Every finding on record at Prairie View Healthcare Center

Based on interview, observation, and policy review, the provider failed to ensure that food was thawed, prepared, kept, and served at a safe temperature in one of one kitchen and that food was palatable, appetizing, and warm by two of two sampled residents (29 and 42), who reported concerns with their food. Findings include: 1. Interview on 8/25/26 at 9:43 a.m. with resident 29 in her room revealed that when she ate in her room, the food was cold most of the time when she received it. She said there were rare days when the food was hot.2. Interview and observation on 8/25/26 at 10:07 a.m. with resident 42 in his room revealed that he did not eat his breakfast. He said the food was terrible. His entire pancake was black on both sides.3. Interview on 8/25/26 at 11:09 a.m. with certified nursing assistant (CNA)/cook I revealed that the cooks had menus they followed for guidance on serving sizes kept by the serving steam table. Then she explained each serving-size scoop used during the noon meal service.4. Observation on 8/25/26 at 11:28 a.m. revealed the lunch menu was chicken, mashed potatoes, bread roll, vegetables, and gravy. The chicken and the gravy were combined during meal preparation, which was then placed on top of the mashed potatoes when served to the residents during the noon meal service. When one-half cup of mashed potatoes was served onto the plate, they did not hold their shape and spread across three-quarters of the plate. Then a 2-ounce ladle was used to put the diced chicken and gravy mixture on top, which continued to spread across the plate. The gravy was watery and see-through when plated, and the chicken did not appear to be the four ounces required by the recipe and menu. CNA/cook I checked the temperatures of the lunch food to be served to the residents. The vegetables temperature was 145 degrees Fahrenheit (F). The minced and moist chicken temperature was 131 degrees F.5. Observation on 8/25/26 at 11:33 a.m. of CNA/cook I in the kitchen revealed she put the vegetables in the oven to reheat.6. Interview on 8/25/26 at 11:36 a.m. with CNA/cook I revealed the vegetables and minced and moist chicken both needed to be reheated, as the food must be at 150 degrees F. She then left the kitchen/meal service to take a break. 7. Observation and interview on 8/25/26 from 11:43 a.m. to 11:49 a.m. in the kitchen revealed CNA/cook I returned to the kitchen and rechecked the food temperatures. The vegetables were 151 degrees F, and the moist and minced chicken that was left on the steam table was 130 degrees F. CNA/cook I stated we can serve it [the moist and minced chicken] like this since we are already late, but it should be at 150 degrees [F]. She then said her process was to reheat the food if it did not reach the desired temperature. She then put the minced and moist chicken into the oven to reheat. At 11:49 a.m., she rechecked the temperature of the chicken, and it was 151 degrees. 8. Observation on 8/25/26 at 12:49 p.m. revealed the last room tray prepared was served to the Department of Health (DOH) surveyors; the vegetables were 108.7 degrees F, and the mashed potatoes with gravy and chicken were 123.1 degrees F. The mashed potatoes, gravy, and meat were spread across most of the plate, with the vegetables partially on top of the potatoes. The gravy was thin, watery, and see-through. The meat was approximately one ounce.9. Interview on 8/26/26 at 8:12 a.m. with cook L revealed that she prepared and served breakfast on 8/25/26. She said, I knew they [the pancakes] were burnt when serving, but I gave them [the residents] the ones [pancakes] that were not as black as others. She did not expect the residents to eat burnt pancakes, but she felt she still had to serve the pancakes. 10. Interview on 8/26/26 at 9:07 a.m. with administrator A revealed she was aware the kitchen was struggling to maintain standards of the facilities and her expectations.11. Observation and interview on 8/26/26 at 11:15 a.m. in the kitchen with cook L revealed cook L checked the temperatures of the food items in the steam table. The minced and moist vegetables were 131 degrees F, the pureed bread was 114 degrees F, the garlic bread was 106 degrees F, and the pureed vegetables were 131.2 degrees F. She expected all the food items to all be above 150 degrees F. She then placed them all in the oven to reheat.12. Interview on 8/26/26 at 11:18 a.m. with cook N revealed the temperatures for hot foods needed to be above 150 degrees F and the temperatures for cold foods needed to be below 30 degrees F. He pureed all food that could be pureed with hot water, unless it's a dessert; then he used milk or yogurt. He did not know what else to use other than water to puree food with. He measured the amount of liquid, based on how the food looked when it was pureed. He had no formal training, only hands-on experience from the previous cook who worked at the facility.13. Observation on 8/26/26 at 11:20 a.m. with cook L in the kitchen revealed the reheated temperature of the moist and minced vegetables were 184 degrees F, the pureed vegetables were 172 degrees F, the pureed bread was 176 degrees F, and the garlic bread was 158 degrees F. 14. Observation on 8/26/26 at 11:23 a.m. in the kitchen sink revealed chicken thawing in a clear plastic bag, within a grey tub with water running over it from the sink faucet.15. Interview on 8/26/26 at 11:24 a.m. with cook N regarding the food thawing process revealed food was removed the night before from the freezer and put in the fridge to thaw. The staff had forgotten to remove the frozen raw chicken from the freezer the night before, so they were thawing it by running cool water over it. [NAME] N checked the temperature of the water that was running over the raw chicken in the sink, which was 87.5 degrees F. [NAME] N said the water temperature was okay. and that the water was running over the chicken for about 40 minutes. The water would continue to run until he was able to break apart the raw chicken to cook. 16. Observation on 8/26/26 at 11:34 p.m. in the kitchen revealed the water continued to run over the raw chicken in the sink.17. Interview and observation on 8/26/26 at 11:36 a.m. with regional dietitian R in the kitchen regarding the process for thawing frozen meat revealed the staff were to pull the frozen item three days before it was needed, or to use running water around 70 degrees F. She said the water should be not too hot, and not too cold. She was aware of the chicken thawing in the sink with running water over it. The expectation was that the chicken would thaw all the way through before cooking, because thawing partially could lead to undercooked food and be unsafe for the residents. She did not consider it safe for the water temperature thawing the chicken to be 87.5 degrees F. At 11:40 a.m., RD R checked the temperature of the water running over the frozen chicken in the sink, and it was 86.8 degrees F. She said this was not a safe thawing process, as the water was too hot, and the chicken was to be thrown away, or the residents could get sick.18. Observation on 8/26/26 at 12:44 p.m. revealed the chicken packages were split open with the chicken still in the package, and all of the chicken was thrown in the trash.19. Interview on 8/26/26 at 4:01 p.m. with RD R revealed that there was a cleaning list for the kitchen staff, and she expected the kitchen to be clean, everything wiped down, swept, and mopped. It was normal for the kitchen to be dirty for a day but not multiple days. She expected the food to be covered when stored in the refrigerator; if it was not, it needed to be thrown away. She expected food temperatures to be checked before service and served as hot as possible on the room trays, but not as hot as if residents were eating in the dining room. She expected the food to be served within safe temperature ranges for the residents.20. Interview on 8/26/26 at 4:16 p.m. with registered dietitian Q revealed she assisted with the cooks and dietary staff's orientation. The staff received a kitchen tour and had three days of training with someone else in the kitchen, more depending on the staff. She expected the kitchen to be clean, with items covered when stored in the refrigerator, and to dispose of expired items in the trash. She expected the staff to follow the recipes given by the company to ensure they provided adequate nutrition for the residents. She did not expect the pancakes to be served burnt to the residents.21. Interview on 8/26/26 at 4:30 p.m. with administrator A revealed that she expected the dietary staff to know safe food temperatures to be served to the residents. She expected the cooks to know the process for thawing frozen meats at safe temperatures. She expected the kitchen to be clean of trash, food debris, and dirty wash rags.She said business office manager (BOM) G oversaw the kitchen because the facility did not have a ServSafe (a nationally recognized food and beverage safety training and certification program developed and administered by the National Restaurant Association) certified staff member or a certified dietary manager (CDM).22. Review of the provider's October 2017 Food Storage policy revealed Cold foods are maintained at temperatures of 41 F [degrees Fahrenheit] or less. Hot foods leave the kitchen or steam table at 140 F or above. 12. Raw eggs and thawing meats are stored in the refrigerator, preferably on the bottom shelf.

Based on observation, interview, and policy review, the provider failed to follow standard food safety practices to ensure two of two cooks (I and L) maintained safe food temperatures during two of two observed meal services, one of one cook (N) thawed frozen chicken safely before food preparation, and that one of one kitchen was cleaned and maintained by three of three cooks (I, L, and N). Findings include:1. Observations on 8/25/26 from 8:09 a.m. to 8:20 a.m. in the kitchen revealed the floors by the stove, ovens, and dishwasher areas had a large amount of black film over the brown floor tiles, and trash debris including paper towels, straws, food, and wrappers. Three hard, crusted, dried washcloths, dark brown and black, were found under the handwashing sinks and under the shelving area by the stove and oven.2. There was a frying pan hanging on the clean dishes rack with a handle that said, the grip. It had grease drippings, a scratched bottom surface, and a peeling non-stick coating.3. In the walk-in refrigerator, there was a jar about one-third full of sliced pickles with no lid on the jar, located on the top shelf in the fridge. 4. There was a Pure Life gallon of water, about a quarter full, with multiple black dots that appeared to be mold on the inside and outside of the gallon jug. 5. There was a large metal bowl of pudding dated 8/25/26 with no cover over the container, and a package of string cheese and an orange on the refrigerator floor.6. In the walk-in freezer there were multiple boxes of strawberry shakes opened, falling onto the floor under the shelving.7. Interview on 8/25/26 at 9:43 a.m. with resident 29 in her room revealed that when she ate in her room, the food was cold most of the time when she received it. She said there were rare days when the food was hot.8. Observation on 8/25/26 at 11:00 a.m. revealed cook L delivered the uncovered pudding from the fridge to the dining room tables for lunch. 9. Interview on 8/25/26 at 11:04 a.m. with certified nursing assistant (CNA)/cook I revealed that if the pudding was stored uncovered in the fridge, then it should not be served to the residents, and she would need to make new pudding. 10. Observation on 8/25/26 at 11:06 a.m. revealed that cook L removed the pudding from the dining room tables, and CNA/Cook I remade the pudding for the lunch service.11. Observation and interview on 8/25/26 from 11:15 a.m. to 11:36 a.m. in the kitchen with CNA/cook I revealed the cooking area floors remained unchanged and dirty with debris, as earlier in the morning. The grill and stove had pancake batter from the breakfast meal service. The frying pan with the grip handle remained hanging on the clean dish rack with grease and peeling nonstick coating.12. There was a whole sausage patty and brown ground-up pieces of meat on the floor by the steam table from the breakfast meal service.13. There were two large storage containers of white sugar and flour, both with expiration dates of 6/30/26.14. On the clean dishes shelving there was a silver tray, a clear glass dish, and a white serving tray with food debris and trash on them. There were four grey baskets that held the clean serving utensils and lids to the pitchers that had food debris in the bottom of the containers. A dried banana slice was on the floor by the clean dishes shelving.15. At 11:28 a.m. CNA/cook I checked the temperatures of the lunch food to be served to the residents. The lunch meal was scheduled to be served at 11:30 a.m. The vegetables temperature was 145 degrees Fahrenheit (F). The minced and moist chicken temperature was 131degrees F.16. CNA/Cook I put the vegetables in the oven to reheat.17.CNA/Cook I said the vegetables and minced and moist chicken would both need to be reheated, as the food must be at 150 degrees. She then left the kitchen to take a break. 18. Observation and interview on 8/25/26 from 11:43 a.m. to 11:49 a.m. in the kitchen revealed CNA/cook I returned to the kitchen and rechecked the food temperatures. The vegetables were 151 degrees F, and the moist and minced chicken that was left on the steam table was 130 degrees F. CNA/cook I stated we can serve it [the moist and minced chicken] like this since we are already late, but it should be at 150 degrees [F]. She then said her process was to reheat the food if it did not reach the desired temperature. She then put the minced and moist chicken into the oven to reheat. At 11:49 a.m., she rechecked the temperature of the chicken, and it was 151 degrees. 