at 11:59 a.m. with administrator A revealed:*He was aware they were given new informed consent forms to use recently.*All residents/families should be provided education for psychotropic medications for consent for use before they were started.*He expected the forms to be signed and scanned into the resident EMR.*He agreed they should have provided resident 10's daughter/POA with the old form since the medication was started in August. 5. Review of the provider's May 2021 revised Psychoactive Drug Monitoring policy revealed:*The facility will provide a rationale for the use of the psychoactive drugs, which are prescribed. Either the facility will provide documentation from the record or from the physician that justifies the specific therapy.*The policy did not reference risk/benefit education or informed consent for the resident or family.

Based on South Dakota Department of Health (SD DOH) Facility-Reported Incidents (FRI), record review, observation, interview, policy review, and job description review, the provider failed to ensure resident safety by:*One of one social worker (D) who did not provide supervision follow-up when the door alarmed for one of one sampled resident (19) who had eloped (left the facility without staff knowledge) and was outside the building for approximately five minutes without supervision.*Two of two certified nursing assistants (CNA) (G and H) who did not follow the care plan for one of one sampled resident (2) who required to be transferred by using two people, a gait belt, and a walker with manual transfers or one to two people using the sit-to-stand lift and fell. Findings include:1. Review of the provider's 6/17/25 SD DOH FRI revealed: *On 6/16/25 at 5:03 p.m. resident 19 exited the building through the east door. *Social worker D reset the door alarm at 5:04 p.m., looked down the hallway at the east door, where she saw a resident who was at risk for elopement and assumed he set the door alarm off. *Another resident came and notified social worker D that they saw resident 19 outside sitting on the bench and social worker D helped resident 19 back inside. 2. Review of resident 19's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview of Mental Status (BIMS) assessment score of 4, which indicated his cognition was severely impaired. *He had a diagnosis of dementia (a group of symptoms affecting memory, thinking, and social abilities), a decline in vision and hearing, and had a high risk for falling. *Elopement assessments were completed on 12/11/24, 2/24/25, and 5/15/25 which indicated he was not a risk for elopement. *His elopement on 6/16/25 was documented and his care plan was updated to alert staff that he was at risk for elopement. *Interventions documented in his care plan to prevent further elopements included monitoring his whereabouts and completing assessments quarterly and PRN (as needed). 3. Observation on 11/4/25 at 9:07 a.m. of resident 19 revealed he was sitting in a chair sleeping by the nurse's station with his gait belt and walker beside him. 4. Interview on 11/4/25 at 9:16 a.m. with certified nursing assistant (CNA) J revealed: *Resident 19 has tried to get up by himself without staff assistance which he needed because he was unsteady. *She did not remember if the resident eloped, but thought he had an elopement protocol in place for him. 5. Observation and interview on 11/4/25 at 1:53 p.m. in resident 19's room revealed: *He was lying on his bed reading a newspaper, with his bed in the lowest position, and his call light within his reach. *He did not remember exiting the facility on 6/16/25. 6. Interview on 11/4/25 at 1:58 p.m. with CNA G revealed: *She was not working during the time of resident 19's elopement due to an injury. *She received education on elopements that had been assigned online for their annual education. *She stated resident 19 was at risk for elopement and that was indicated on his pocket care plan (a document that identifies residents' care needs and interventions). 7. Review of the pocket care plan revealed that it indicated resident 19 was an elopement risk, but it did not list any interventions to prevent him from elopement. 8. Interview on 11/5/25 at 10:50 a.m. with administrator A revealed: *They had staff meetings for CNA's and nurses where they were educated about the elopement that occurred on 6/16/25 and the updated elopement policy. *They taped staff meetings so if someone missed the meeting then they could listen to the recordings. *Director of nursing (DON) B had the meeting sign in sheets that indicated who received the education. *He expected that all staff members to check outside for residents if a door alarmed. 9. Interview on 11/5/25 at 10:59 a.m. with social worker D revealed: *On 6/16/25 she had reset the door alarm and then checked the east door, where she saw a resident who was at risk for elopement and assumed he set the door alarm off. *She did not check the outside area to ensure a resident did not leave the facility or was outside without supervision. *She received verbal education on 6/17/25 about checking the outside area to ensure a resident had not eloped when a door alarmed, as well as the elopement education provided in the Quality Assurance and Performance Improvement (QAPI) meeting on 6/20/25. 10. Interview and education documentation review on 11/5/25 at 11:19 a.m. with DON B revealed: *Education regarding the elopement on 6/16/25 was provided at the staff meetings. *Staff members who did not attend the staff meetings were to read the meeting minutes and the policy that was attached and sign the sheet to indicate they received the education. *She verified that two nurses' and seven CNAs' signatures were not on the education sign-in sheet. She confirmed those staff members had not received the elopement education after resident 19's 6/16/25 elopement, and had all worked since that incident. *She stated those staff members had received annual education regarding elopements the month prior to the 6/16/25 incident, and she thought that was sufficient. 11. Interview on 11/5/25 at 12:04 p.m. with administrator A revealed: *Four dietary staff members had not received the education regarding the elopement and had worked since the incident on 6/16/25. *Maintenance worker F was at the 6/20/25 QAPI meeting and received the education regarding the 6/16/25 elopement, but administrator A did not believe he provided that education to the housekeeping or laundry staff. *Administrator A was responsible for QAPI, and the facility's current performance improvement plan was focused on skin tears. *There was no plan for monitoring or performing any audits related to elopements. 12. Review of the provider's revised July 2025 Elopement Assessment and Handling of Eloped Residents policy revealed: *Responding to an actual elopement is the responsibility of all staff, regardless of the department they work in, to respond to activated door alarms and to return residents to their units. *If an employee observes a resident leaving the premises or suspects that a resident has left the facility grounds, the employee will get help from other staff members in the immediate vicinity to have them inform the charge nurse of what resident is leaving or can't be found. *It did not indicate staff should check the outside area for residents who may have left the facility after the door alarmed. 13. An interview on 11/3/25 at 2:26 p.m. with resident 2 revealed that he expressed the staff did not always use two people to transfer him, and those staff were mainly staff members from other states. He reported he usually used a machine to stand up and needed to have two people assist him, but sometimes they only used one person to transfer him. He reported his pain made it difficult for him to walk, and he had fallen without being injured. He stated that his pain was being addressed, and he had an appointment with the pain clinic soon. 14. Observation on 11/3/25 at 2:40 p.m. in resident 2's room revealed that contracted travel certified nursing assistant (CNA) H entered resident 2's room in response to his call light. Resident 2 wanted to transfer from his recliner to his wheelchair. Without applying a gait belt (a waist strap gripped as support for safe mobility and transfer), CNA H assisted resident 2 using a stand and pivot transfer technique (when assisted to a standing position, the resident then turns their body to move to another surface). 15. Review of resident 2's electronic medical record (EMR) revealed his 9/11/25 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated he was cognitively intact. He had diagnoses of: compression fracture of lumbar one vertebra (a break in one of the bones in the lower spine), spinal stenosis (a narrowing of the spinal canal), chronic low back pain, lumbar degenerative disc disease (wear and tear of spinal discs cushions between the vertebrae in the spine] in the lower back), chronic atrial fibrillation (irregular heart rhythm), anticoagulated on warfarin (taking a medication to slow blood clotting ability), Parkinson's disease (a progressive brain disorder that affects the nervous system, leading to a gradual decline in movement), and hypophonia (slurred speech secondary to Parkinson's disease.) He fell on 9/29/25 and 10/7/25 when he was walking with staff, while using a gait belt and a walker; His legs gave out, and they lowered him to the floor. He had orders for physical therapy (PT), occupational therapy (OT), speech therapy, and restorative therapy. His PT and OT notes from 9/12/25 to 10/31/25 did not address recommendations regarding how staff should transfer him. A 10/7/25 progress note from his primary physician indicated that nursing staff informed him they were transferring the resident with a sit-to-stand lift to help prevent future falls. That note stated, Patient is anticoagulated on warfarin for history of atrial fibrillation, so need to continue implementing safety measures to avoid falls. Resident 2's 9/11/25 care plan revealed staff were to: transfer-substantial/dependent x 2 assist with walker and gait belt-enc [encourage] him to get up slowly from sitting/lying position. May use standing [sit-to-stand] lift x1-2 [with one to two staff] assist [assistance]., Be alert to unsteady gait/standing balance deficits/pain/wt [weight] bearing and report variances., and Fall f/u [follow up] 10/7/25 resident 2 will be a x2 assist for all walking and manual transfers until staff feels Resident 2 is stronger. 16. Observation and interview on 11/4/25 at 8:43 a.m. with CNA G in Resident 2's room revealed CNA G assisted Resident 2 independently to transfer using a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position). She did not apply the strap to secure his lower legs. The resident's knees slightly buckled, when being moved while standing in the lift, but he caught himself and stood up straighter. CNA G reported Resident 2 was to be transferred by one to two staff using the sit-to-stand lift or with two staff and a gait belt without a lift. She stated she should have used two people to transfer him with the lift since he dipped. She determined how many staff were needed to assist him when using the sit-to-stand lift by how he was feeling that day, and stated she would use two staff to assist him for the rest of the day. 17. Interview on 11/5/25 at 8:19 a.m. with CNA I revealed that staff would know how to transfer the residents by referring to the pocket care plans. 18. Interview on 11/5/25 at 8:24 a.m. with Resident Assessment Instrument/Minimum Data Set (RAI/MDS) Coordinator C revealed that resident 2 was care planned to be transferred with the assistance of two people, a gait belt, and a walker without a lift or one to two people while using the sit-to-stand lift. CNAs were not to determine how many staff were needed to transfer residents while using the sit-to-stand lift. She stated the nurse would have to direct the CNAs regarding that. 19. Interviews on 11/5/25 at 11:44 a.m. and at 12:40 p.m. with DON B revealed she expected CNA H to follow resident 2's care plan when transferring him and expected CNA G to use the leg strap on the sit-to-stand lift when transferring him to secure his lower legs. She stated she interviewed CNA H, and she had admitted that she did not follow the resident's care plan when transferring the resident. DON B stated she took her off the floor until an investigation was completed. DON B reported that to ensure contracted traveling staff competencies, the contracted CNA completed a facility checklist, and she reviewed those skills travel staff members completed with the travel staffing employment agency. She stated that all nursing staff competencies were to be completed by December 2025. They were last completed on 8/21/24. 20. Review of CNA H's training documentation revealed a training checklist indicated she completed training in accident prevention and safety procedures, abuse and neglect, and care of residents with unique needs on 9/24/25. She completed competencies regarding patient safety, patient fall prevention, and elderly abuse on 9/3/25 through her travel employment agency. 21. A review of the provider's 11/3/25 pocket care plan (a document that identifies residents' care needs and interventions) regarding resident 2 revealed it indicated staff were to: TRANSFER-substantial [significant physical support] x 2 assist or may use 1-2 with standing lift. Ambulate 2 assist Walker/gaitbelt to all meals, follow with wheelchair and sit when tired. 22. Review of the provider's December 2023 Lifting/transferring policy revealed the facility administrator is accountable for establishing policies, procedures, training and motivation to avoid injuries. Each facility should adopt and communicate safety policies and procedures to all staff. Safety is also a responsibility of every employee. 1. All nursing personnel will have annual in-services on the correct procedures for lifting and transferring, including the correct use of gait belts. 2. Gait belts: are to be used for transferring residents who are able to bear weight.4. Mechanical Stand may be 1 or 2 staff depending on resident needs and is to be used for partial or limited weight bearing residents in the following: A. Any resident who requires more than standby or contact guard assist as identified by therapists.C. Any resident who, because of their medical condition (MS, comatose, rigidity, etc.) are difficult to control during a transfer but can bear weight.