19. Interview on 8/25/26 at 12:12 p.m. with business office manager (BOM) G revealed she threw the grip large skillet away from the clean dishes rack because the bottom of the non-stick pan was peeling due to the use of metal on the pan, so the staff could no longer use it.20. Observation on 8/25/26 at 12:19 p.m. of cook L and CNA/cook I in the kitchen revealed they prepared resident room trays.21. Observation on 8/25/26 at 12:49 p.m. revealed the last room tray was served to the Department of Health (DOH) surveyors. The vegetables were 108.7 degrees F, and the mashed potatoes with gravy and meat were 123.1 degrees F.22. Observations and interview on 8/26/26 from 8:03 a.m. to 8:08 a.m. in the kitchen with cook N revealed the dishwashing area continued to have the black film over the brown floor tiles. The trash debris remained on the floor. The food debris remained under the stove and ovens. The washcloths and trash debris remained under the shelving between the stove and ovens. The dried banana slice remained on the floor by the clean shelving, and the dirty dishes remained on the clean shelving, including the silver platter, white platter, and clear dish with food debris and trash on them.23. The large white flour storage bin had the expiration date of 6/30/26. The white sugar storage bin had an 8 written over 6/30/26 to appear to be changed to 8/30/26.24. [NAME] N stated the stovetops and griddles were cleaned weekly by soaking them and running them through the dishwasher. He removed the stove cooktop plates to clean them. 25. The pickles remained uncovered on the top shelf in the walk-in fridge.26. Interview and observations on 8/26/26 from 8:14 a.m. to 8:29 a.m. with cook L in the kitchen revealed that the resident diet cards were printed each night for use the next day.27. The bins the clean utensils were in continued to have food debris in them. 28. The vent above the steam vent above the steam table continued to have black buildup inside of the metal area of the vent.29. The two plate warmer drawers that held clean plates continued to have food debris at the bottom of both drawers.30. At 8:27 a.m. [NAME] L touched the eating surfaces of the plates with her bare hands after wiping her face, touching the drawer handle, and the countertop that had food debris on it. 31. The microwave used to heat the resident's food continued to have the same food debris as at lunchtime on 8/25/26.32. Interview on 8/26/26 at 9:07 a.m. with administrator A revealed she was aware the kitchen was struggling to maintain standards of the facilities and her expectations.33. Observation on 8/26/26 at 11:14 a.m. in the kitchen revealed there were missing baseboard tiles on the wall separating the stove and the clean dishes area. The exposed wood had dark brown areas approximately four inches long on the front side and two inches long on both sides.34. Observation and interview on 8/26/26 at 11:15 a.m. in the kitchen with cook L revealed cook L checked the temperatures of the food items in the steam table. The minced and moist vegetables were 131 degrees F, the pureed bread was 114 degrees F, the garlic bread was 106 degrees F, and the pureed vegetables were 131.2 degrees F. She expected all the food items to all be above 150 degrees F. She then placed them all in the oven to reheat.35. Interview on 8/26/26 at 11:18 a.m. with cook N revealed the temperatures for hot foods needed to be above 150 degrees F and the temperatures for cold foods needed to be below 30 degrees F. 36. Observation on 8/26/26 at 11:20 a.m. with cook L in the kitchen revealed the reheated temperature of the moist and minced vegetables were 184 degrees F, the pureed vegetables were 172 degrees F, the pureed bread was 176 degrees F, and the garlic bread was 158 degrees F. 37. Observation on 8/26/26 at 11:23 a.m. in the kitchen revealed chicken thawing in sealed plastic, within a grey tub in the kitchen sink with running water over it.38. Interview on 8/26/26 at 11:24 a.m. with cook N revealed that the thawing process for food was that the food was removed the night before from the freezer, but since the staff forgot to remove the food, they could thaw it by running cool water over the food. [NAME] N then took the temperature of the water that was running over the chicken in the sink at 87.5 degrees F. [NAME] N said the water temperature was okay, since it's the cool water running. [NAME] N said the water has been running over the chicken for about 40 minutes. The water would continue to run until he was able to break apart the chicken for cooking preparation.39. Observation on 8/26/26 at 11:23 a.m. in the kitchen sink revealed chicken thawing in a clear plastic bag, within a grey tub with water running over it from the sink faucet.40. Interview and observation on 8/26/26 at 11:36 a.m. with regional dietitian R in the kitchen regarding the process for thawing frozen meat revealed the staff were to pull the frozen item three days before it was needed, or to use running water around 70 degrees F. She said the water should be not too hot, and not too cold. She was aware of the chicken thawing in the sink with running water over it. The expectation was that the chicken would thaw all the way through before cooking, because thawing partially could lead to undercooked food and be unsafe for the residents. She did not consider it safe for the water temperature thawing the chicken to be 87.5 degrees F. At 11:40 a.m., RD R checked the temperature of the water running over the frozen chicken in the sink, and it was 86.8 degrees F. She said this was not a safe thawing process, as the water was too hot, and the chicken was to be thrown away, or the residents could get sick.41. Observation on 8/26/26 at 12:44 p.m. revealed the chicken packages were split open with the chicken still in the package, and all of the chicken was thrown in the trash.42. Interview on 8/26/26 at 4:01 p.m. with RD R revealed that there was a cleaning list for the kitchen staff, and she expected the kitchen to be clean, everything wiped down, swept, and mopped. It was normal for the kitchen to be dirty for a day but not multiple days. She expected the food to be covered when stored in the refrigerator; if it was not, it needed to be thrown away. She expected food temperatures to be checked before service and served as hot as possible on the room trays, but not as hot as if residents were eating in the dining room. She expected the food to be served within safe temperature ranges for the residents.43. Interview on 8/26/26 at 4:16 p.m. with registered dietitian Q revealed she assisted with the cooks and dietary staff's orientation. The staff received a kitchen tour and had three days of training with someone else in the kitchen, more depending on the staff. She expected the kitchen to be clean, with items covered when stored in the refrigerator, and to dispose of expired items in the trash. 44. Interview on 8/26/26 at 4:30 p.m. with administrator A revealed that she expected the dietary staff to know the temperatures the food should be served at to be safe; she expected the room trash to have safe, hot food temperatures. She expected the cooks to know the process for thawing frozen meats at safe temperatures. She expected the kitchen to be clean of trash, food debris, and dirty wash clothes. She said BOM G oversees the kitchen at this time because the facility does not have anyone with ServSafe (a nationally recognized food and beverage safety training and certification program developed and administered by the National Restaurant Association) or a certified dietary manager (CDM).45. Review of the provider's updated October 2017 Food Storage policy revealed Procedure: 1. Food storage areas are kept clean at all times. 4. Remove food from the packing boxes upon delivery (to minimize pests). Loose items such as cookies and crackers are placed in containers or bins. Empty food cans are not used. Only food grade reusable containers are used for food storage. 5. Foods are dated with month and year of delivery to the Center. Exceptions: Food items with used by dates of less than 30 days (e.g. milk, cottage cheese, fresh bread, and produce) do not require labeling with the month and year of delivery. 6. Food products are used within one year unless the manufacturer's expiration date is different. 7. Cold foods are maintained at temperatures of 41 F [degrees Fahrenheit] or less. Hot foods leave the kitchen or steam table at 140 F or above. 10. Opened items have use by dates indicated on them. This use by date may be circled to differentiate it from the date received or date opened. May indicate date opened or date prepared if required by your survey agency. 11. The manufacturer's expiration date, when available, is the use by date for unopened items. 12. Raw eggs and thawing meats are stored in the refrigerator, preferably on the bottom shelf. 13. Supplemental shakes, which are taken from the frozen state and thawed in the refrigerator, are dated with use by dates when they are placed in the refrigerator. Follow the manufacturer's recommendations for shelf life.46. Review of the provider's updated September 2019 Sanitation policy revealed Procedure: 1. Kitchens, kitchen areas, and dining areas are kept clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. 2. Utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosion, open seams, cracks, and chipped areas. 7. Cleaning schedules are developed by the FANS Manager or Person in Charge. 8. The FANS [Food and Nutritional Services] Manager or Person in Charge monitors compliance to the cleaning schedule.47. Review of the provider's updated December 2025 Keeping Resident Food Safe Policy revealed cooked chicken, turkey, and stuffed foods to 165 degrees F.

Based on observation, interview, and policy review, the facility failed to ensure infection prevention and control practices were followed by one of one registered nurse (RN) (E) and one of one licensed practical nurse (LPN) (F) who did not use enhanced barrier precautions (EBP), including gown and glove use, while changing wound dressings for three of three residents (1, 9, and 25) on EBP and one of one LPN (F) who did not use EBP when administering medications to one of one resident (3), who had a gastrostomy tube (a soft, flexible tube placed through the abdomen directly into the stomach) and a suprapubic catheter (a thin, flexible tube inserted through the lower abdomen into the bladder) and was on EBP. Findings include: 1. Observation on 8/25/26 at 8:52 a.m. revealed resident 9 did not have an EBP sign on his door as RN E entered his room to complete his wound care to his legs. 2. RN E entered resident 9's room to complete his wound care to his legs. She did not perform hand hygiene before applying gloves. RN E touched the exterior of both dressings, which did not have a date. She did not complete hand hygiene (involves either handwashing with soap and water or using alcohol-based hand rubs (hand sanitizer) to remove or kill harmful germs) before she put on a pair of gloves and did not put on a gown. She removed the previous dressing from the right leg wound and did not remove her soiled gloves or clean the wound area before she applied a skin prep (a liquid that forms a thin barrier between the adhesive dressing and the skin) and applied a new adhesive dressing to his right leg wound. Her soiled glove had touched the clean surface of the clean dressing that touched the wound area. 3. Interview on 8/25/26 at 1:51 p.m. with CNA T revealed she was not sure if the contact precautions sign was for resident 1, or his previous roommate. 4. Observation on 8/26/26 at 7:44 a.m. revealed RN E did not use the required enhanced barrier precautions of wearing a gown when she provided wound care to resident 25's pressure injury on his left heel. 5. Observation on 8/26/26 at 9:00 a.m. revealed resident 9's room had an EBP sign on the door. 6. Observation on 8/26/26 at 9:01 a.m. revealed resident 45 had a contact precaution sign on their door. 7. Observation on 8/26/26 at 9:03 a.m. revealed resident 3 had an EBP sign on his door. 8. Observation on 8/26/26 at 9:05 a.m. revealed resident 4 had an EBP sign on their door. 9. Review of resident 9's EMR revealed he admitted to the facility on [DATE]. His 7/23/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact. 10. Review of resident 4's EMR revealed he admitted to the facility on [DATE]. His 5/28/26 BIMS assessment score was 8, which indicated his cognition was moderately impaired. His undated care plan indicated he was on EBP due to having an indwelling urinary catheter (flexible tubing placed in the bladder to drain urine). 11. Review of resident 1's EMR revealed he admitted to the facility on [DATE]. His 6/15/26 BIMS assessment score was 13, which indicated his cognition was intact. He had a diagnosis of extended-spectrum beta-lactamase (ESBL) (enzymes that break down common antibiotics, so those antibiotics stop working and the infections become harder to treat). His undated care plan indicated he was on EBP due to his ESBL diagnosis. It was identified that this was in his urine. 12. Review of resident 45's EMR revealed she admitted to the facility on [DATE]. Her 8/21/26 BIMS assessment score was 14, which indicated her cognition was intact. Her diagnoses included a fractured humerus in her right arm, and resistant Staphylococcus aureus infection (an illness caused by Staphylococcus aureus bacteria, which could live on the skin or in the nose and could cause serious infections if they enter the bloodstream, lungs, or other organs). Her undated care plan indicated that she was on EBP due to a skin opening requiring a dressing change. 13. Observation on 8/26/26 at 9:18 a.m. of resident 3's medication administration in his room with LPN F revealed there was an EBP sign on the door. LPN F entered resident 3's room with the medication cart, washed her hands in the bathroom, placed a barrier on resident 3's bedside table, prepped five medication cups with one medication each at the medication cart, put on a pair of gloves, and administered 30 milliliters (mL) of water via resident 3's gastrostomy tube. She then administered the prepared five medications with a syringe into resident 3's gastrostomy tube followed by another 30 mL of water. LPN F did not put on a gown anytime during the medication administration process with resident 3. 14. Review of resident 3's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. He had a diagnosis of dysphagia, oropharyngeal phase (difficulty moving food and liquid from mouth into throat and upper esophagus). He had an 8/12/26 physician's order for EBP due to an indwelling catheter and gastrostomy tube. His care plan indicated the staff were to follow EBP interventions due to his indwelling catheter and gastrostomy tube initiated on 6/23/26. The interventions for EBP involved gown and glove use during high-contact activities, which included dressing, bathing/showering, transferring, changing linens, changing briefs, assisting with toileting, device care/use, and wound care. 15. Observation on 8/26/26 at 9:57 a.m. revealed LPN F completed resident 1's wound care to both of his arms without wearing a gown. 16. Observation on 8/26/26 at 10:57 a.m. in resident 9's room with LPN F revealed she did not use EBP before she changed the dressings to both of resident 9's legs. She did not clean the wound area before the new dressings were applied. 17. Interview on 8/26/26 at 12:49 p.m. with CNA T revealed the EBP and contact precaution signs were put up before she arrived for her shift that morning. She thought that resident 45 was on contact precautions because she had some cuts on her arms from surgery and resident 1's EBP sign was on his door because of his roommate who passed away on 8/25/26. The EBP signs for residents 3, 4, and 6 were for their catheters. She was aware that EBP needed to be worn for direct patient care. 18. Interview on 8/26/26 at 1:16 p.m. with RN E revealed that yesterday (8/25/26) the EBP and contact signs were put on the residents' doorways. Residents 12 and 45's signs were added because resident 45 was being treated for a urinary tract infection until the culture comes back to the provider. She said contact precautions was done all the time when you enter the resident's room who was on isolation precautions. The staff should follow EBP when they were going to be in direct contact with the resident. She did not know the process for a resident on isolation precautions sharing a room with another resident. 19. Interview on 8/26/26 at 1:23 p.m. with director of nursing (DON) B revealed that when isolation precaution signs needed to be changed or switched to alternate precautions, then a staff member removed all the signage, which was why they were not originally posted on the residents' doors. If a resident on contact precautions shared a room, then the contact precautions should be worn while providing care for both residents and changed between different residents' cares. If the provider had an open room, they would move the resident; if not, they would increase the cleaning schedule. She expected the nursing staff to know who was on isolation and why. Contact precautions PPE should be used when entering the room. She expected the staff to use EBP personal protective equipment (PPE) for direct patient care. 20. Interview on 8/26/26 at 1:29 p.m. with medical director (MD) S revealed he expected the staff to clean the resident's wounds or skin areas before they applied a clean dressing to the area. He expected facility staff to follow EBP and contact precautions and wear appropriate PPE when caring for patients to prevent the spread of infections. 21. Interview on 8/27/26 at 7:57 a.m. with LPN F revealed she did not think she needed to use EBP while administering medications through resident 3's gastrostomy tube. She agreed that EBP should be used for indwelling devices, which included gastrostomy tubes. She then agreed that she probably should have been using EBP while administering resident 3's medications through his gastrostomy tube on 8/26/26. 22. Review of the provider's updated March 2026 Transmission-Based Precautions (Isolation) policy revealed Transmission-Based Precautions (previously referred to as isolation precautions) are implemented for residents known to be, or suspected of being, infected with infectious agents. Procedure: 3. The need to implement Transmission-Based Precautions is determined by the facilities Infection Preventionist (IP), Director of Nursing and/or consultation with the local health department. Precautions are based on CDC [center for disease control] guidelines. Precautions are the least restrictive possible for the resident. 4. The facility documents in the resident's medical record the rationale for the type of transmission-based precautions selected as well as the length of time the precautions are maintained. 5. Communication of Transmission-Based Precautions is accomplished with pertinent signage and verbal reports to personnel and visitors. 6. Residents on TBP, apart from EBP, should remain in their room for the duration of precautions, except for medically necessary care or resident choice. 7. Indirect transmission of infectious agents can occur through contact with resident care equipment. Contact Isolation Precautions: Personnel having contact with the infected resident should wear gloves and a gown. Prior to leaving the resident's room, gown and gloves are removed and hand hygiene performed. Options for residents on contact precautions may include a private room, cohorting with another infected or colonized resident or sharing a room with a resident with limited risk factors (no immunosuppression, IV's, indwelling catheters or open skin lesions). Residents with wound drainage, fecal incontinence, or diarrhea that cannot be contained should be placed on contact precautions until a specific organism of the origin of the medical issues is identified. Enhanced Barrier Precautions: involve the use of gown and gloves by care providers, during high-contact resident care activities. EBP are used when caring for residents with colonization or infection with a targeted and epidemiologically important MDRO [multidrug-resistant organism], chronic wounds, or indwelling medical device/s.

Based on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of four sampled residents' (30) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the area of Pre-admission Screening and Resident Review( a federal requirement that ensures individuals with serious mental illness, intellectual disabilities, or related conditions are not inappropriately placed in nursing homes and receive appropriate services) (PASRR), and one of three sampled residents' (20) MDS assessment was accurately coded for the area of special treatments, procedures, and programs. Findings include: 1. Review of resident 20's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 8/18/26 Brief Interview for Mental Status (BIMS) assessment score was 11, which indicated his cognition was moderately impaired. He had a 2/23/26 diagnosis of Senile degeneration of the brain. He had a 2/23/26 physician's order to be admitted to hospice services provided by [NAME] Hospice. Resident 20's 5/28/26 quarterly MDS Assessment Section O question O0110 Special Treatments, Procedures, and Programs K1 Hospice Care was marked no by former MDS P. 2. Interview and EMR review on 8/27/26 at 11:32 a.m. with MDS D revealed she had started completing the residents' MDS Assessments in July 2026. She confirmed that resident 20's 5/28/26 quarterly MDS Assessment was completed remotely by former MDS P. She agreed that Section O question O0110 K1 was marked wrong and should have been marked yes as he was on hospice at that time. She confirmed she used the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 to complete the resident's MDS assessments. She referred to the residents' diagnoses and physician's orders to complete the resident MDS assessment. 3. Review of resident 30's EMR revealed she admitted to the facility on [DATE]. Her 7/17/26 Brief Interview for Mental Status (BIMS) assessment score was 10 which indicated her cognition was moderately impaired. She had a diagnosis of Huntington's Disease (a fatal inherited genetic disorder that causes the progressive breakdown of nerve cells in the brain), and Schizophrenia (a chronic and severe mental disorder that affects how a person thinks, feels, and behaves, often making it hard to tell what is real and what is imaginary) dated 4/8/26. Resident 30 had a 4/9/26 Maximus (a federally mandated program used to evaluate individuals with serious mental illness, intellectual disabilities, or developmental disabilities before they are admitted to reside in a Medicaid-certified nursing facility) notice of PASRR Level 1 screen outcome. It indicated if a resident was currently in a Medicaid-certified nursing facility, the facility would need to document their PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for question A1500 on the MDS assessment. Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? Also, their specific PASRR condition(s) should be checked in question A1510, Level II Preadmission Screening and Resident Review (PASRR) Conditions. Resident 30's 4/18/26 admission MDS Assessment, Level II PASRR question A1500 was marked no by former MDS P. There was no ability to answer A1510 and list the resident's diagnosis. 4. Interview and EMR review on 8/27/26 at 11:41 a.m. with MDS D revealed that resident 30's 4/9/26 Maximus notice of PASRR Level 1 screen outcome letter indicated that resident 30's 4/18/26 MDS assessment question A1500 should have been marked yes by former MDS P when she completed the assessment. That would have made question A1510 available to put in resident 30's current diagnosis. 5. Interview on 8/27/26 at 11:48 a.m. and 11:54 a.m. with director of nursing (DON) B revealed resident 30's 4/18/26 admission MDS assessment section A question A1500 was marked incorrectly by former MDS P and should have been marked yes, which would have enabled question A1510 to be answered. She agreed that resident 20's 5/28/26 quarterly MDS assessment section O question O0110 K1 was marked no, incorrectly and it should have been marked yes by former MDS P. She expected the MDS assessment to be completed correctly to represent the care the residents were provided. 6. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed section A, item A1500 indicated to Code 1, yes if PASRR Level II screening determined that the resident has a serious mental illness and/or ID/DD [intellectual disability/developmental disability] or related condition and section O revealed item O0110 K1 Hospice Care Code residents identified as being in a hospice program for terminally ill persons where an array of services was provided for the palliation and management of terminal illness and related conditions. The hospice must be licensed by the state as a hospice provider and/or certified under the Medicare program as a hospice provider.

Based on observation, interview, record review, and policy review, the provider failed to ensure residents' care plans (a personalized plan addressing a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for one of two sampled residents (3) who had a suprapubic catheter (a thin, flexible tube inserted directly into the urinary bladder through a small incision in the lower abdomen), and for one of two sampled residents (6) who had a wound on his buttocks. Findings include:1. Interview on 8/25/26 at 9:02 a.m. with resident 3 revealed he had a catheter coming from his stomach. He had the catheter for approximately four months because he had to urinate every hour of the day before he had the catheter put in.2. Review of resident 3's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 6/5/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact. His diagnoses included amyotrophic lateral sclerosis (ALS) (a disease or motor neuron disease, a progressive neurodegenerative disorder affecting the brain and spinal cord), retention (inability to empty the bladder) of urine, and benign prostatic hyperplasia (BPH) with lower urinary tract symptoms (an enlarged prostate that makes it harder to urinate).His undated care plan indicated that he had an indwelling catheter that needed to be anchored to prevent tension for urethral tears, erosion, or dislodging. The staff was to provide catheter care every shift. The goals for resident 3 were to have no indication of pain, urethral erosion, or other significant complications associated with an indwelling catheter.He had a 6/5/26 physician's order for a suprapubic catheter, and a 8/26/26 physician's order for the suprapubic catheter site to be cleaned with wound cleanser and a T-sponge (a medical sponge used to absorb fluids and protect tissues) to be applied daily and as needed (PRN). 3. Observation on 8/26/26 at 2:23 p.m. with licensed practical nurse (LPN) F while she completed resident 6's wound care revealed she performed hand hygiene (the practice of cleaning your hands with soap and water or alcohol-based hand rub) and applied a gown and gloves. She transferred resident 6 using a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) from his wheelchair to the toilet in his bathroom. LPN F removed the soiled wound dressing and cleansed the area with wound cleanser. The area was allowed to air dry. Her gloves were changed, and hand hygiene was performed. She applied Medihoney (a medical-grade wound dressing made from Active Leptospermum (Manuka) honey) and then applied a bordered gauze dressing to each buttock and dated them using a black permanent marker.4. Review of resident 6's EMR revealed that he admitted to the facility on [DATE]. His 6/9/26 BIMS assessment score was 14, which indicated his cognition was intact. His diagnoses included BPH without lower urinary tract symptoms, malignant neoplasm of the bladder (bladder cancer), memory deficit, weakness, extended spectrum beta lactamase (ESBL) (are enzymes made by certain bacteria that break down and resist many common antibiotics, making infections harder to treat), reduced mobility, pyogenic arthritis (septic arthritis, a serious infection in a joint caused primarily by bacteria), spinal stenosis, and polyneuropathy (a type of peripheral neuropathy where multiple peripheral nerves across the body are damaged).His undated care plan indicated that he had the potential for skin impairment. There was no documentation of a wound to his buttocks or interventions for repositioning assistance by the staff documented on his care plan. His orders indicated his dressing to his buttocks was to be completed daily for excoriation (a scratch or abrasions to the skin).5. Interview on 8/26/26 at 3:16 p.m. with LPN F revealed that the facility did not have an order to provide catheter care on the treatment administration record. Nurses were expected to complete this care for his suprapubic catheter. The nurses would not know to complete the catheter care if the order was not on the TAR. 6. Observation on 8/26/26 at 3:19 p.m. revealed LPN F and certified nursing assistant (CNA) M completed resident 3's catheter care. 7. Interview on 8/27/26 at 8:09 a.m. with CNA H revealed she used the Kardex (a report of the resident's care needs and interventions) to know how to take care of her assigned residents. If the information was not on the Kardex, she would not know how to take care of her assigned residents. If the information was not on the Kardex, she would not know the necessary care for the resident. She expected the resident's care plan to specify what kind of catheter a resident had because different types of care were necessary for each. She confirmed by looking at the kardex that resident 3's kardex did not indicate his catheter type. She stated that resident 6 was able to reposition himself in small adjustments, but he did need one staff member's assistance to completely offload his weight from his buttocks. The staff did not document repositioning or when it occurred, but they repositioned him about every two hours and whenever he requested additional assistance with position changes. She would find the information on when and how to reposition residents, what pressure-relieving cushions were used, and if the resident was incontinent (involuntary urine or bowel leakage) or wore incontinent supplies in the kardex.8. Interview on 8/27/26 at 11:53 a.m. with LPN F revealed that she expected the staff to use the Kardex to know how to take care of the residents. The charge nurse or interdisciplinary team updated the resident's care plans as needed. The nurses were responsible for obtaining a physician's order for a resident's catheter care to change the T-sponge and assess the catheter insertion site. If the information was not included in the resident's care plan, the staff would have to ask a nurse, and then it could be updated. She expected the catheter type to be in the care plan since the type of care varies. She expected the order for the catheter cleaning to be in the resident's treatment administration record (TAR) for the nurses to complete. There was no documentation that resident 3's suprapubic foley catheter care was completed since his admission, as nothing was documented and the order was obtained on 8/26/26.Resident 6 was repositioned every two hours and when he requested additional assistance to change positions. He was able to reposition himself enough to have changes in circulation but would need one staff member to assist him to fully reposition off of his buttocks. The staff did not document when a resident was repositioned. She expected wounds, pressure-relieving cushions, continence, incontinence, and incontinent products used to be on the kardex. Specific wound cares were documented on the TAR.9. Interview on 8/27/26 at 12:30 p.m. with DON B revealed she expected the staff to use the Kardex. She said, Everything they need to know is in the Kardex. The nursing staff and management team updated the care plans. She said that if there was no individual information to the resident, she would expect the CNAs to use the standard of care they learn in CNA training and their education to care for the resident. She would expect the care plan to identify the specific catheter type used by the residents, as they require different care. She said the standard of care is that the residents within the facility are repositioned every two hours, but the staff do not document when that is completed. She would expect generalized wound information, the cushions used to offload residents, repositioning, catheter cleaning, and skin concerns to be in the residents' care plan. Specific wound treatments would be on the TAR.Interview on 8/27/26 at 12:30 p.m. with director of nursing (DON) B revealed she expected the staff to use the Kardex. She said, Everything they need to know is in the Kardex. The nursing staff and management team updated the care plans. She said that if there was no information individualized to the resident, she expected the CNAs to use the standard of care they learned in the CNA training and their education to care for the resident. She expected the care plan to identify the specific catheter type used by the residents, as they require different care. She said the standard of care was that the residents within the facility were repositioned every two hours, but the staff did not document when that was completed. She expected generalized wound information, the cushions used to offload residents, repositioning, catheter cleaning, and skin concerns to be in the residents' care plan. Specific wound treatments were documented on the resident's TAR.10. Review of the provider's 1/9/26 Policy 8.1 Evaluations, Re-Evaluations, and Plan of Care policy revealed Scope of evaluations include case history, prior level of function, determination of medical necessity, onset of functional decline, as well as contraindications and precautions. Clinicians will determine and implement a plan of treatment consistent with current best practices in the field of rehabilitation, in collaboration with the patient and family. This should be documented in the plan of care.11. Review of the provider's October 2025 CMS (Centers for Medicare & Medicaid Services) RAI (Resident Assessment Instrument, a standardized tool used in long-term care to evaluate residents' strengths, needs, and overall status) version 3.0 Manual Chapter 4 CAA (Care Area Assessment) Process and Care Planning policy revealed the comprehensive care plan is an interdisciplinary communication tool. It must include measurable objectives and time frames and must describe services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. The care plan must be reviewed and revised periodically, and the services provided or arranged must be consistent with each resident's written plan of care.