Based on review of South Dakota Department of Health (SD DOH) complaint, interview, record review, and policy review, the provider failed to report suspected neglect for one of one (1) sampled residents. Findings include: 1. Review of the SD DOH complaint filed anonymously on 12/31/2025 revealed: *On 12/28/24, the anonymous writer observed resident 1 in a soiled (incontinent) brief after CNA D had documented changing resident 1's brief at 4:00 a.m. *The anonymous writer reported at 4:00 a.m., the brief was dated 0000 (indicating it was changed at 12:00 a.m.), concluding the brief could not have been changed at 2:00 a.m. by CNA D. *The anonymous writer reported that night shift staff had written multiple reports of CNA D's neglectful behavior, but the reports had not led to any change in CNA D's behaviors. 2. Review of the provider's [NAME] Care Center [NAME] Health Corrective Action Plan form submitted by LPN C revealed: *A CNA brought it to LPN C's attention that CNA D had not been completing required checks on residents but was falsely documenting she was. *LPN C verified one of the residents was incontinent of urine. *When LPN C confronted CNA D, CNA D told me [LPN C] I was in for a world of shit if reported. *CNA A felt she was being targeted by LPN C. *LPN C told CNA D she had been getting complaints from other CNAs alleging CNA D was not performing her job duties. *LPN C wanted to take a picture of a resident's incontinent brief, but CNA D would not allow this and made a scene. *LPN C then sent the DON a message to call and discuss the incident. 3. Phone interview on 2/5/25 at 10:42 a.m. with a staff member who requested to remain anonymous revealed: *Some of the CNAs would lie about having completed their work duties. *CNA D had made verbal threats before to a night shift nurse. *The anonymous interviewee was aware of at least three staff members that had reported CNA D neglecting her duties to director of nursing (DON) B and administrator A. *The anonymous interviewee reported that staff are fearful of retaliation from management. 4. Interview on 2/5/25 at 12:07 p.m. with administrator A revealed: *He considered cares not getting done was neglect. *It was his expectation that if two staff did not get along or accused each other of abuse/neglect, the floor nurse was to investigate the allegations and report the investigation findings to DON B. *He reported education had been provided on how to file a report with the SD DOH to the nursing staff on 8/26/24 and to CNAs on 8/27/24 at staff meetings. *There were step-by-step instructions on how to file a report with the SD DOH in the medication room tip sheets binder. *It was his expectation that these allegations should have been reported to the SD DOH. 5. Interview on 2/5/25 at 2:31 p.m. with RN F regarding SD DOH online reporting revealed: *She was aware of the online reporting site. *She had used it to report fall incidents. *She had not used it to report allegations of neglect, she would report allegations of neglect directly to DON B for investigation. 6. Review of the provider's 1/2025 Abuse Prohibition Policy & Reporting of Crimes (in Long Term Care, Hospital, & Home Settings) policy revealed: *Neglect Neglect is the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *The facility will thoroughly investigate all alleged violations and will prevent further potential abuse while the investigation is in progress. *Policy: [NAME] Health Center [NAME] has established a zero tolerance policy for any form of abuse or neglect toward any resident/patient. 50915

Based on South Dakota Department of Health (SD DOH) complaint review, interview, record review, and policy review, the provider failed to thoroughly investigate allegations of neglect of one of one sampled resident (1) by certified nursing aide (CNA) D and failed to adequately document the process for reporting neglect. Findings include: 1. Review of the SD DOH complaint was anonymously on 12/31/2025 revealed: *On 12/28/24, the anonymous writer observed resident 1 in a soiled (incontinent) brief after CNA D had documented having changed resident 1's brief at 4:00 a.m. *The anonymous writer reported at 4:00 a.m., the resident's incontinence brief was dated 0000 (indicating it was changed at 12:00 a.m.), and concluded the brief could not have been changed at 2:00 a.m. by CNA D. *The anonymous writer reported that the night shift staff had written multiple reports of CNA D's neglectful behavior, but the reports had not led to any change in CNA D's behaviors. 2. Interview on 2/5/25 at 12:07 p.m. with administrator A revealed: *Reports of abuse or neglect were to be reported to the SD DOH by director of nursing (DON) B during daytime hours and by the night shift nurse during nighttime hours. *Instructions for reporting to the SD DOH could be found in the medication room in the tip sheet binder. *He described neglect to surveyors as cares not done. *It was his expectation that neglect allegations would be reported. *When asked if there had been any recent allegations of neglect, he replied There have been rumors. *When asked how he would have expected rumors of neglect to be handled, he explained he expected staff to report the allegations to the nurse. -The nurse was to then investigate the allegations. -He thought the last rumors of neglect had occurred about two or three months ago. *He was not aware of any written reports of neglect allegations. 3. Follow-up interview on 2/5/25 at 1:30 p.m. with administrator A revealed: *On 12/26/24, a [NAME] Care Center [NAME] Health Corrective Action Plan form had been submitted to DON B by licensed practical nurse (LPN) C regarding suspected neglect by CNA D. *He had just received that form from DON B. *He was not aware that form had been received by DON B. *His statement regarding that form and the incident information included on it was It should have been reported. 4. Review of the provider's [NAME] Care Center [NAME] Health Corrective Action Plan form submitted by LPN C revealed: *A CNA had reported to LPN C's that CNA D had not been completing the required checks on residents and was falsely documenting that she had. *LPN C verified one of the residents had been incontinent of urine. *When LPN C confronted CNA D, CNA D replied CNA D told me [LPN C] I was in for a world of shit if reported to management for not performing her required duties. *CNA D felt she was being targeted by LPN C. *LPN C told CNA D she had been getting complaints from other CNAs alleging CNA D was not performing her job duties. *LPN C wanted to take a picture of a resident's incontinent brief, but CNA D would not allow that and made a scene. *LPN C then sent DON B a message to call and discuss the incident. 5. Interview on 2/5/25 at 2:10 p.m. with CNA E revealed: *If she witnessed abuse or neglect, she would first remove the resident from the immediate threat. *She would then report the abuse or neglect to the charge nurse. *It was her expectation that suspicion of abuse or neglect would be reported. 6. Interview on 2/5/25 at 2:47 p.m. with DON B revealed: *On the night of the above incident (12/26/26), she had missed a phone call from both LPN C and CNA D. *She later got a call from LPN F letting her know the [NAME] Care Center [NAME] Health Corrective Action Plan form had been placed on her desk. *The [NAME] Care Center [NAME] Health Corrective Action Plan form was placed on DON B's desk on 12/26/24 while DON B was on vacation. *Upon her return from vacation, she interviewed CNA D about the accusation of not completing cares by LPN C. -CNA D was adamant her duties had been performed. *A follow-up communication with LPN C with the use of Volt (a messaging application on cell phone used by the facility for staff to communicate with each other) revealed CNA D had apologized to LPN C for yelling and refusing to talk to LPN C. *At this point, it was the DON's opinion the argument had been settled. 7. Review of the provider's 1/2025 Abuse Prohibition Policy & Reporting of Crimes (in Long Term Care, Hospital, & Home Settings) policy revealed: *Neglect Neglect is the failure of the facility, its employees or service provider to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *The facility will thoroughly investigate all alleged violations and will prevent further potential abuse while the investigation is in progress. *Policy: [NAME] Health Center [NAME] has established a zero tolerance policy for any form of abuse or neglect toward any resident/patient.