Based on observations and interviews, the provider failed to ensure that the daily posted nurse staffing information was updated each shift to reflect the current date. Findings included:Observation on 8/25/26 at 1:57 p.m. showed that the posted daily nurse staffing sheet at the South nursing station displayed the previous day's date, 8/24/26.Observation on 8/25/26 at 4:14 p.m. showed the posted staffing sheet updated to 8/25/26.Observations on 8/26/26 at 9:41 a.m. showed that the same staffing sheet from 8/25/26 remained posted and was not updated at the beginning of the shift.Observation on 8/27/26 at 11:43 a.m. showed that the same staffing sheet from 8/25/26 remained posted and was not updated at the beginning of the shift.Interview on 8/25/26 at 2:01 p.m. with registered nurse (RN) E stated that the night shift nurse was responsible for completing and posting the staffing sheet for the following day and that business office manager (BOM) G updated the sheet when schedule changes occurred.Interview on 8/25/26 at 2:06 p.m. with BOM G confirmed that the night shift nurse was responsible for updating and posting the staffing sheet.Interview on 8/27/26 at 11:46 a.m. with licensed practical nurse (LPN) F stated that the night shift staff posted the staffing sheet for the next day.The Daily Nurse staff posting policy was requested on 8/27/26, and it was not provided by the end of the survey.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, record review, interview, observation, and policy review, the provider failed to ensure two of two registered nurses (social services director D and interim director of nursing B) initiated cardiopulmonary resuscitation (CPR) (a life-sustaining measure) for one of one resident (1) who was found unresponsive. The resident was designated as a Full Code/Full treatment (receive all life-saving interventions, such as CPR, defibrillation, intubation, and mechanical ventilation, in the event of a medical emergency). She was found in her bed at approximately 8:24 a.m. and appeared to be pale (light shade of color) and ashen (gray) in color, cool to the touch, with no visible movement, and without a pulse. The resident had passed away. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incident.Findings Include: 1. Review of the provider's [DATE] submitted FRI to the SD DOH revealed on [DATE] at approximately 8:24 a.m., certified nursing assistant (CNA) H, social services director (SSD) D, and interim director of nursing (IDON) B did not follow facility's CPR policy and did not initiate life-sustaining measures for resident 1 when she was found unresponsive. The resident was deceased as of [DATE] at 8:30 a.m.On [DATE] at approximately 8:24 a.m., CNA H called for assistance to resident 1's room. SSD D responded immediately and upon her arrival she found the resident in her bed, and appeared pale, ashen, cool to the touch, and had no visible movement. The resident had no blood pressure, pulse, or respirations. A significant amount of blood was observed on the resident's bed linens. IDON B and licensed practical nurse (LPN) E reported to resident 1's room after SSD D.At 8:26 a.m., SSD D attempted to contact certified nurse practitioner (CNP) G but was unable to speak directly with her.At 8:28 a.m., SSD D called medical director (MD) F to inform him of resident 1's passing.At 8:30 a.m. CNP G arrived at the facility and assessed resident 1 and confirmed the resident was deceased . CNP G indicated that the resident's cause of death was likely uterine hemorrhage (excessive or abnormal bleeding from the uterus) followed by cardiac arrest (heart suddenly and unexpectedly stops beating due to an electrical malfunction). SSD D and CNP G notified resident 1's family that she had passed away.The FRI had indicated that resident 1 was diagnosed with cervical cancer, suspected to be stage IV (more advanced stage) with possible liver metastasis (metastatic liver cancer), and presented with post-menopausal bleeding that was experienced for several months prior to admission on [DATE].Resident 1 was a full code/full treatment status, but no life-sustaining measures had been initiated from the immediate staff upon their arrival and finding the resident unresponsive.SSD D and IDON B were suspended pending the full investigation.Immediate education was provided for all staff on CPR procedures and proper use of the code status binder (the binder that had a list of all residents who resided in the facility, that indicated their code status) that was readily available for all staff to view.The FRI indicated that resident 1 was assessed at 4:00 a.m. by the night nurse. The FRI did not include any additional information about why the night nurse assessed the resident, or the results of that assessment.Interview on [DATE] at 3:05 p.m. with administrator A revealed resident 1 was not assessed at 4:00 a.m. as the initial FRI had indicated. The night nurse had observed resident 1 in her bed at that time while the nurse administered medications to another resident whose room was close to resident 1's room.2. Review of resident 1's electronic medical record (EMR) revealed her Brief Mental Status (BIMS) score was 15, which indicated she was cognitively intact. She was admitted to the facility with a diagnoses of chronic kidney disease (CKD), peripheral vascular disease (narrowed or blocked arteries), major depressive disorder, morbid (severe) obesity, hypothyroidism, type 2 diabetes, and gastro esophageal reflux disease (chronic condition where the stomach contents flow back into the esophagus).Review of Resident 1's [DATE] care plan revealed she had an advanced directive. The goal was, I will have my desires and wishes followed according to my signed directive. One of the associated interventions read, Staff will understand and follow my healthcare directives.Her CPR/DNR directive dated [DATE] indicated that she was to receive CPR/Full Resuscitative measures in the event of a cardiac arrest (heart attack).A gynecologic oncology report dated [DATE] revealed resident 1 was diagnosed with cervical cancer, possible stage IV (liver metastasis).3. Interview on [DATE] at 11:10 a.m. with CNA I revealed she had not received CPR training. She had worked at the facility as a cook prior to being a CNA and she knew where the code status binder was to tell her if a resident was designated as a DNR or a full code status. She stated she was CPR certified in the past, but her certificate had expired.She planned to take the next CPR class that was offered for staff to become CPR certified. She indicated that in the event of finding an unresponsive resident, she would have called for help and initiated CPR. She pointed out the crash cart (cart with personal protective equipment (PPE) and life-sustaining equipment) located in the clean supply closet.4. Interview on [DATE] at 11:37 a.m. with dietary manager (DM) J revealed when she entered resident 1's room around 8:26 a.m., she noticed the resident appeared to have passed away (died) and was not breathing. She confirmed CPR had not been initiated by SSD D, IDON B, LPN E, or CNA H when she entered the room. She told them that the resident was a full code and had asked them if they needed her to get the resident status binder. SSD D had asked LPN E to get a stethoscope (a device used for listening to a person's heartbeat) for her.She remembered SSD D touching the resident's face and saying, She was a full code too. While still in the resident's room, SSD D called the clinic to speak with CNP G, but she was not available. SSD D then called MD F and informed him of resident 1's passing. SSD D told MD F over the telephone, I am not going to mutilate her body like that.DM J had not started CPR on resident 1, as she felt that if her supervisory staff who were already in the resident's room had not initiated it, then it was not needed. She now knew, after receiving education following the incident with resident 1, to initiate CPR on any resident who is designated to be a full resuscitation.5. Interview on [DATE] at 11:55 a.m. with administrator A revealed there was always a licensed nurse (RN or LPN) on duty at the facility. All licensed nursing staff were CPR certified. CNAs were offered to become CPR certified, but it was not required.SSD D and IDON B had gone through CPR training and were certified in [DATE]. It was her expectation that SSD D and IDON B should have initiated CPR on resident 1 when they found her unresponsive.6. Interview on [DATE] at 1:11 p.m. with CNA H revealed she went to get resident 1's roommate the morning of [DATE] to take her to breakfast in the dining room. Resident 1 was lying in her bed and appeared to have been sleeping. Resident 1 had always gotten herself out of bed in the morning and dressed herself before she propelled herself in her wheelchair down to the dining room. She grabbed resident 1's foot in a shaking manner and asked her if she was going to get up for breakfast. She noticed resident 1's foot was stiff (hard to the touch), so she looked to see if the resident was breathing. That was when she noticed the resident's skin color was gray.She went to SSD D's office and told her that resident 1 was deceased and that she needed her assistance. SSD D and CNA H went back to resident 1's room. There was a very large amount of blood on the resident's bed linens. She remembered SSD D touching the resident 1's face and saying, She was a full code too. She stated, No matter what anyone would have done that day, there was no way of bringing the resident back.7. Phone interview on [DATE] at 1:23 p.m. with SSD D revealed on the morning of [DATE] around 8:24 a.m., CNA H came to SSD D's office door, and she was distraught. She needed help with resident 1.When she entered resident 1's room, the resident was gray, pale, and ashen in color. The resident's left hand was stiff and closed shut (fist position), and a blood clot was in the resident's hand. She could not feel an apical (heart) or femoral (major artery in the groin) pulse on resident 1. The resident was mottled (a blotchy appearance) from her chest on down the rest of her body. There was a large amount of blood on the resident's bed linens and had soaked into the mattress. The resident was wearing an incontinence brief. There was a very large blood clot on the inside of her brief.Resident 1 was considered a full code status, but it was her opinion that the resident had been deceased too long, and life-sustaining measures would not have changed the outcome of her dying. Resident 1 recently had talked to SSD D about changing her code status, but she was wanting to speak with her brother before she changed it.CNP G arrived at resident 1's bedside at approximately 8:30 a.m. and requested for the resident's temperature to be checked. CNP G determined that resident 1 had been deceased for 2-3 hours prior to staff finding her unresponsive.8. Phone interview on [DATE] at 2:15 p.m. with IDON B revealed that on [DATE] at approximately 8:35 a.m. when she entered resident 1's room, the resident had no pulse, was cold, and had dried blood on her fingers. There was so much blood that it saturated the mattress pad.SSD D had informed her that resident 1 was a full code but was beyond resuscitation. She confirmed that SSD D had called CNP G and MD F to inform them of the resident's passing. CNP G arrived at the facility, assessed the resident, and determined that the resident was deceased .9. Review of the provider's implemented Cardiopulmonary Resuscitation (CPR) policy dated [DATE] revealed the policy statement was Centers provide CPR as requested.The procedures included: 1. Licensed nurses (LN) employed by the center have current CPR certification. Acceptable certification is completed using a provider training on the American Heart Association (AHA) or Red Cross.5. A CPR certified licensed nurse is on duty at all times. 6. CPR is not initiated in the following instances: a. Decapitation - Removal of the head. b. CPR would place rescuer in danger, c. Dependent lividity - settling of blood, d. Transection - transverse cut/cut in half, e. Decomposition - state of rotting or decay. 7. CPR is initiated for those residents who: a. Have requested, through advanced directive or POLST/POST/other state approved methods, to have CPR initiated when cardiac or respiratory arrest occurs.9. In the event of a code blue event: a. Staff member identifies a resident with absence of pulse absence of breathing, b. Staff member immediately seeks assistance from a licensed nurse and ask another staff member to announce code blue, c. A staff member is assigned to obtain the [resident's] code status via POLST (state form) from the facility binder, d. The licensed nurse validates the [resident's] code status by reviewing the Advanced Directive or POLST (state form) and following their wishes.10. Review of the provider's implemented Advanced Directive policy dated [DATE] revealed the policy statement read, It is the policy of this facility that residents have the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.*Definitions:- Advance Care Planning: is a process of communication between individuals and their healthcare agents to understand, reflect on, discuss, and plan for future healthcare decisions for a time when individuals are not able to make their own healthcare decisions.- Advance Directive: is a written instruction, such as living will or durable power of attorney for health care, recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care when the individual is incapacitated. An Advance Directive is not a medical order for care but is taken in to account when orders for care are given.*Procedure:- 1. During the admission process, written information is given to the resident/representative regarding the resident's rights to make decisions concerning medical care, including the right to request, refuse, and/or discontinue medical or surgical treatment, to participate in or refuse to participate in experimental research and the right to formulate an advance directive. This includes the right to revoke these decisions at any time.- 2. During the admission process, the facility identifies if the resident has an advance directive or medical orders related to life sustaining treatment. If the resident does, a copy is requested and kept in the resident's medical chart, accessible to the physician and care staff.11. Review of the provider's immediate implemented corrective actions revealed that CPR and Code Status Education was conducted on [DATE] with staff across all departments. The training covered the CPR policy, where to find the crash cart and code status binder, when to start CPR, and when CPR should not be started. Staff who were not present at the facility on [DATE] were provided the education over the phone. A post-test was created to assess the staff's comprehension of the training and policies. Audits included checking the supplies at the crash cart daily, and reviewing licensed nurse's CPR certification to ensure all licensed nurses possessed a current and valid CPR certificate.12. Based on the above information, noncompliance at F678 occurred on [DATE]. Based on the provider's [DATE] implemented corrective action for the deficient practice confirmed on [DATE], the noncompliance is considered past noncompliance.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review, the provider failed to ensure one of one certified nursing assistant (CNA) E transported a resident with the use of the wheelchair pedals according to American Healthcare guidelines implemented by the facility, for one of one resident (1) who developed pain to her right knee, and could not bear weight on her right leg, and was transferred to the hospital emergency department (ED) for further evaluation. Findings include:1. Review of the provider's 10/20/25 submitted FRI to the SD DOH regarding resident 1 revealed on 10/19/25 at approximately 6:30 p.m. CNA E did not follow guidelines for the use of wheelchairs implemented by the facility according to the American Healthcare Association for the resident. She developed pain to her right knee and could not bear weight on her right leg and as a result, she required an evaluation at the hospital's ED for radiographic images (X-ray). The facility did not have a policy that was specifically related to the use of wheelchairs and indicated they follow the American Healthcare guidelines for wheelchair use. This citation is considered past noncompliance based on review of the corrective actions the provider implemented immediately following the incidents. On 10/19/25 at approximately6:30 p.m. resident 1 was self-propelling herself in her w/c following the evening meal. She had foot pedals on the w/c, but the pedals were not in use at the time of the incident. Both foot pedals had been rotated to the sides of the w/c. CNA E had come from behind her w/c and provided assistance by pushing the w/c without using the foot pedals. While pushing resident 1 in the w/c CNA E had turned the corner of the hallway and her right foot had become lodged under the w/c and resulted in the wheelchair's right front wheel rolling over the resident's foot. Resident 1 had yelled Stop after the chair had rolled on top of her right foot and CNA E immediately stopped the w/c. CNA E had offered resident 1 an ice pack following the incident, but the resident had declined the offer. Neither CNA E nor the resident had reported the incident to the nurse. Resident 1 had no concerns following the incident until she had therapy the evening of 10/19/25. During the therapy session, resident 1 could not bear weight on her right leg because of the knee pain. The nurse was notified of the incident that occurred with resident 1 earlier in the evening, and the pain she was having in her right knee. The resident's primary care physician and power of attorney were notified of the incident. Orders were received by the physician to transfer the resident to the ER for further assessment and X-rays. Resident 1 received x-rays while she was the ED and the findings had shown Tri compartment degenerative change (deterioration of cartilage in all three major compartments of the knee joint, medial, lateral, and patellofemoral) with no fractures. Resident 1 was given a knee immobilizer for her right knee and it was to be worn as needed for comfort until the pain in her knee subsides. Resident 1 was able to bear weight on her right leg and transfer with minimal discomfort. She continued to receive physical, occupational, and skilled therapy that had begun when she was first admitted to the facility on [DATE]. On 10/21/25 resident 1 was measured for a manual custom fit w/c. The custom fit w/c would allow the resident to have easier movement and motion. She had been using a wheelchair that belonged to the facility since her admission on [DATE]. On 10/23/25 documentation was provided and revealed interim director of nursing (IDON) B provided one on one training with CNA E prior to her next working shift after the incident that occurred on 10/19/25. CNA E was educated on the process to report any change in condition of residents, wheelchair etiquette, and the use of foot pedals on wheelchairs. She was required and completed additional education on CareFeed (online education) on how staff make themselves aware of the resident, ask the resident for their permission to assist them prior to moving their wheelchair. Stop-Listen-then action to prevent injuries and respect resident rights and dignity. 2. Review of resident 1's electronic medical record (EMR) revealed her Brief Mental Status (BIMS) score was 15, which indicated she was cognitively intact. She was admitted to Prairie View Healthcare Center with a diagnoses of chronic kidney disease (CKD), peripheral vascular disease (narrowed or blocked arteries), major depressive disorder, morbid (severe) obesity, hypothyroidism, type 2 diabetes, and gastro esophageal reflux disease (chronic condition where the stomach contents flow back into the esophagus). Review of resident 1's most updated care plan revealed she used a four-wheel walker and a wheelchair for transfers. Resident 1 had difficulties related to activities of daily living related to CKD, frequent falls prior to admit, morbid obesity evidence-based deconditioning and weakness from recent hospitalization prior to admit. 3. Interview and observation on 11/5/25 at 10:48 a.m. with registered nurse, social services director (RN,SSD) C revealed wheelchair audits were initiated since the incident that occurred on 10/19/25. The audits were initiated on 10/23/25 by administrator A and were completed 3-5 times per week. Resident wheelchairs were noted to have large bags on the back of the wheelchair that were available to put wheelchair pedals in when not being used. 4. Interview and observation on 11/5/25 at 11:02 a.m. with resident 1 revealed she had a w/c with bilateral foot pedals that were attached to the chair. She could have self-propelled herself in her w/c, she turns the pedals to the side of the chair, so they are out of her way. Resident 1 indicated that on 10/20/25 at approximately 6:30 p.m. she was on her way back to her room after having dinner in the dining room . She stated CNA E had come from behind her and pushed her in her w/c. She stated CNA E did not ask her if she wanted help prior to pushing her. She stated as CNA E turned the corner of the hallway, her right foot had bent forward (rolling maneuver) on the floor and then was under the front wheel of the wheelchair. She stated she yelled out stop due to the pain from the wheel of the wheelchair rolling on top of her right foot. She indicated she did not report the incident to the nurse and assumed CNA E would have. She states she was sent to the emergency room at the hospital and received X-rays. She stated there were no fractures found. She was issued an immobilizer to wear on her right knee and leg until the pain subsides. She indicated she does not always wear the immobilizer because she needs help to put it on and stated, I am stubborn and don't want to ask for help but will wear it when they ask me if I want it on.She stated staff usually ask her if she needs a ride, but that day CNA E did not. She received an immobilizer for her right knee to wear as needed. She states she had an order for Tylenol when she is having pain and when she asks for it, she receives it. 5. Interview and observation on 11/5/25 at 11:20 a.m. with resident 2 revealed that nursing staff always asked her if she needed assistance with being pushed in her w/c. She stated she will ask for help to be pushed in her wheelchair but is usually independent with that. The resident had been propelling herself in her room with the use of her w/c and the foot pedals had been in place. 6. Interview on 11/5/25 at 12:02 p.m. with IDON B revealed that she expected that staff stop and listen to the residents and ask them if they wanted help prior to just doing something for them. She stated the most important thing is to make sure the resident is safe and provide them dignity. 7. Interview on 11/5/25 at 1:35 p.m. with CNA F revealed wheelchair safety education was provided on 10/23/25 to all of the staff who work at the facility through Care Feed. There was also a group meeting where staff huddled together to discuss anything that needed to be shared amongst one another, she stated they had signed a form at that time indicating the education on wheelchair safety was received. She indicated that the facility purchased bags to be placed on the resident's wheelchairs for the pedals to be placed into when they are not being used and felt this was very beneficial and the residents really like them. She stated it helped keep track of the resident's wheelchair pedals, especially when a resident who self-propels themselves is not using them. 8. Interview on 11/5/25 at 12:08 p.m. with RN, minimum data set coordinator (MDS) D revealed that the w/c audits will continue 3-5 times per week through 11/26/25. The results will be brought to quality assurance and performance improvement (QAPI) and it will be determined at that time if they need to be continued. She stated that QUAPI is done every month on the last Wednesday of that month. 9. Interview and observation on 11/5/25 at 12:16 p.m. with RN, SSD, C revealed she had developed an audit form to document observations of resident's wheelchair pedals and if they are being used appropriately. She had verified large bags had been purchased for all residents to place on the back of their wheelchairs to be used for foot pedals to be placed in if not being used. 10. Interview on 11/5/25 at 12:41 p.m. with physical therapy assistant ( PTA) revealed the facility works with a company called Nu Motion. An employee from the company came to the facility and measured resident 1 for a manual custom fit wheelchair. 11. Interview on 11/5/25 at 1:58 p.m. with CNA E revealed she believed resident 1 was struggling on 10/22/25 at 6:30 p.m. when she was self-propelling herself in her wheelchair going down the hallway. She stated she had come up from behind the resident's wheelchair and began to push her. She stated when she had turned the corner of the hallway, resident 1 had indicated to stop. CNA E indicated that the resident's care plan looked like she needed help. 12. Interview on 11/5/25 at 2:45 p.m. with administrator A revealed she had completed weekly wheelchair pedal audits 3-5 times per week to verify that all residents being transported in wheelchairs had footrests securely attached and used them correctly to ensure safety and comfort for residents. The audits would be evaluated at the next QUAPI meeting and determined if she will need to continue with the audits. 13. Review of the provider's implemented guidelines associated with the American Healthcare associated correlated to assisted transfer with an assistive device. Preparation steps include:*Check the care plan.*Explain the procedure and ask about resident preferences.*Respect privacy and rights at all times.*Make sure the leg rests are out of the way.*Guidelines for pushing wheelchairs: Communication is key when pushing the wheelchair, and make sure the user is comfortable and secure in the chair.*Be aware of the user's needs and preferences and adjust the wheelchair accordingly. 11. The provider's 10/20/25 implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/5/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing care staff regarding wheelchair safety for locomotion and mobility and safety and comfort for residents, assessments and appropriate documentation of findings, interviews revealed staff understood the education provided regarding those topics, and a review of the provider's follow-up audits revealed substantial compliance. Based on the above information, noncompliance at F689 occurred on 10/20/25. Based on the provider's implemented corrective action for the deficient practice confirmed on 11/5/25, the noncompliance is considered past noncompliance.