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), interview, record review, and policy review, the provider failed to protect one of one sampled resident (11) from abuse by one of one agency certified nursing assistant (CNA) (F) who insinuated she was videoing the resident when providing her care. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 11's incident revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated her cognition was intact. *On 7/9/24 at 9:00 p.m. she reported to licensed practical nurse (LPN) K that CNA F had been recording her while helping her with her bathroom care needs. *LPN K questioned CNA F who told her that she was not actually recording, but she had wanted resident 11 to believe she was. *LPN K reported the incident to administrator A. *CNA F was assigned to a different hallway for the rest of the night and monitored. *Interventions following their investigation of this incident included: -CNA F was terminated. -All residents received education regarding how to report abuse allegations. -Residents with a BIMS score of 8-15 were interviewed for signs or suspicions of abuse by staff. -Resident 11 was offered mental health services. -All staff were to receive education regarding abuse and how to report it. 2. Interview on 11/20/24 at 11:10 a.m. with CNA D revealed: *They had received education on abuse in their huddles and online. *She knew how to report abuse to the designated people which included administrator A and director of nursing (DON) B. *She knew how to identify signs and symptoms of resident abuse. 3. Interview on 11/20/24 at 11:14 a.m. with resident 11 in her room revealed: *She had issues with CNA F prior to the video recording incident, but she never reported anything. *She had been offered mental health services, but she declined because she didn't think it was necessary. 4. Interview on 11/20/24 at 2:28 p.m. with administrator A revealed: *CNA F had a background check that indicated no prior abuse allegations when hired. *CNA F had completed education on abuse prior to being hired and completed the facility's education on abuse during her orientation. *He had contacted her agency and reported the incident. *Law enforcement had been notified of the incident. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/20/24 after record and policy review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding abuse and how to report it, resident education and interviews had been completed, and interviews revealed staff understood the education provided regarding those topics. Based on the above information, non-compliance at F600 occurred on 7/9/24, and based on the provider's 7/12/24 implemented corrective action for the deficient practice confirmed on 11/20/24, the non-compliance is considered past non-compliance.

Based on observation, record review, interview, and policy review, the provider failed to ensure the dishwasher temperatures were monitored, recorded, and interventions were documented for temperatures out of range for one of one dishwasher used for the cleaning and sanitization of dishes and items used to prepare and serve residents' food. Findings include: 1. Observation on 11/19/24 at 11:30 a.m. of cook H revealed: *She removed the plates from the serving stack and placed them in the dishwasher. *After the dishwashing cycle was completed, she returned the plates to the serving stack. *She then served the lunch meal on the plates that she had washed. 2. Review of the provider's Dishwasher Temperature Record revealed: *The dishwasher was a high-temperature dishwasher. *The Dishwasher Temperature Record had areas for documentation of the Wash Cycle Temp and the Rinse Cycle temperatures. *There were areas for documentation labeled B [breakfast], L [lunch], and D [dinner] for each date. *There were grayed-out areas on the temperature log that coincided with the bottom of the form indicated that the temperatures were in degrees Fahrenheit (F) and that the Wash Temps needed to be [between] 150-165 [degrees F] and Final Rinse Temps need to be 180 [degrees F] or> [greater]. *There was an area on the form that indicated, If not in appropriate range, put date here and what was done to fix the issue:. *There were multiple areas on the form where there were no documented temperatures. *There was documentation of the Wash Cycle Temp being out of range. -On 11/3 the dinner temperature was documented as 148 degrees F. -On 11/10 the lunch temperature was documented as 149 degrees F. -On 11/13 the dinner temperature was documented as 149 degrees F. *There was no documentation in the interventions temperatures that were out of range. 3. Record review on 11/20/24 of the provider's 2024 September, October, and November dishwasher temperature logs revealed: *The September log indicated there were: -Eighteen missed opportunities for temperature documentation. -Three days that had no temperature documentation for all three mealtimes (9/11, 9/12, 9/22). -Five times when the wash cycle temperature was documented as having been out of range. -Thirteen times when the rinse cycle temperature was documented as having been out of range. -No documented interventions for when those temperatures were out of range. *The October log indicated there were: -Thirty-four missed opportunities for temperature documentation. -Two days had no temperature documentation for all three mealtimes (10/30 and 10/31). -One time when the wash cycle temperature was documented out of range. -Seven times when the rinse cycle temperature was documented out of range. -No documented interventions for when those temperatures were out of range. *November's log indicated there were: -Eighteen missed opportunities for temperature documentation. -Two days had no temperature documentation for all three mealtimes (11/1 and 11/2). -Three times when the wash cycle temperature was documented out of range. -No documented interventions for when those temperatures were out of range. 4. Interview on 11/20/24 at 10:03 a.m. with dishwasher I regarding the dishwasher temperatures indicated: *Temperatures were to be recorded after every meal. *The temperatures were read from a digital display that indicated if it was a wash or rinse cycle and the temperature. *She recorded the temperatures from the last wash cycle of each meal service on the Dishwasher Temperature Form. *She identified the gray areas on the form indicated the acceptable range for the wash and rinse temperatures. *She stated if the temperatures were out of range, she would notify her supervisor. 5. Interview on 11/20/24 at 11:10 a.m. with dietary manager G regarding the high-temperature dishwasher revealed: *She had been in her position for one month. *She would expect the dishwasher temperature to be read and documented by staff twice daily. *She had not reviewed the dishwasher policy or the dishwasher temperature documentation. *If the dishwasher temperature was out of range, she would expect staff to notify maintenance and she would notify administrator A. *She stated that she would expect that staff would not continue to wash dishes if the dishwasher temperature was not in the appropriate range. 6. Interview on 11/20/24 at 11:52 a.m. with administrator A regarding the high-temperature dishwasher revealed: *He expected the temperatures would be checked by staff three times daily with meals. *He agreed the temperatures were not being taken as often as he expected and there was no documentation of interventions for the out-of-range temperatures. *He indicated the temperatures in the kitchen were being followed in QAPI (quality assurance and performance improvement) and there was a PIP (performance improvement plan) that had been developed but had not been implemented. *He expected staff to notify maintenance if the temperatures were out of range. *Maintenance verified the accuracy of the gauges on the high-temperature dishwasher monthly. 7. Review of the provider's 10/2024 Sanitation, Safety, Equipment---Machine Dishwashing policy revealed that Temperature/appropriate sanitation levels are checked & recorded daily.

Based on observation and interview the provider failed to ensure the posted daily staff data reflected the actual hours worked by certified nursing assistants (CNAs). Findings include: 1. Observation on 11/20/24 at 1:13 p.m. revealed: *The facility's staff hours posting form was located in the front entrance hallway on a bulletin board. -The form included the facility name, date, resident census, and hours scheduled for licensed nurses and certified nurse aides. --The hours scheduled were pre-printed on a computerized form. Interview on 11/20/24 at 1:15 p.m. with CNA E, director of nursing B, and administrator A, regarding the posting of staff hours revealed: *CNA E and another staff person were responsible for posting the staff hours. *The CNA area of the form used to post staffing hours did not include actual hours worked. *The form that was posted included only hours scheduled and was not updated to include any changes in CNA hours worked. *They stated the scheduled licensed nurse hours were always accurate to actual hours worked. *They confirmed they were not aware the staff hours posted should be actual hours worked.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of three observed certified nursing assistants (CNA) A sanitized all surfaces after personal care for one of three observed residents (12). *One of one observed licensed practical nurse (LPN) (B) followed infection control measures during the dressing change for one of one sampled resident (28). Findings include: 1. Observation on 2/4/20 at 8:57 a.m. of CNA A after she had completed personal care for resident 12 revealed: *She had assisted the resident onto a bedside commode. -Removed her soiled brief and placed it in a small garbage bag. -She then placed that bag on the bathroom counter by the sink. *After she had completed the resident's personal care she used Super-Sani cloths and: -Sanitized the EZ lift, the frame of the commode, and emptied the contents of the commode into the toilet. -Rinsed the commode with water from the sink and emptied the contents in the toilet. *She did not sanitize the toilet seat, faucet, or the counter. *She used the paper towel she had dried her hands with to wipeup the water that had splashed around the sink. 2. Observation on 2/5/20 at 10:50 a.m. of LPN B during dressing changes to resident 28's right elbow wound and bilateral lower legs revealed: *She entered the room, put on a barrier gown, then stepped outside of the room, and got a pair of gloves. She had not completed any hand hygiene. *She had already removed the bilateral leg dressings prior to this observation and had placed a clean barrier on the resident's bed with the following laying on that barrier: packages of ABD dressings, a roll of kling wrap, a roll of silk tape, a small plastic medication cup that contained ointment, and a can of saline wound cleanser. *She: -Removed the resident's right arm protective skin sleeve and pushed up her shirt sleeve. -Placed a barrier under her right elbow. -Removed the soiled dressing and put it in a small garbage bag that was on the residents bed. *Without changing her gloves: -She cleaned the wound with the saline wound cleanser. -Placed the can of saline wound cleanser back on the clean barrier next to the clean dressing items. -She took the medication cup that had ointment in it and put the ointment on the opened wound area with her finger. -Applied the 4X4 gauze dressing, wrapped Kling around that dressing, and secured it with silk tape. -She placed that roll of tape back on the clean barrier. *Removed her gloves and with no hand hygiene she: -Retrieved gloves from the hall dispenser and two rolls of Kling from the resident's dressing tote on top of the treatment cart. -She placed those rolls of Kling wrap on the clean barrier. -Opened the packages of ABDs and put them on the resident's: --Right heel, right shin, top of her left foot, and left shin using the silk tape. --Wrapped both legs with Kling and then ACE wraps on both of her legs. She secured both the Kling wrap and ACE wraps with silk tape. *Removed her gloves and with no hand hygiene she placed the can of saline wound cleanser, two packages of ABDs, and the roll of silk tape back in the resident's dressing tote on top of the treatment cart. -That tub contained a pair of scissors and other packages of clean dressings. *Removed her barrier gown and placed it in the regular garbage. *Removed her gloves and washed her hands. *After she dried her hands she used the same paper towel to dry off the counter top around the sink. *She then placed the soiled dressing garbage bag into the treatment cart garbage bin. *She documented the dressing change on the electronic medical record. Review of resident 28's medical record revealed: *On 1/27/20 her primary physician had assessed her right elbow due to increased [MEDICAL CONDITION], reddened skin, and pain. *An antibiotic was ordered. *On 2/3/20 her physician lanced the abscess area to her right elbow and took a swab sample for a culture and sensitivity. *On 02/05/20 at 1:36 p.m. it was noted the wound had a positive culture for [MEDICAL CONDITION] (MRSA) to her right elbow. 3. Interview on 2/5/20 at 4:00 p.m. with director of nursing C revealed: *She had done education on infection control within the last month. *LPN B had attended that education. *Agreed LPN B had missed opportunities for glove changes and hand hygiene. *Agreed CNA A should have sanitized the toilet seat and the countertop. Review of the provider's (MONTH) 2019 Long Term Care Standard Precautions policy revealed: Employees shall wash their hands/perform hand hygiene immediately or as soon as feasible after removal of gloves and other personal protective equipment.

Based on observation and interview, the provider failed to ensure two of two hallways (East and North) were free from resident use equipment to allow access to one of two hand rails in each hallway and to allow residents to maneuver through the hallways in a safe manner. Findings include: 1. Observation on 11/6/18 at 7:45 a.m., 9:27 a.m., and 10:40 a.m. in the East hallway revealed: *Wheelchairs (w/c), walkers, lifts, trash, and linen bins were lined up on the north wall outside of residents' rooms blocking access to the hand rail on that side. *The equipment had been lined up all the way down the hallway on that one side. *At 7:45 a.m. resident 30 was ambulating with a walker and was trying to walk to her room, but she had to stop due to resident 25 coming down the hall. -Staff were attempting to walk resident 25, and it was going very slow. -There was no way to pass by resident 25 due to the resident use equipment lined up in the hall. -An unidentified resident had been sitting in her wheelchair against the wall waiting for resident 25 to pass. Observation on 11/7/18 at 8:08 a.m. in the East hallway revealed two lifts, five walkers, five wheelchairs, and three bins were lined up against the north wall blocking access to the hand rail on that side of the hall. 2. Random observations on 11/5/18 at 3:30 p.m. 11/6/18 at 7:40 a.m., 10:30 a.m., and 2:10 p.m., and 11/7/18 at 7:45 a.m. of the North hallway revealed: *Residents 5 and 41's w/cs had been placed out in the hallway along the west side. *Multiple w/cs of different shapes and sizes, lifts, trash, and linen bins had been placed up against the west wall. *The above equipment on that side had: -Blocked access to the hand rail. -Been lined up all the way down the hallway. -Been outside of the residents' rooms creating only an opening as large as the doorway for an entrance into their rooms. *Random residents in their w/cs were observed waiting against the other wall until staff, visitors, and other residents had passed them. *The surveyor had to move out of the way multiple times to allow enough space for residents, staff, and visitors to get by her. 3. Observation on 11/7/18 at 3:15 p.m. of the North hallway revealed: *There were two standing lifts, one Hoyer lift, seven unfolded w/cs, one utility cart, and two trash containers sitting on the west side of the North hallway. *The hand rail on the west side was not available for the residents to use. *Residents would have to wait for others to pass before they could proceed to their own room. Surveyor: 4. Interview on 11/7/18 at 8:15 a.m. with certified nursing assistant (CNA) E revealed she: *Confirmed the above observation in the North hallway. *Stated: -The lifts are supposed to be put away in the soiled and clean linen rooms when we are done. -The w/cs in the hallway are mostly to prevent accidents and falls for confused residents who would try to use them. -Some residents do have their w/cs in their rooms. -The rooms are really small so we try to make more room for them to. *Agreed the above process had created the potential for accidents and falls to have occurred for those residents who required the use of the hand rail. Interview on 11/7/18 at 8:30 a.m. with registered nurse F revealed she: *Confirmed the above interview with CNA E. *Agreed the process above had created the potential for accidents and falls to have occurred by limiting access to the hand rail for those residents trying to move around the equipment and get into their rooms. Observation on 11/7/18 at 10:30 a.m. of North hallway, revealed the staff had moved several of the w/c's out of the way to create some access to the west side handrail. Interview on 11/7/18 at 11:00 a.m. with the director of nursing revealed: *There was no policy or process in place for the safe storage of resident use items. *She stated: -This is brought up all the time and I don't know where we would store them. -Yes, they are stored out there for safety concerns with transferring and falls, but also because the rooms are small. -Then the rooms are too cluttered. *She agreed the process above had created a safety concern with no access to that handrail for the residents.