Based on observation, interview, record review, and policy review, the provider failed to:*Follow standard food safety practices to ensure one of one kitchen had been cleaned to maintain a sanitary environment to store, prepare, and serve food to residents related to the cleanliness of the food preparation areas.*Follow acceptable food safety practices by not having ensured that food packages were dated when opened and outdated food items were discarded from inventory in one of one observed kitchen related to food items requiring refrigeration.*Properly temp foods to prevent the spread of cross-contamination by one of one observed cook M during one of one meal services.*Ensure the use of a beard net by one of one food and nutrition service (FANS) manager (F).Findings include:1. Observation and interview on 7/21/25 at 3:30 p.m. with FANS manager F in the kitchen revealed:*He was cooking food in a pot on the stove.*He had a short beard and was not wearing a beard net.*He was the acting FANS manager.*FANS manager N had been on leave since June 2025. 2. Observation on 7/21/25 at 3:55 p.m. in the main kitchen revealed:*There were uncovered containers of whipped margarine labeled Keep Refrigerated and peanut butter on the counter near the food serving area.*Two unopened and one partially used one-pound blocks of margarine labeled Refrigerate for best quality, were on a shelf in the rear of the kitchen.-The partially used margarine had an orangish-pink discoloration on two sides. It had not been labeled when it had been opened or with a use-by date.*Four cereal dispensers containing dry cereal, on the shelf near the three-compartment sink, were not labeled with the contents or the date they had been opened, or their use-by date.*Two open bags of dry cereal that were not labeled with the contents or the date they had been opened, or their use-by date.*The food preparation sink contained unidentifiable orange and brown pieces of food and a significant amount of coffee splatter.*A coffee machine with two plastic trays beneath it.-The trays contained at least four wet, stained, crumpled rags and a significant amount of pooled cold coffee that was not absorbed by the rags.*The counters, a white plastic scoop, and other utensils in the utensil tray adjacent to the coffee machine contained coffee splatter.*An approximately eight-inch by four-inch coffee spill was noted on the floor to the left of the coffee machine.*The walk-in refrigerator contained:-At least nine uncovered cups with an orange puree dessert.-At least 20 uncovered cups of a white creamy dessert with what appeared to be chunks of fruit.-Peas dated 7/18 that did not contain a use-by date.-Carrots dated 7/17 that did not contain a use-by date.-Baked beans dated 5/21/25 use by 5/22/25.- BBQ chicken dated 5/21/25 use by 5/23/25.-A cart contained nine plastic pitchers of juice dated 7/16 use by 7/19 and ten open boxes of juice that had not been labeled with their open date, which indicated use within seven days.*On the floor, under the metal shelf, in the walk-in freezer, were two individual frozen waffles and two ice cream cups. 3. Observation on 7/21/25 at 5:05 p.m. in the main dining room revealed:*FANS aide P poured juice from the plastic pitchers dated 7/16 use by 7/19 and the ten open boxes of juice that had not been labeled with their open date, which indicated use within seven days during the meal service.*He served the creamy white and orange desserts to resident at their tables. 4. Observation on 7/21/25 at 5:25 p.m. of FANS manager F in the kitchen serving area revealed he did not wear a beard net while he plated resident meals and placed them on the window ledge to be served. 5. Observation and interview on 7/22/25 at 11:27 a.m. with dietitian O and FANS manager F revealed:*Dietitian O was at the facility once a week.*Dietitian O expected that FANS manager F or any dietary staff with facial hair would wear a beard net during food preparation and serving.-She confirmed that FANS manager F had not been wearing a beard net and she provided him with one.*Dietitian O expected that boxed juice containers would be dated with the date they were opened and discarded within seven days after that.*FANS manager F confirmed that the opened boxed juice on the cart in the walk-in refrigerator had not been dated when opened.*The juice pitchers on the top shelf that appeared to be the same pitchers observed above, contained new labels dated 7/21 use by 7/24.*Dietitian O stated that she followed the food code and that juice prepared from a powdered mix was to be discarded after seven days.*FANS manager F confirmed that the carrots and peas observed in the refrigerator had been discarded, but she thought that the baked beans and BBQ chicken had been prepared and served yesterday (7/21/25) and had been mislabeled with May dates.*There had been no meal substitutions documented in June or July. 6. Observation on 7/23/25 at 11:00 a.m. with cook M and dietician O of the food temperature monitoring of food to be served at the lunch meal revealed:*Cook M took the thermometer from its protective sleeve and, without cleaning the thermometer probe, placed it into a piece of fish.*Cook M took a second thermometer from its protective sleeve and, without cleaning the thermometer probe, placed it into a second piece of fish.*Cook M removed both thermometers from the fish and placed them on the counter with the probes touching the counter. He then placed the first probe back into another piece of fish from the same tray.*Dietician O then assisted cook M with monitoring the temperatures of the vegetables and cleaning the thermometer with an alcohol wipe before and after she used it.*Cook M then removed a thermometer from its protective sleeve, cleaned that probe with an alcohol wipe, and temped the rice. Without cleaning the thermometer probe he temped the potatoes. 7. Interview on 7/23/25 at 2:25 p.m. with dietitian O revealed she:*Expected that cook M would have cleaned the food thermometer before using it, when it became soiled or touched a potentially contaminated surface like the counter, between food items, and when he was finished.*Expected that foods would be labeled to identify the item, when they were opened, and when they needed to be discarded to ensure food safety.*Expected food to be discarded by the use-by date or by the date indicated on the item.*Had been unaware that the margarine items had been left out on the counter and expected them to have been stored as the package indicated.*Confirmed there had been no menu items substituted, and therefore it was unknown if the items in the refrigerator had been mislabeled for May 2025.*She completed weekly walk-throughs of the kitchen and felt that the kitchen had been maintained in a sanitary manner. 8. Review of the provider's 7/21/25 menu revealed:*Oven-fried chicken and mashed potatoes had been served.* BBQ chicken and baked beans had not been on the menu that day or within the past three days. Review of the providers' FANS DAILY INSPECTION logs revealed:*The logs were completed approximately once a week.*On 5/21/25, Food is within use by date guidelines was marked No.*On 6/4/25, Food is within use by date guidelines was marked No.*On 6/11/25, EVERYTHING: Covered, labeled, dated;. (date made/opened and use-by date)? was marked No.*On 6/25/25, EVERYTHING: Covered, labeled, dated;. (date made/opened and use-by date)? was marked No. Review of the Orange Juice Blend Base manufacturer's product label revealed there was no recommendation for a use-by date. Review of the Classic Lemonade Drink Mix manufacturer's product label revealed there was no recommendation for a use-by date. 9. Review of the provider's May 2017 Food Safety and Temperatures policy revealed:*Label, date, cool, and store any left-over food in compliance with the Food Code.*Dispose of all food items according to the time team frames noted in the Food Code.*Dispose of any questionable food items.*Prior to preparing or serving food to residents the food is inspected by the Dietary Supervisor or designate to guarantee that the food is fresh and without any evidence of contamination or spoilage.*The policy did not address the cleaning of the thermometer when temping food items. Review of the provider's March 2018 Food Labeling Reference Guide for Opened Foods policy revealed:*Area, Refrigerator.margarine.*Cooked leftovers.use by date 3 days after original cooking date.*Dry items such as bulk cereal.use by 3 months after opened.*Fruit juice.use by date 7 days after open. Review of the provider's June 2021 Personal Hygiene Standards policy revealed:*For all employees with beards, beer guards are worn. Review of the provider's October 2017 Menus policy revealed:*If any meal served varies from the planned menu the change is posted for the residence and on the posted menu in the kitchen and/or in the substitution log used solely for recording such changes. Review of the provider's March 2025 Food and Nutrition Service Managers job description revealed:*Verifies compliance with both State and Federal standards of participation for long-term care facilities.*Supervises food preparation and service; Verifies high level of food quality and compliance with food service regulations.*Verifies high sanitation standards, Maintains current cleaning schedules.

Based on observation, record review, interview, and policy review, the provider failed to ensure proper infection control practices had been followed for the cleaning and storage of oxygen equipment for two of two sampled residents (21 and 22) who required the use of a Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open).Findings Include:1. Observation and interview on 7/22/25 at 9:59 a.m. with residents 21 and 22 in their shared room revealed:*There were two CPAP machines on the nightstand between the residents' beds.*Resident 21's CPAP mask was attached to the machine by a hose and was on the top of his CPAP machine.*Resident 22's CPAP mask was attached to the machine by a hose and was on her pillow.*They both indicated they had brought their CPAP machines when they were admitted to the facility a couple of weeks ago.*Resident 22 stated prior to moving in she had cleaned their CPAP masks, hoses, and water tanks every day at home with hot water and dish soap and allowed them to air dry.*She had been unable to clean their CPAP masks, hoses, and water tanks at the facility because she could not stand at the sink long enough and did not have any dish soap.*The staff members had assisted her with adding distilled water to the tanks, if they spot that it is low.*She thought the staff did not know that the CPAP machines and masks needed to be cleaned or how to clean them.*She stated she would have known if the staff had cleaned their CPAP masks because she felt they are getting smelly. 2. Review of resident 21's electronic medical record (EMR) revealed:*He was admitted on [DATE].*His diagnoses included obstructive sleep apnea (a chronic condition in which the throat muscles relax during sleep and the airway may become partially or fully blocked) and dementia (a group of symptoms affecting memory, thinking, and social abilities).*His 7/5/25 Brief Interview of Mental Status (BIMS) assessment score was 3, which indicated he was severely cognitively impaired.*A 7/1/25 physicians order APAP (automatic CPap) with settings of 5-20 cm [centimeters of] H2O [water] every night.*There was no documentation in his EMR that indicated his CPAP mask and tubing were being cleaned. 3. Review of resident 22's EMR revealed:*She was admitted on [DATE].*Her diagnoses included obstructive sleep apnea and fracture of the right lower leg.*Her 7/5/25 BIMS assessment score was 14, which indicated she was cognitively intact.*A 7/1/25 physicians order CPap with 8 cm of water nightly every night shift for OSA [obstructive sleep apnea].*There was no documentation in her EMR that indicated her CPAP mask and tubing were being cleaned. 4. Interview on 7/24/25 at 12:10 p.m. with director of nursing (DON) B and administrator A regarding residents 21 and 22's CPAPs revealed:*DON B was aware that residents 21 and 22 had brought their CPAPs with them when they were admitted and that they were using them every night.*DON B expected there would be a nursing order on the residents' treatment administration record (TAR) to ensure that the CPAPs were cleaned daily between uses.*Administrator A and DON B confirmed that residents 21 and 22 did not have that nursing order on their TARs.*Administrator A confirmed that the provider's oxygen use policies did not address the use of CPAPs and that they would follow the manufacturer's instructions for the cleaning of the CPAP machines and masks. 5. Review of the undated ResMed CPAP manufacturer's instructions revealed:*Regularly clean your tubing assembly, water tub and mask to receive optimal therapy and to prevent the growth of germs that can adversely affect your health.*You should clean your device weekly as described. Refer to the mask user guide for detailed instructions on cleaning your mask.*Wash the water tub and air tubing in warm water using only mild detergent.*Rinse the water tub and air tubing thoroughly and allow to dry.*Wipe the exterior of the device with a dry cloth. 6. The provider had not provided cleaning instructions for the CPAP masks. 7. Review of the provider's November 2018 Respiratory Care: Equipment Care and Handling policy revealed it did not address the use or cleaning of CPAP machines or CPAP masks. 8. Review of the provider's December 2017 Guidelines for Administration of Aerosolized Care policy revealed it did not address the use or cleaning of CPAP machines or CPAP masks.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure the resident representative had been notified of an elopement and change in the resident's status for one of one sampled resident (24) with cognitive impairment. The resident was identified as at risk for elopement and had eloped (left the facility grounds without staff knowledge) on 7/4/25.Findings include:1. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed:*On 7/4/25 at 6:57 p.m., resident 24 was found to be at the apartment building across the street.*She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.*The resident had a 5/5/25 contract agreement that the resident would not leave the premises of the facility.-This contract had been signed by resident 24 and social services director (SSD) C. It had not been signed by resident 24's resident representative.*The resident had left the facility without staff awareness on 7/4/25, and that event had not been reported to resident 24's representative or SD DOH until 7/24/25. 2. Review of the facilities' sign-out log revealed on 7/4/25, resident 24 signed out at Noon and returned at 1:00 p.m. That was the only time resident 24 signed out that day. 3. Review of resident 24's Guidelines for Outside Activity contract agreement with the facility revealed:*Resident MUST sign herself out and in each time she leaves the building.*Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.*Resident will remain on facility property when [she] goes outside: will not go up town to any place of business or location w/o [without] family or facility personnel.*Resident [24] will not go to the apartments to the East or North of the facility.*The contract was signed on 5/5/25 by resident 24 and SSD C. 4. Review of resident 24's electronic medical record revealed:*She was admitted on [DATE].*Her diagnoses included anxiety, nicotine dependence, and dementia (a group of symptoms affecting memory, thinking, and social abilities).*Her 4/19/25 Elopement Risk Evaluation indicated that she was an elopement risk; her wandering placed her at significant risk of getting [in] to an unsafe situation, had a history of leaving the center without notifying staff members, and on 4/19/25 she left [a] supervised area to walk around outsid[e].*Her 5/19/25 Brief Interview of Mental Status (BIMS) assessment score was 10, which indicated she was moderately cognitively impaired.*A 2/14/25 Durable Power of Attorney (POA) for Health Care was signed by resident 24, designating her daughter and son as her POAs.-Her POAs had been involved in assisting the resident with making decisions and with signing documents since that time.*Resident 24's POAs were listed as her emergency contact persons. 5. Interview on 7/24/25 at 9:25 a.m. and again at 4:38 p.m. with resident 24's son revealed:*His mother was admitted to the facility after a hospitalization and illness several months ago because she required more assistance and supervision than he or his sister could provide to her at home.*He had been notified in April 2025 when his mother had walked away from an outside group activity at the facility, but he had not been notified when she left the faciity on 7/4/25.*On 7/5/25, while at the facility, he was informed that the board had decided that his mother could come and go from the facility, including on overnight visits, if she signed herself out, that the facility did not need to notify him or his sister when she left the facility, and that the facility was not responsible if something happened after she signed herself out of the facility.*He was unsure who the board members were who had made those decisions.*SSD C made a phone call to her supervisor while he was present in the facility on 7/5/25, to confirm the above information he was told, because he was questioning the decision to change her status at that moment, and he continued to be worried for her safety. 6. Interviews on 7/24/25 between 9:45 a.m. and 10:45 a.m. with staff members S and T, who requested anonymity, revealed:*On 7/4/25, around 7:00 p.m., staff members identified they had not seen resident 24 for some time that day and began looking for her.*Resident 24 was allowed to sign herself out to go outside and smoke, but she was not allowed to leave the facility property.*Resident 24 had not signed out that evening and was not found within the facility or outside the facility in the designated smoking area.*Staff were worried about resident 24's safety because she had not indicated that she was leaving, and it was raining that day.*Resident 24 was found at the apartments next door. Staff encouraged her to return to the facility; however, resident 24 refused to return to the facility.*Resident 24 then went to the shed, behind the facility, and took out her trike [a three-wheeled bicycle] and took off down the street, which was when staff members reported they lost sight of resident 24.*Resident 24 was then seen by one of those staff members about a block away from the facility on that trike.*Charge nurse U had called the supervisors on call that evening while staff members searched for resident 24 and tried to convince the resident to return to the facility.*Staff members S and T were told, Just let her go, not to report the incident, not to document the incident, and not to mention or talk about the incident again by charge nurse U.*Resident 24's son and daughter were her POAs and had not been notified of the resident's elopement.*Resident 24's son had been angry about the incident that had occurred on 7/4/25 and he came to the facility on 7/5/25 to talk to the facility staff about his concerns of his mother's safety. 7. Interview on 7/24/25 at 2:00 p.m. and again at 2:50 p.m. with director of nursing (DON) B, administrator A, and SSD C revealed:*DON B confirmed that resident 24's son and daughter had not been notified of the 7/4/25 incident because it had not been considered an elopement.*Administrator A stated that after reviewing additional documentation, it was determined that the incident on 7/4/25 should have been considered an elopement.*Administrator A expected that resident 24's POA or resident representative would be notified of all elopements or changes in her status. 8. A resident representative rights and notification policy was requested from DON B on 7/24/25 at 12:10 p.m. with referral to the Facility admission Agreement. 9. Review of the provider's June 2020 Facility admission Agreement packet revealed:*A November 2016 Notice of Resident Rights Under Federal Law document indicated:- The resident has the right to formulate an Advance Directive.- The resident has the right to be informed, in advance, of the care furnished.-The resident has the right to be informed of, and participate in his/her treatment, including: The right to be fully informed.participate in the planning process.to be informed I advance of any changes in the plan of care.*The provider's December 2023 Resident Handbook indicated:-The center will abide by any instructions provided in your Advance directive.Health Care Power of Attorney.*There was no information specific regarding notification to a resident's representative of a change in status or of an elopement.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, record review, and policy review, the provider failed to report an elopement in the required timeframe to the SD DOH for one of one sampled resident (24) with cognitive impairment and identified at risk for elopement, who had eloped (left the facility grounds without staff knowledge).Findings include:1. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed:*On 7/4/25 at 6:57 p.m., resident 24 was found to be at the apartment building across the street.*She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.*The resident had a 5/5/25 contract agreement that the resident would not leave the premises of the facility.*The resident had left the facility without staff awareness on 7/4/25, and that event had not been reported to resident 24's representative or SD DOH until 7/24/25.-That was 20 days later. 2. Review of the facilities' sign-out log revealed on 7/4/25, resident 24 signed out at Noon and returned at 1:00 p.m. That was the only time resident 24 signed out that day. 3. Review of resident 24's Guidelines for Outside Activity contract agreement with the facility revealed:*Resident MUST sign herself out and in each time she leaves the building.*Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.*Resident will remain on facility property when [she] goes outside: will not go up town to any place of business or location w/o [without] family or facility personnel.*Resident [24] will not go to the apartments to the East or North of the facility.*The contract was signed on 5/5/25 by resident 24 and social services director D. 4. Interviews on 7/24/25 between 9:45 a.m. and 10:45 a.m. with staff members S and T, who requested anonymity, revealed:*On 7/4/25, around 7:00 p.m., staff members identified that they had not seen resident 24 for some time and began looking for her.*Resident 24 was allowed to sign herself out to go outside and smoke, but she was not allowed to leave the facility property.*Resident 24 had not signed out that evening on 7/4/25 and was not found within the facility or outside in the designated smoking area.*Staff were worried about resident 24's safety because she had not indicated that she was leaving, and it was raining that day.*Resident 24 was found at the apartments next door. Staff encouraged her to return to the facility; however, resident 24 refused to return to the facility.*Resident 24 then went to the shed and took out her trike [a three-wheeled bicycle] and took off down the street, which was when staff members reported they lost sight of resident 24.*Resident 24 was then seen by a staff member about a block away from the facility on that trike.*Registered nurse (RN) U had called the supervisors on call that evening while staff members searched for resident 24 and tried to convince resident 24 to return to the facility.*Staff members S and T were told by LPN U that she had been instructed by the supervisors to just let her go, not to report the incident, not to document the incident, and not to mention or talk about the incident again. 5. Interview on 7/24/25 at 2:00 p.m. and again at 2:50 p.m. with director of nursing (DON) B, administrator A, and social services director (SSD) C revealed:*DON B stated that there was no investigation into resident 24's 7/4/25 incident because it had not been considered an elopement at that time.*Administrator A stated that after reviewing additional documentation, it was determined that the incident on 7/4/25 should have been considered an elopement.*Administrator A expected that all elopements would be reported to the state agency immediately and investigated. She expected the results of any investigation related to a resident's elopement to have been documented and reported to the state agency within five working days.*DON B and Administrator A confirmed that there was no documentation of resident 24's 7/4/25 elopement in her electronic medical record, and there was no investigation documentation from that 7/4/25 elopement. 6. Review of resident 24's electronic medical record revealed:*She was admitted on [DATE].*Her diagnoses included anxiety, nicotine dependence, and dementia (a group of symptoms affecting memory, thinking, and social abilities).*Her 4/19/25 Elopement Risk Evaluation indicated that she was an elopement risk; her wandering placed her at significant risk of getting [in] to an unsafe situation, had a history of leaving the center without notifying staff members, and on 4/19/25 she left [a] supervised area to walk around outsid[e].*Her 5/19/25 Brief Interview of Mental Status (BIMS) assessment score was 10, which indicated she was moderately cognitively impaired. 7. Attempts made to contact RN U by phone were unsuccessful, and she was not available for an interview during the survey. 8. Review of the provider's February 2025 Elopement/Wandering policy revealed:*The resident/patient exits the Center without staff knowledge OR the resident/Patient enters an unsafe area without staff knowledge or presence.*A resident is found in the parking lot of the Center by a staff [member] or visitor without staff knowledge or presence. This is elopement.*A resident exits the front door without staff knowledge or presence. This is elopement.*If [the] resident exhibits exit seeking behavior, the episodes are documented in the resident medical record. Documentation includes interventions used and their effectiveness. Review of the provider's September 2017 Abuse Reporting and Response policy revealed:*The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents.in accordance with state and federal laws.*Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director.*The Executive Director or designee reports alleged violations to the state's survey agency and other officials in accordance with state law.*The Center reports the results of all investigations to the Executive Director and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident.*It had been Updated October 202. It was unknown what year, as the last digit of the date was not present.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to:*Provide adequate supervision for one of one sampled resident (24) during an outside activity by one of one activities assistant L.*Ensure the safety of one of one sampled resident (24) with cognitive impairment, identified at risk for elopement, who had eloped (left the facility grounds without staff knowledge) on 7/4/25. Findings include:1. Review of the 4/19/25 SD DOH FRI regarding resident 24 revealed: *On 4/19/25 at 5:32 p.m. the report had been submitted that indicated resident 24 had eloped from the facility at 2:50 p.m. on 4/19/25. *The resident had told activities assistant L she wanted to see the kids at the easter egg hunt on the other side of the facility. *Resident 24 had walked around to the other side of the facility and was out of staff’s sight. *The resident was found by activities director (AD) V walking around the back side of the facility towards an entrance to the facility. *The resident refused to be assessed or to have her vitals (blood pressure, temperature, pulse, respirations, and oxygen level) taken after returning to the facility. -The resident was assessed an hour later by nursing staff and her vitals were stable. *The on-call physician, family, and the local sheriff were notified of the resident’s elopement. *Resident 24's care plan indicated she needed to be accompanied by family, a responsible party, or a staff member when leaving the facility. 2. Review of resident 24's electronic medical record (EMR) revealed she: *She was admitted on [DATE]. *Her diagnoses included anxiety, nicotine dependence, depression, sepsis (serious condition in which the body responds improperly to an infection), dementia (decline in mental ability that interferes with daily life), and behavioral disturbance (disruptive behaviors). -A Brief Interview for Mental Status assessment (BIMS) completed on 2/12/25 with a score of 10, indicated she was moderately cognitively impaired. *On 2/12/25 she had been assessed and was determined not at risk for elopement. *On admission she had a smoking safety evaluation, and determined she could smoke independently. *She was instructed to only smoke outside in the designated area. - When she would go outside to smoke, she was to sign in a book with her name, date, time of leaving and time of returning. *Prior to 4/19/25, she did not have a history of wandering, exit-seeking, or elopement. 3. Interview on 7/22/25 at 10:00 a.m. with resident 24 revealed: *She reported on 4/19/25 she had walked around to the other side of the building during an outside activity. *She had indicated, she told activities assistant L that she was going to walk around the building. *At that time, she was allowed to be outside with staff supervision. *After she had returned to the facility, she had indicated to staff that she went for a “walkabout” when she had walked around the building. 4. Interview on 7/22/25 at 10:12 a.m. with director of nursing (DON) B, regarding resident 24's 4/19/25 elopement revealed: *The resident had walked around the facility on 4/19/25 at 2:50 p.m. and she was out of sight of staff for only a short amount of time, about 45 seconds. *The resident had returned on her own to the facility without harm. * On 4/19/25 resident 24’s care plan had been updated to reflect she was an elopement risk. *Resident 24’s care plan indicated all exit seeking behaviors must be documented in resident 24’s EMR. *The resident’s care plan indicates an elopement risk will be completed quarterly on her and this was initiated on 4/19/25. 