Based on observation, record review, interview, and policy review, the provider failed to ensure one-to-one activities were in place for three of eight sampled residents (4, 5, and 18) who had cognitive impairment. Findings include: 1. Review of resident 5's medical record revealed: *Her admitted was 11/8/13. *Her [DIAGNOSES REDACTED]. *Her Brief Interview for Mental Status (BIMS) score was three, indicating that her memory recall was impaired. *She was dependent upon the staff to anticipate and assist her with all activities of daily living (ADL). Random observations on 11/6/18 from 7:30 a.m. through 4:27 p.m. of resident 5 revealed: *At 7:30 a.m. she was laying in her bed sleeping. -The bed had been lowered to the floor with a scoop mattress on it. -She had been laying on her right side and facing the wall. -The wall was bare with no visual items for her to look at when she was awake and laying on that side. *At 7:41 a.m. two staff members had assisted her with getting out of the bed. *She had been able to answer yes/no questions only. *At 8:03 a.m. she had been brought to the dining room for breakfast. -She had been dependent upon the staff to assist her with the meal. *From 8:50 a.m. through 11:15 a.m. she had been observed laying in the bed sleeping and again on her right side facing the wall. *At 11:35 a.m. she had been in the dining room waiting for her meal. *From 1:30 p.m. through 3:30 p.m. she had been laying in the bed in the same position as observed above. *From 4:00 p.m. through 4:27 p.m. she had been observed sitting in her recliner in her room. *There had been no music or television on in her room from 7:30 a.m. through 4:27 p.m. *No other staff than the direct care givers had been observed in her room to provide one-to-one activities. Random observations on 11/7/18 from 7:30 a.m. through 12:00 noon of resident 5 revealed she had been either in the dining room for meals or laying in her bed sleeping and facing the wall. There continued to be no music or television on for her to watch or listen to. Review of resident 5's 9/25/18 comprehensive care plan revealed: *She was to get one-to-one activities for added stimuli. *Staff were to have assisted her to activities of interest. *Her individual preferences included: church, music, devotional readings, being around people, visiting with people, and having stories read to her. *The activities staff were to have: -Apply pretty smelling lotion. -Fix my hair. -Take me for a stroll in my wheel chair (w/c). -Read stories to me. -Talk to me. Review of resident 5's activity logs from 10/1/18 through 11/6/18 revealed: *She had received one-to-one activities three times per week. *Her one-to-one activities done during the above time frame included: -Twenty-three conversations/visits with the staff. -One instance when the staff had read to her. *Daily activities included: -Twenty conversations/visits from either staff or a family member. -Fives instances of her attending some type of special event. *There was limited variety in the activities that were provided to her. *No documentation to support: -How long the visits and reading of a book had taken. -The staff had applied lotion to her skin, fixed her hair, played music, or took her for strolls in the w/c. Record review and interview on 11/7/18 at 2:42 p.m. with the activities coordinator regarding resident 5 revealed: *She confirmed: -The above record review of the resident. -The resident had been appropriate and set-up on a one-to-one activity program. -There was no way to review how long the activity staff would have spent with a resident who was on a one-to-one program. *She stated: -There is no amount of time allotted or set for them to spend with a resident. -They tell us not to put in a time. -We don't have a set time as every resident is different and their attention span is different. *She confirmed the one-to-one activities occurred three times a week, but there was no specific guidelines or parameters for the staff to have followed. *After review of the above activity documentation regarding the resident she could not identify the difference between the daily program and the one-to-one program. *She would have expected the staff to have spent more time with the one-to-one residents on more meaningful and stimulating programs. -She stated I would hope they spent more time with the residents when doing those activities. 2. Review of resident 18's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Alzheimer's dementia. -Depression. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. *Her BIMS score was three indicating her memory recall was impaired. Observations on 11/6/18 of resident 18 revealed: *At 8:40 a.m. she was sleeping in her recliner in her room. -She answered to her name but was unable to answer questions. -Upon saying goodbye she hung her head down and closed her eyes. *At 9:27 a.m., 10:40 a.m., and again at 1:38 p.m. she was sitting in her recliner with her head hanging down sleeping. *There had been no music or TV on during the above observations. *At 4:00 p.m. she was sitting in her recliner, eyes opened, and the TV on. -When asked open ended questions she responded with yes indicating she was unable to answer the questions appropriately. Observation on 11/7/18 of resident 18 revealed: *At 8:08 a.m., 10:38 a.m., 1:36 p.m., and again at 1:55 p.m. she was sitting in her recliner in her room with her head down and was sleeping. *There was no TV or music on at those times. Review of resident 18's 9/26/18 care plan revealed: *She was on a one-to-one activities program due to paranoia and not wanting to be around people. *She liked to watch dog videos on the I-pad. *She liked one-to-one visits, listening to music on occasion, and watching old shows on her TV. *Her power of attorney would visit and bring her dogs. *There was no indication of how often she was to have received one-to-one activities. Review of resident 18's 10/1/18 through 11/7/18 one-to-one activity logs revealed: *There had been documentation for eighteen out of thirty-eight days during that period of time. -Sixteen of those days they watched videos about puppies or dogs on the I-pad. -One day they visited about puppies and dogs. -One day had not listed the activity but stated She laughed and smiled. Review of resident 18's 10/1/18 through 11/7/18 daily activity logs revealed: *There had been documentation for twenty-four days during that period of time. *Thirteen out of the twenty-four days they had documented TV as the daily activity. *Five out of twenty-four days they had documented discussion/talking. *Three out of twenty-four days she had listened to the volunteer play the piano. *One day a friend had visited. *One day the kids from school came to visit. *One day someone brought a pet in to visit. Interview on 11/7/18 at 4:00 p.m. with the activities coordinator regarding resident 18 revealed: *She was not able to run any other reports except for the past thirty days due to changing computer systems. *She agreed the activities provided for her had been very similar with no variety. *She stated there was no specific amount of time staff would stay with a resident for the one-to-one activities. 3. Review of resident 4's medical record revealed: *Her admitted was 3/20/12. *Her [DIAGNOSES REDACTED].>-Lack of Interest. -Dementia. -[MEDICAL CONDITION] of knee. -Familial [MEDICAL CONDITION]. -[MEDICAL CONDITION]. *Her BIMS score was four indicating her cognition was impaired. Review of resident 4's 9/21/18 care plan revealed: *I enjoy individual activities in my room listening to music and watching my roommate on her computer and watching her TV. *I enjoy when the girls come in and read to me and, visit with me, and show me pictures on the computer and in books. *Staff and my roommate give me lots of TLC (tender loving care), my family visits when able. Review of resident 4's activity logs from 10/1/18 through 11/5/18 revealed: *One-to-one activities were done three times per week. *One-to-one activities done during the above time frame included: -Fifteen conversations with staff. -Two instances of listening to music with staff. *Daily activities included: -Four times she listened to music from the music and memory program. -Four conversations with staff. -One coffee time. -Two times of listening to the piano being played. -Once her family visited. -Twice children from the school came to the care center. -Once her pastor visited. *There were no activities provided on 10/29/18 or 11/1/18. *There was limited variety in the activities that were provided to her. Observations on 11/5/18 of resident 4 revealed: *At 3:43 p.m. during a conversation with her roommate she was sitting in her recliner with her eyes closed, and she had not responded to the conversation. *At 4:56 p.m. she was in her room with her eyes closed, sitting in her recliner, and had not responded to a knock on her door. Observation on 11/6/18 of resident 4 revealed: *At 7:59 a.m. she had been sitting in her wheelchair (w/c) in the East hallway. -She had been placed up against a wall. -A sit-to-stand lift was directly in front of her. -Her eyes were closed. *At 8:10 a.m. two unidentified certified nursing assistants (CNA) took her into her room. *At 8:20 a.m., 8:39 a.m., and 9:17 a.m. she was sitting in her room in her recliner with the lights off, and her eyes were closed. She had not responded to the knock on her door. *At 9:34 a.m. her eyes were closed, she was sitting in her recliner, her feet were up, and the lights were off. *At 10:43 a.m. her eyes were closed, she was in the recliner, her feet were up, and she had headphones on. *At 11:29 a.m. she was sitting in her w/c at the dining room table, her eyes were closed, and she was not interacting with her peers. *At 1:38 p.m. she was laying in her bed, her eyes were closed, and she had not responded to a knock on her door or her name being said. Interview on 11/6/18 at 2:43 p.m. with resident 4 revealed: *She was laying in her bed, the lights were off, and her eyes were opened. *She indicated she liked to read and visit with people. *She stated she enjoyed being in her room. *There was no music or other stimulation on in the room. *She closed her eyes and stopped responding to questions after approximately two minutes. Observations on 11/7/18 of resident 4 revealed: *At 8:09 a.m., 9:42 a.m., and 10:28 a.m. she was in her recliner, her eyes were closed, and she had not responded to the knock on her door. *At 11:02 a.m. she was in her w/c, her eyes were opened, and she was sitting next to the wall in the hallway near the dining room. She had not responded when I said hello or smiled at her. Interview on 11/7/18 at 1:23 p.m. with the activities coordinator revealed: *One-to-one activities had no minimum amount of time for an interaction to be considered a one-to-one. *She reported resident 4's level of engagement was different from time-to-time. *She was a private person and preferred to be in her room. *The resident's family removed her television from her room after her husband had passed away due to her no longer wanting it. *She loved to watch her roommate play on her computer. *She liked to watch her roommate's TV. *She verified one-to-ones were done three times a week, but there were no specific parameters of what was considered a one-to-one. 4. Review of the provider's 7/23/18 Nursing Home/Swing Bed Activities 1 to 1 Program policy revealed: *One to one programming refers to programming provided to residents who cannot effectively plan their own activity pursuits, or residents needing specialized or extended programs to enhance their overall well being and quality of life. *All residents receive one to one visiting from activities but this policy aims to identify and provide additional activities for those residents for a minimum of 3 times per week. 1. Are bed bound. 2. Residents are withdrawn. 3. Residents that were unable to handle group stimulation activities. 4. Residents with severe communication problems. *Residents who are unwilling to attend an activity and/or actively refuse activities are not eligible for the 1:1 program. *Purpose: Is to provide individual activities for those who are unable to attend due to becoming over stimulated, confused, bed bound, withdrawn, and or upset during a group activity just to mention a few. *Procedure: Identify residents that would benefit being on the one to one program. Get to know the residents likes/dislikes and implement those meaningful activities into their one to one visits. Making sure they are person appropriate and relevant to their like and dislikes.

Based on observation, interview, label review, and procedure review, the provider failed to ensure: *Resident door frames were free of Velcro and adhesive for 18 of 23 residents' door frames. *Clothes hangers were cleanable for 27 of 71 hangers in laundry. *The proper chemicals for the rinse cycle were used in one of one laundry room. Findings include: 1. Observation on 11/7/18 at 9:13 a.m. revealed Velcro and adhesive were found on thirteen residents' room door frames on the north hallway and five residents' door frames on the east hallway. Observation and interview on 11/7/18 at 10:15 a.m. with staff A and B revealed: *Twenty seven hangers in the laundry room were wire hangers wrapped with yarn. *Advacare 120 Sanitizer/Sour had been used for visibly soiled laundry. *Staff A and B reported: -They worked in the laundry area. -Those hangers were used for all residents. -They had yarn wrapped around wire hangers. -There cleaning process was to wipe them off with quat (disinfecting) wipes. -They agreed those hangers would not be cleanable surfaces. -They used a code posted on the wall to automatically add detergent into the washing machines. -They used a rinse cycle for visibly soiled laundry. Interview on 11/7/18 at 10:45 a.m. with the housekeeping director revealed: *She supervised the housekeeping and the laundry department. *She agreed the Velcro and adhesive were not a cleanable surface. *She agreed the hangers with yarn wrapped around them were not cleanable surfaces. *Ecolab filled their laundry chemicals and the rinse cycle killed everything. *They used the rinse cycle for visibly soiled laundry. -That laundry was co-mingled with the nursing home and hospital laundry. Interview on 11/7/18 at 1:48 p.m. with the director of nursing (DON) revealed she agreed the Velcro and adhesive on the door frames and the hangers covered with yarn would not have been cleanable surfaces. Further interview at 2:20 p.m. with the DON revealed: *She had contacted Ecolab, and the rinse chemical (AdvaCare 120) did not sanitize against bacteria [MEDICAL CONDITIONS]. *Ecolab stated the dryer would also kill [MEDICAL CONDITION] if in for fifteen minutes. -She could not guarantee that this laundry had been in the dryer for 15 minutes. Interview on 11/7/18 at 4:30 p.m. with the administrator revealed he was not aware the rinse chemical they were using did not sanitize against [MEDICAL CONDITION]. Review of the AdvaCare 120 Sanitizer/Sour product specification sheet revealed the product was not effective for disinfection of the [MEDICAL CONDITION] bacteria. Review of the provider's revised (MONTH) (YEAR) General Laundry Information procedure revealed: *Heavily soiled linen (bloody, bowel movement, vomit, or urine) would be sorted and set aside to be washed as a separate load. *Wash machines had an automatic soap dispensing system, so no detergent would be added by hand.

Based on observation, interview, and policy review, the provider failed to ensure: *Proper hand hygiene was used during one of one meal service by two of two observed staff (C and D) in the kitchen. *Tena classic washcloths had not been used by staff to clean their hands while assisting residents with eating. *Documentation for testing the sanitizer had been thoroughly completed for three of three months (September (YEAR), (MONTH) (YEAR), and (MONTH) (YEAR)). Findings include: 1a. Observation on 11/5/18 from 5:01 p.m. through 6:03 p.m. of cook C revealed: *From 5:01 p.m. through 5:24 p.m. cook C had been pureeing and temping the different food items. *At 5:26 p.m. she used hand sanitizer and put on gloves to dump the soup into the bowl. *At 5:31 p.m. she again used hand sanitizer. *At 5:32 p.m. she started dishing up the first plate. *She had not washed her hands prior to serving the residents' food or during any of the above observation. Observation on 11/5/18 at 5:09 p.m. of dietary aide D revealed: *She had dropped a glass of prune juice spilling it onto the floor. *She had cleaned up the spill with towels and her bare hands. *After cleaning up the floor she used hand sanitizer but had not washed her hands prior to serving the residents' beverages and desserts. Interview on 11/5/18 at 5:57 p.m. with cook C revealed she had not washed her hands prior to serving the food. She agreed she should have washed her hands instead of using the hand sanitizer. b. Observation on 11/6/18 from 11:32 a.m. through 11:52 a.m. in the dining room revealed: *There were bags of Tena classic washcloths on all the tables. *Staff were using the wipes to wash their hands and the residents' hands. Review of the Tena classic washcloth bag revealed the wipes were Waterless cleansing for frequent use on the delicate perineal area. Gentle cleansing formula contains aloe, vitamin E and chamomile. c. Interview on 11/7/18 at 4:25 p.m. with the dietary manager revealed: *The staff should have washed their hands prior to serving the food and after cleaning up the floor. *She had nothing to do with the Tena classic wipes being used in the dining room. Interview on 11/7/18 at 4:48 p.m. with the director of nursing revealed she was not aware staff had been using the above wipes on their hands. They should have been washing their hands and then using the hand sanitizer between helping residents. Review of the provider's (MONTH) (YEAR) Nutrition Services Infection Control Handwashing policy revealed: *Hand washing is required: -Before starting in the kitchen, -After handling soiled dishes and utensils, -Before and after doing housekeeping procedures, -Before and after handling foods, -After using the toilet, -After sneezing and using a tissue, -After touching the face or hair, -Before and after taking a break, eating a meal or smoking, -After handling raw meat, poultry, or fish, -After using the telephone, -Before and after working with individual clients, -Before and after handling facility animals. 2. Observation and interview on 11/7/18 at 9:19 a.m. with the dietary manager revealed: *Staff were supposed to check the sanitizer being used in the buckets and in the sinks three times per day and document on the sheets in the kitchen. *Review of the (MONTH) (YEAR) sanitizer logs revealed twenty-five out of ninety-three opportunities had been completed. -Sixty-eight opportunities had not been documented. *Review of the (MONTH) (YEAR) sanitizer logs revealed twenty out of ninety-three opportunities had been completed. -Seventy-three opportunities had not been documented. *Review of the 11/1/18 through 11/6/18 sanitizer logs revealed one out of eighteen opportunities had been completed. -Seventeen opportunities had not been documented. *She stated the staff were to be completing the documentation at 8:00 a.m. 12:00 noon, and 6:00 p.m. *She agreed the documentation was incomplete.

Based on interview, record review, and job description review, the provider failed to ensure social service interventions were implemented for one of one sampled resident (32) who had recently been instructed to stop drinking alcohol during a hospital stay. Findings include: 1. Interview on 11/6/18 at 8:40 a.m. with resident 32 revealed: *He had a physician's orders [REDACTED]. *After he had returned from the hospital they had taken that order away. *He stated his son would come in and they would have a drink together, but they could not do that anymore. *He would have liked to return to what he had been doing prior to the hospital stay and did not see what one drink a night would hurt. Review of resident 32's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Hypertensive [MEDICAL CONDITION]. -[MEDICAL CONDITION], lower extremity. -[DIAGNOSES REDACTED]. -[MEDICAL CONDITION]. -Obesity. -[MEDICAL CONDITIONS]. -[MEDICAL CONDITION], daily use. *His Brief Interview for Mental Status (BIMS) score was fourteen indicating his cognition was intact. Interview on 11/7/18 at 10:39 a.m. with registered nurse (RN) G regarding resident 32 revealed: *He had an order to have one to two alcoholic beverages per night before he went to the hospital. *When he returned from the hospital he had not had the order. *She thought the certified nurse practitioner (CNP) and family had a discussion about him quitting. *He went into the hospital on [DATE] and returned on 9/25/18. *He had mentioned he would like to have the order back and did not see what one to two drinks would hurt. *She had not talked with him about getting the physician's orders [REDACTED]. *He did not see a counselor. *She was unaware if the social worker had been working with him. Review of resident 32's 9/25/18 hospital discharge paperwork revealed: *Substance use status was In withdrawal. *He had been admitted To continue to de-escalate IV antibiotics related to leg infection as no other source was identified. *Great discussion was had with (resident's name) care team and his family in regards to his etoh ([MEDICATION NAME] also called alcohol) usage and no orders were placed at discharge to continue drinking. Review of resident 32's 10/9/18 physician's visit progress note revealed: *(Resident name) is seen today for his official hospital f/u (follow-up) for [MEDICAL CONDITION], most likely an acute [MEDICAL CONDITION], which then became acute etoh withdrawal with tremors, confusion, and then lethargy. *He recovered from all those problems, although was very rough with withdrawal. *Upon returning to the nursing home decision was made with the nursing home administration, staff as well as (resident's name) family to no longer provide him with etoh. -There had been no indication that resident 32 had been included in that decision. *Today he is upset. He doesn't know what one drink a day hurts. *He tells me he would like to drink with his son and brother when they come to visit. *We had a prior discussion approx (approximately) 10 days ago as well.*Our stance is he will have to leave our facility if he cannot comply with abstinence. Review of resident 32's progress notes revealed: *On 10/15/18 his cousin had brought him in a cup of alcohol disguised in a Pepsi cup. *On 10/17/18 the staff had met with two of his daughters to discuss the incident. *Resident 32 had not been included in that meeting. *The family Acknowledged that they still concur and support the plan of care they made with the (name) CNP that if (resident's name) begins to drink again the facility will provide a 30 day notice and they will need to find alternate placement for (resident name). *It stated the resident was aware of the plan and had agreed to it. Review of resident 32's 9/27/18 care plan revealed an area for mood and behavior with the following interventions: *CNA's (certified nursing assistants) complete mood/behavior logs daily, after every shift. *Social services adds/deletes moods/behaviors on the logs per residents' exhibition. *See emar (electronic medication administration record) for medications. *Moods will be reviewed quarterly/PRN (as needed) and noted on the LTC (long term care) conference summary, my family is invited to care plans. *Mood program is evaluated PRN by looking at mood logs. *There had been no other interventions implemented regarding his alcohol withdrawal. Interview on 11/7/18 at 11:12 a.m. with the social worker and the director of nursing regarding resident 32 revealed: *He had a history of [REDACTED]. *They had let him drink one to two drinks a night prior to his hospitalization on [DATE]. *He was on a mood program. -The CNAs documented every shift regarding things like [MEDICAL CONDITION] and refusal of care. *Neither of them had spoken with him regarding how he was coping with not drinking. *The family and doctor had not wanted him to drink. *They stated they were unaware he had wanted to start drinking again, but the above documentation contradicted that. *They had not referred him to counseling or any other addiction programs. *There were no other interventions implemented for him regarding him not drinking anymore. Review of the 6/1/16 Long Term Care Social Worker Job description revealed: *Provides direct social work service and counseling to residents and their families. *Formulates plan to meet psycho/social/population specific and cultural needs and includes residents and families when formulating plan. Provides resource information to residents and their families.

Based on observation, record review, and interview, the provider failed to prevent a burn injury for one of three sampled residents (1) whose beds were located near a heat register with no measures in place to prevent burns. Findings include: 1. Review of resident 1's medical record revealed:*He was admitted on [DATE]. *His admission history and physical had indicated he had weakness, falls, and weight loss prior to his admission. *He had [DIAGNOSES REDACTED]. *A 1/2/17 interdisciplinary note at 12:45 a.m. by registered nurse (RN) B indicated the resident had a large blister to the left great toe and a small blister to the left second toe. Both blisters were intact. *RN B had written an addendum to the above note on 1/3/17 at 11:23 p.m.: Resident had two blisters to left foot. One on great toe and one on 2nd toe. Staff believes these happened because resident had foot on heater next to bed. Resident is able to move himself in bed. Resident tends to lie on his right side at all times while in bed. Blisters are both intact. Will continue to monitor. Review of resident 1's 1/2/17 event report sent to the South Dakota Department of Health (SD DOH) indicated on 1/2/17 at 12:10 p.m.: *Certified nursing assistant (CNA) A notified RN B of blisters on resident 2's left first and second toes she had found while toileting him during night rounds. *The nurse checked the blisters. *The bed had been positioned against the wall. *The heat register was located on the same wall between the wall and the bed frame. *The resident had been able to move about in bed independently, but tended to sleep on his right side in bed toward the edge of the bed. *The staff then placed a body pillow in the bed with the resident, so the pillow was between the resident and the wall that the register was on. *RN B left a note for the patient care coordinator regarding needing to rearrange the bed away from the wall and added the injury findings to the on-coming shift report. Review of resident 1's SD DOH 1/5/17 final event investigation report revealed:*The resident was not capable of providing an explanation of the event or participating in the investigation. *His bed was moved away from the heater on the evening of 1/2/17 prior to his bedtime. *The provider failed to recognize resident 1 could lay in bed in such a manner that he would burn his feet on the heater. *The action taken by the provider was: -Educate the personnel -Change position of the bed. -Surveyed all rooms for risk. *Resident 1 had been relocated prior to this survey to accommodate a female admission. -The bed in the new room was placed away from the heat register. Review of resident 1's 1/11/17 physician's progress note revealed: *He had second degree burns to his left first and second toe. *The physician could not palpate a pedal pulse. *Hopefully his vascular status is good enough so this will heal. Observation of all 47 residents' rooms including resident 1's room revealed of those beds that were near the heat registers:*Some of the head boards of the beds were placed against the heat registers. *Some of the beds were positioned against the wall where the heat register was located. *Of those beds placed against the same wall as the heat register: -Four beds had braces made of plastic PVC pipe to keep the bed safely away from the heat register. -Seven beds did not have the PVC pipe braces in place to keep the bed away from the heat register. *Resident 1's bed had not been placed near a heat register at the time of the survey. Interview on 1/18/17 at 12:30 p.m. with the director of nursing (DON) revealed:*She confirmed resident 1 had received burns from the heat register. *He was able to walk independently and move about in bed independently at the time of his admission. *After his admission on 12/20/16 he began to decline physically required extensive assistance with bed mobility and toileting. *She was aware of another resident who had been burned on a heat register in 2014. *Preventative measures developed after that resident was burned had included the PVC braces. *Those braces were placed between the beds and heat registers of residents who were at risk of getting burned. *Not all residents had PVC braces on their beds. *RN/Minimum Data Set coordinator C was in charge of deciding which residents required the PVC braces. *There was no policy regarding who required the braces. *Every autumn when the weather cooled down the beds were all checked to see that they were moved away from the heat registers. RN C monitored to see if there were new or physically declining residents who needed the PVC braces. *The CNA staff performed safety checks for each resident every shift and after night rounds to ensure the resident was safe. Those checks had included checking to see that safety equipment had been in place such as: -Personal safety alarms. -Beds in the low position. -Floor mats. -Call lights. -Bed rails. -Body pillows or wedges. -Bed wheels in locked position. *The safety checks had not included checking to see that the residents' limbs were not near the heat registers. *Another type of safety check was done monthly by RN D and the maintenance supervisor to monitor the building for safety hazards. Interview on 1/18/17 at 2:25 p.m. with RN C revealed: *She assessed the residents' abilities when she completed the MDS assessments.*She had decided resident 1 did not need a PVC brace by his bed, because he was able to walk and move around in bed. He could move his arms and legs independently when he had been admitted . *I did not anticipate there would be a problem. *She stated if the resident could move their limbs independently and was alert and aware of their surroundings she did not feel they required the PVC braces. *She had not considered the residents' [DIAGNOSES REDACTED]. *It is just nursing judgement. I look at the residents individually. I did not foresee it. *She confirmed resident 1 had overall declines in his health and physical abilities after his admission. Interview on 1/18/17 at 3:00 p.m. with RN D revealed:*She and the maintenance supervisor performed safety checks to the building monthly. *Items they monitored had included:-Electric outlets and need for outlet plugs by the beds. -Missing calk by toilets and sinks. -Paint chips or marks. -Clothing in closets too close to the fire sprinklers. *She had not monitored for the need for PVC braces or beds too close to the heat registers. *There was no policy regarding what was to have been monitored on their monthly rounds. Interview on 1/18/17 at 2:00 p.m. with RN B regarding resident 1 revealed:*He had a fall just a few days before the burns occurred. *He had been taking himself to the toilet when he was admitted . *His physical abilities had declined, and he needed assistance with toileting on the night his burns had occurred. *She was not sure if staff would have seen his leg off the bed during safety checks, because the bed covers would have covered it. *She was not aware of any other residents who had received burns from the heat registers. Interview on 1/18/17 at 3:20 p.m. with CNA A revealed: *She confirmed resident 1 had declined in his health and physical abilities after his admission. *She was not aware of other residents who had been burned by the heat registers. *She was not sure why some residents used the PVC braces and others did not. Review of the provider's December 2016 Abuse Prohibition policy revealed: *All employees were responsible to assist in monitoring compliance with policy and plans of care. *The care plan team would utilize the resident assessment instrument (RAI) process to assess residents, identify needs and behaviors, plan interventions, and monitor effectiveness of the process on an ongoing basis. *The process had included the resident's extent of dependence upon staff to meet daily care needs.

Based on interview and policy review, the provider failed to ensure four of four randomly interviewed staff members (A, B, C, and F) were able to identify and respond to a tornado warning situation. Findings include: 1. Interview on 6/21/16 at 9:35 a.m. with licensed practical nurse A regarding a tornado warning situation revealed she: *Was not sure what would be announced on the overhead paging system. *Would have staff pull the window shades. *Would move residents out to the nurses station area. Interview on 6/21/16 at 9:40 a.m. with certified nursing assistant (CNA) C regarding a tornado warning situation revealed she: *Was not sure what would be announced on the overhead paging system, severe weather or tornado warning. *Would pull the window curtains. *Would move residents to the dining room and pull room divider partitions. Interview on 6/21/16 at 9:45 a.m. with CNAs B and F regarding a tornado warning situation revealed: *CNA B had never been in a tornado warning situation. -Was not sure what would be announced on the overhead paging system. -Would pull the window shades. -Would move residents out to the nurses station area. *CNA F stated she would move residents to the dining room and pull room divider partitions. *Neither had been in a tornado warning drill. Interview on 6/22/16 at 11:00 a.m. with the director of nursing revealed: *She believed severe weather warning and tornado warnings were different events and had different responsibilities. *She provided the education for new staff regarding weather emergencies. *She stated they were to move residents into the hallway area and close doors and drapes. *There was a computerized annual training segment each employee needed to complete that identified what to do during weather emergencies. *They had not had a tornado warning drill. *She had no response regarding the above four staff members not being sure of what: -Was announced for a tornado warning. -To do during a tornado warning. Review of the provider's undated New Employee Checklist revealed: *Fire and disaster were identified as areas covered. *Severe weather/tornado warning were not on the checklist. Review of the provider's January 2011 External Disaster Plan policy revealed: *The external disaster situation list included: -Weather. -Tornado watch. -Tornado alert. *Severe weather watch was listed separately. *If a tornado warning for the area was made the provider announced Severe weather alert: Tornado warning three times over the public address system. *Staff were to move residents and visitors to safe areas in hallways and close doors. *Staff were to give each person a blanket for protection if time permitted. *Disaster tags were to have been issued for each resident.

Based on interview, record review, and policy review, the provider failed to ensure there was no limit on the amount of funds any resident could place in one of one resident trust fund. Findings include: 1. On 6/21/16 at 9:00 a.m. the individual quarterly statement of one resident with funds in the resident trust fund was requested of the director of nursing and administrator. That information was not received before the end of the survey. Interview and record review on 6/21/16 at 1:55 p.m. with the administrator revealed: *A resident was allowed to put a maximum of $50 in his or her resident trust fund account. *Any amount over $50 would need to be removed and put in a separate account elsewhere. Interview on 6/22/16 at 9:30 a.m. with the administrator revealed: *He understood the concern regarding the $50 limit on the resident trust fund. *There were individual statements sent out quarterly to the residents who had funds in the resident trust fund account. *There were residents who had funds in the petty cash and also had an interest bearing bank account, but he was not able to provide a list of those residents. Review of the provider's 4/9/14 Protection and Management of Resident's Funds policy revealed: *The provider established a resident trust fund account for any resident that wanted to maintain an easily accessible means of maintaining petty cash funds. *When a resident had funds over $50 an account would have been opened in a bank or savings and loan. That would have: -Alleviated the problem of maintaining large sums of cash in the facility. -Provided accurate records. -Given earned interest. *Whenever an eligible resident's personal funds were at or over $2,000 the department of Social Service was to be notified. Review of the provider's undated Residents Bill of Rights revealed: *Residents were allowed to keep less than $50 in the resident trust fund. *Those funds under $50 would not be interest bearing.

Based on observation, interview, policy review, and owner's manual review, the provider failed to ensure nebulizer equipment was properly cleaned after each use for three of three randomly observed residents (3,12, and 13) receiving nebulizer treatments. Findings include: 1. Observation on 6/21/16 at 9:20 a.m. with licensed practical nurse (LPN) G during medication pass revealed she: *Took the mask off resident 12 at the conclusion of his nebulizer treatment. *Disassembled the face mask, medication cup, and tubing, and placed them in a small plastic basket. *Put the basket inside a small mesh bag and placed it near the nebulizer machine. *Did not rinse the nebulizer equipment before placing it in the basket or the mesh bag. Observation on 6/21/16 at 9:30 a.m. with LPN G during medication pass revealed she: *Took the mask off resident 13 at the conclusion of his nebulizer treatment. *Disassembled the face mask, medication cup, and tubing, and placed them in a small plastic basket. *Put the basket inside a small mesh bag and placed it near the nebulizer machine. *Did not rinse the nebulizer equipment before placing it in the basket or mesh bag. Observation on 6/21/16 at 9:43 a.m. with LPN G during medication pass revealed she: *Took the mouthpiece from resident 3 at the conclusion of her nebulizer treatment. *Disassembled the mouthpiece, medication, and tubing, and placed them in a small plastic basket. *Put the basket inside a small mesh bag and placed it near the nebulizer machine. *Did not rinse the nebulizer equipment before placing it in the basket or mesh bag. Interview on 6/21/16 at 9:45 a.m. with LPN G regarding nebulizer treatments revealed: *She did not rinse or wash the nebulizer equipment after each treatment. *The nebulizer equipment was washed in a vinegar solution for all residents each night. Interview on 6/22/16 at 9:40 a.m. with registered nurse (RN) I regarding cleaning nebulizer equipment revealed she rinsed the nebulizer parts with water after each use. Interview on 6/22/16 at 10:30 a.m. with LPN H regarding cleaning nebulizer equipment revealed she followed the same practice as LPN G. Interview on 6/22/16 at 12:45 p.m. with the director of nursing revealed: *It was not her expectation the nebulizer parts were cleaned after each use. *The overnight shift was responsible for cleaning all nebulizer parts in a vinegar solution. Review of the provider's 11/9/11 Hand Held Inhalers/Nebulizers policy revealed: *Following each use take the equipment apart and allow to air dry. *Each evening the equipment will be soaked in a vinegar solution (3 ounces of vinegar to 1 quart of water) for 30 minutes. *The policy did not address cleaning the nebulizer equipment after each use. Review of the Direct Supply Attendant Compressor Nebulizer owner's manual revealed: *It is recommended that the nebulizer and mouthpiece are thoroughly cleaned with hot water after each use. *The cleaning section of the owner's manual revealed instructions for rinsing after each use and included: -Step 1: Disconnect the air tube, nebulizer, and mouthpiece. -Step 2: Gently twist the nebulizer to open it. -Step 3: Rinse the nebulizer and mouthpiece with water. -Step 4: Dry them with a clean soft towel or let air dry. -Step 5: Reassemble the nebulizer when completely dry and put these parts in a dry, sealed container.

Based on observation, record review, interview, lift operating instructions review, and Smart Lift Competency Checklist review, the provider failed to ensure safe practices for one of one sampled resident (2) who required a total mechanical lift transfer. Findings include: 1. Review of resident 2's 4/12/16 care plan revealed he: *Had increased [DIAGNOSES REDACTED] in his legs and limited mobility and weakness. *Required a two person assist with showering and transfers. *Used a shower bed. Observation on 6/22/16 at 8:50 a.m. of resident 2 as certified nursing assistants (CNA) D and E revealed: *The resident required a total mechanical lift for the transfer from his bed to a shower bed. *Due to the resident's physical condition he was unable to assist with the transfer. *A mesh sling was placed under the resident and the sling was attached to the mechanical lift. *As the mechanical lift was in motion and the resident was lifted off of the bed it was noted: -The sling only came up to his mid back leaving the upper one-third of his back, neck, and head unsupported. -A surplus of material on the sling was also observed below his buttock as if the sling was not properly in place. *The resident had a spell of [DIAGNOSES REDACTED] and rigidity during the transfer that lasted a couple of seconds. *The resident stated Oh my back is killing me. *At one point the resident's upper body teetered towards the floor. CNA E re-balanced the resident. *The resident was then placed on the shower bed. Interview on 6/22/16 at 9:10 a.m. with the director of nursing (DON) regarding resident 2 revealed: *She had not observed his transfer recently but she was aware he had a decline in his condition. *She could not explain why the above transfer had occurred as it had. *They used to have a sling for EZ lifts that supported the head, but they had not used it for many years. Observation and interview of resident 2 on 6/22/16 at 9:25 a.m. with CNAs D and E revealed: *They transferred him from the shower bed to his wheelchair using the same mechanical lift. *The sling was placed so his entire upper back was covered by the sling. -The resident only had to support his head during the transfer. *The resident verbalized this transfer had gone much better and had been more comfortable. *CNA E stated during the previous transfer the sling had not been properly placed and that was why the resident had been so uncomfortable. -The sling should have come up to his shoulders. Interview on 6/22/16 at 9:30 a.m. with the DON revealed: *Staff received ongoing training on the use of mechanical lifts. *CNAs D and E had completed that training in the past year. *The sling should have been placed at his shoulders. Review of the provider's Lift operating instructions and Smart Lift Competency Checklists revealed neither of them addressed where on the resident's back the sling should have been placed.

Based on interview, record review, and policy review, the provider failed to ensure medical record documentation for 1 of 11 sampled residents (8) had been complete and accurate regarding a personal loss. Findings include: 1. Interview on 6/20/16 at 3:30 p.m. with resident 8 revealed he had a significant personal loss in the past year. Review of resident 8's 3/1/16 physician progress notes [REDACTED]. Interview on 6/22/16 at 1:00 p.m. with the social services designee (SSD) regarding resident 8 revealed: *She had followed the resident closely after his loss. *He had many friends and family that supported him and visited often. *She would stop in frequently and make sure he was doing okay. -She had not documented those visits. -She primarily documented every three months with the required assessments. -Interventions such as those visits should have been documented if there was something significant. *He had been seen by the counselor on an informal basis, because the counselor was not being reimbursed for those visits. -They did not have any copy of the reports from those visits. -She wondered if the physician had visited with the counselor, and that was how the physician knew the resident was being seen. -She could call the counselor's office and see if she had any reports to send them. *The activity director (AD) was responsible for the psychosocial piece of the care plan. Interview and review of resident 8's care plan on 6/23/16 at 1:15 p.m. with the AD revealed: *She visited with the resident frequently and thought he was doing quite well. *Review of the 4/17/16 care plan revealed it had not addressed the loss the resident had. *The AD explained the care plan had been updated, but the resident's loss had been taken off because he was doing so much better. *Their electronic medical record required they complete an audit to retrieve the original care plan, but they were unsure how to do that. Review of the provider's 3/17/75 Medical Record Documentation and Corrections policy revealed the purpose of the policy was to Set standards of document which will assure a permanent legal record; to provide a mechanism for interdisciplinary communication; to enhance quality patient care and continuity.