5. Interview on 7/24/25 at 9:30 a.m. with certified medication aide (CMA) Q revealed: *She referred to a pocket care plan staff used to care for the residents. Those included resident cares and information about them. *She had indicated resident 24 was only to be outside with supervision of staff or a responsible person. *She had indicated that on 4/19/25 resident 24 had a BIMS score of 10 and needed staff supervision. 6. Interview on 7/24/25 at 12:24 p.m. with activities director (AD) V revealed: *On 4/19/25 at 2:50 p.m. resident 24 was outside being supervised by activities assistant L. *That day the resident had walked around to the other side of the facility and was out of sight of the staff for only a couple minutes . *A code white (missing resident) was called to inform all staff of a missing resident for them to start looking for her. *Staff then found the resident had been seen by staff walking up the sidewalk next to the building and had come from the opposite side of the facility. 7. Review of the provider's 7/24/25 SD DOH FRI regarding resident 24 revealed: *On 7/4/25 at 6:57 p.m., resident 24 “was found to be at the apartment building across the street.” *”She [resident 24] had signed out of the facility earlier in the day, therefore the incident was not reported.” *The resident had a 5/5/25 contract agreement “that the resident would not leave the premises of the facility.” *The resident had left the facility without staff awareness on 7/4/25, and that event had not been reported to resident 24’s representative or SD DOH until 7/24/25. 8. Review of the facilities’ sign-out log revealed on 7/4/25, resident 24 signed out at “Noon” and returned at 1:00 p.m. That was the only time resident 24 signed out that day. 9. Additional review of resident 24’s electronic medical record revealed: *Her 4/19/25 Elopement Risk Evaluation indicated that she was an elopement risk; her wandering placed her at “significant risk of getting [in] to an unsafe situation, had a history of leaving the center without notifying staff members, and on 4/19/25 she “left [a] supervised area to walk around outsid[e].” *Her 5/19/25 BIMS assessment score was 10, which indicated she was moderately cognitively impaired. *There was no documentation of resident 24’s elopement on 7/4/25 as indicated in the 7/24/25 SD DOH FRI. *There was no documentation of the resident’s exit-seeking or other behaviors or incidents on 7/4/25. *A 7/5/25 BIMS assessment score of 13, which indicated she was cognitively intact. -That BIMS assessment was completed the day after resident 24 left the facility without staff knowledge on 7/4/25. *A 7/20/25 Elopement Risk Evaluation indicated a score of “NA [not applicable]”: -Her cognition was impaired with poor decision-making skills. -She had a history of wandering. -She had a diagnosis of dementia/cognitive impairment. -She had a history of leaving the facility without notifying staff. -She had a substance use disorder. -She had “no reported episodes of wandering in the past 3 months.” -Risks included: “Hospitalization, Fall/Injury/Bone Fracture, Being reported as a missing person/elopement.” -The resident had been educated on signing out and telling a staff member that she was leaving before she left, and the risks associated with leaving the facility.She acknowledged the risks and understood the process of leaving the facility. -She was determined not to be an elopement risk and “allowed to leave facility is signed out/policy [It was unclear what this indicated].” 10. Review of resident 24’s “5/5/25 Guidelines for Outside Activity” contract agreement with the facility revealed: *”Resident MUST sign herself out and in each time she leaves the building.” *”Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.” *”Resident will remain on facility property when [she] goes outside: will not go up town to any place of business or location w/o [without] family or facility personnel.” *”Resident [24] will not go to the apartments to the East or North of the facility.” *The contract was signed on 5/5/25 by resident 24 and social services director C. 11. Review of resident 24’s care plan revealed: *A 5/28/25 problem area indicated “[Resident 24] is dependent on staff for meeting emotional, intellectual, physical, and social needs r/t [related to] Cognitive deficits, Depression, Mood/Behaviors, [and] Physical Limitations.” *A 6/16/25 problem area indicated “[Resident 24] has an alteration in safety r/t: cognitive impairment and being a risk for elopement off the [facility name] Campus.” That was deleted and revised on 7/5/25 to indicate “Resident [24] is her own responsible party.” *A 6/16/25 goal for the above problem area was to “Prevent [resident 24] from risk, including exposure to dangerous environmental factors, increased risk of falls or accidents, and potential for exploitation or abuse.” *A 6/6/25 intervention indicated “[Resident 24] will be accompanied by family, responsible party, or center staff member when leaving the center. Or approved outings by daughter POA [Power of Attorney].” That was deleted and revised on 7/5/25 to indicate “[Resident 24 will be compliant with facility sign [sign] out/sign in process. These are approved outings by [her] daughter POA.” *A 6/16/25 intervention indicated ”If [resident 24] exhibits behavior leaving campus, the episodes are documented in [resident 24’s] medical record. Documentation includes interventions used and their effectiveness.” That was deleted and revised on 7/5/25 to indicate “If [resident 24] exhibits behaviors of not signing B/4 [before] leaving then [the] facility & [and] signing in after returning, the episodes are documented in [resident 24’s] medical record. Documentation includes interventions used and their effectiveness.” *Resident 24’s care plan had been revised on 7/5/25 the day after she left the facility without staff knowledge. 12. Review of resident 24’s “7/6/25 Guidelines for Outside Activity” contract agreement with the facility revealed: *”Resident MUST sign herself out and in each time she leaves the building.” *”Inform Charge Nurse on duty of her going outside & [and] how long she plans to be outside.” *”Resident will notify staff on duty, sign out & [and] back in when [she] goes uptown to any place of business or location on her three wheeled bicycle.” *The contract was signed on 7/5/25 by resident 24 and social services director C. *The contract was signed two days after resident 24 had left the facility without staff knowledge on 7/4/25. 13. Interviews on 7/24/25 between 9:45 a.m. and 10:45 a.m. with staff members S and T, who requested anonymity, revealed: *On Friday, 7/4/25, around 7:00 p.m., staff members identified they had not seen resident 24 for some time that day and began looking for her. *Resident 24 was allowed to sign herself out to go outside and smoke, but she was not allowed to leave the facility property. *Resident 24 had not signed out that evening and was not found within the facility or outside in the designated smoking area. *Staff were worried about resident 24’s safety because she had not indicated that she was leaving, and it was raining that day. *Resident 24 was found at the apartments next door to the facility. Staff encouraged her to return to the facility; however, resident 24 refused to return to the facility. *Resident 24 then went to the shed behind the facility and took out her “trike” [a three-wheeled bicycle] and “took off down the street,” which was when staff members reported they lost sight of resident 24. *Resident 24 was then seen by one of those staff members about a block away from the facility on that trike. *The charge nurse had called the supervisors on call that evening while they searched for resident 24 and tried to convince the resident to return to the facility. *Staff members S and T were told by the charge nurse, “Just let her go,” not to report the incident, not to document the incident, and not to mention or talk about the incident again. *Staff members S and T knew resident 24 was allowed to “sign out” to smoke independently in the designated smoking area, but she was not to leave the facility property that day unsupervised because it was part of a posted outside activity agreement for resident 24, and the resident had not been care planned to leave the facility independently. 14. Interview on 7/24/25 at 9:25 a.m. and again at 4:38 p.m. with resident 24’s son revealed: *His mother was admitted to the facility after a hospitalization and illness several months ago because she required more assistance and supervision than he or his sister could provide for her at home. *He had been notified in April 2025 when his mother had walked away from an outside group activity at the facility, but he had not been notified when she left the faciity on 7/4/25. *On 7/5/25, while at the facility, he was informed that the “board” had decided that his mother could “come and go” from the facility, including on overnight visits, if she signed herself out, that the facility did not need to notify him or his sister when she left the facility, and that the facility was not responsible if something happened after she signed herself out of the *He was unsure who the “board” members were who had made those decisions. *Social services director (SSD) C made a phone call to her supervisor while he was present at the facility on 7/5/25, to confirm the above information he was told, because he was questioning the decision to “change her status at that moment,” and he continued to be worried for her safety. 15. Interview and review of resident 24’s occupational therapy records on 7/24/25 at 3:58 p.m. with director of rehabilitation R regarding resident 24’s participation in therapy revealed: *Resident 24 received occupational therapy services from 6/5/25 through 7/23/25. *Her occupational therapy evaluation included assessing her safety with the use of an adult tricycle on facility grounds and in the community. *On 7/23/25, resident 24 was discharged from occupational therapy with the recommendation “not realistic for off campus due to safety concerns of use with traffic. Can use on campus.” *The occupational therapy assistant who completed the safety assessment was on leave and unavailable for interview. 16. Interview on 7/24/25 at 2:00 p.m. and again at 2:50 p.m. with director of nursing (DON) B, administrator A, and social services director (SSD) C revealed: *DON B stated there was no documentation or investigation of resident 24’s 7/4/25 “incident” because it had not been considered an elopement. *Administrator A stated after reviewing additional documentation, it was determined that the “incident” on 7/4/25 should have been considered an elopement as the resident had left the facility without the staff’s knowledge or supervision. *Administrator A had not been aware of the ”Guidelines for Outside Activity” contracts that had been made with resident 24 on 5/5/25 before the incident on 7/4/25 and again on 7/6/25 after the incident occurred on 7/4/25. *Administrator A was surprised that resident 24 had a BIMS assessment score of 10 before the incident on 7/4/25 and had been reassessed to have a BIMS of 13 “magically” on 7/5/25. *SSD C confirmed she had completed resident 24’s 7/5/25 BIMS assessment, had updated the outside activity contract, and updated resident 24’s care plan to reflect the new agreement. *SSD C stated that resident 24’s family had not been involved in the development of the contract but had agreed with it on 7/5/25. -Those documents had been updated after the incident on 7/4/25. *Administrator A expected that all elopements would be reported to the state agency and investigated for potential abuse, neglect, or additional interventions. She expected the results of any investigation related to a resident's elopement to have been documented and reported to the state agency. *DON B and Administrator A confirmed there was no documentation of resident 24’s 7/4/25 elopement in her electronic medical record, and there was no investigation documentation from that 7/4/25 elopement. *DON B was unaware of occupational therapy’s 7/23/25 discharge recommendation that resident 24 was assessed as unsafe for off-campus use of her trike due to safety concerns. 17. Review of the provider’s February 2025 Elopement/Wandering policy revealed: *”The Center evaluates residents for wandering and/or exit seeking behavior and implements appropriate interventions as indicated via the evaluation process.” *”The resident/patient exits the Center without staff knowledge OR the resident/Patient enters an unsafe area without staff knowledge or presence.” *”A resident is found in the parking lot of the Center by a staff [member] or visitor without staff knowledge or presence. This is elopement.” *”A resident exits the front door without staff knowledge or presence. This is elopement.” “Residents deemed at risk to elope…are accompanied by family, responsible party, or a center staff member when leaving the center for appointments… are ai eyesight when on center sponsored outings. If staff are unable to keep the resident in line of sight, the resident is accompanied by a staff member assuring resident safety.” *” Recurrent evaluations are completed quarterly for those at risk to elope… with [a] change in condition and following elopement events. The care plan is reviewed and updated as appropriate.” *”If [a] resident exhibits exit seeking behavior, the episodes are documented in the resident's medical record. Documentation includes interventions used and their effectiveness.” Review of the provider’s June 2020 Facility admission Agreement packet revealed: “Your stay begins with a complete assessment of cognitive and physical health so that your care team may provide you with comprehensive attention specific to the care you need.” *”Care plans are individualized for every patient based on their diagnosis and needs. The goal is to maximize each patient’s functional abilities…your needs and the risks associated with them change over time, and we review your plan of care regularly to make sure it continues to meet your needs.”

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review, the provider failed to ensure one of one sampled resident (29) was safely transferred out of the facility van while using the hydraulic wheelchair lift, which resulted in the resident sustaining injuries. Findings include: 1. Review of the provider's submitted SD DOH FRI revealed: *On 5/22/24 at around 5:15 p.m., resident 29 was transferred to the facility from the emergency room (ER) via the facility van. *Certified nurse aide (CNA) L instructed the resident several times to keep his arms folded in and on his lap prior to attempting [to] transfer out of the can using the [wheelchair] lift. *CNA L positioned herself on the ramp with the resident. *The wheelchair lift was still in the process of lowering to the ground when resident 29 reached out to grab onto the bar of the lift causing the platform to move which caused [CNA L] and [resident 29] to tip backwards over the lift. *CNA L immediately called for help, and a charge nurse and the nurse manager came outside to assist. *Vitals were taken. Range of motion was within normal limits for the resident. -While at the ER, he was diagnosed with a urinary tract infection and had been experiencing a decline in cognition. *Resident 29 reported pain in his right flank [his hip area]. *An abrasion was noted on the back on his head, and his right flank was reddened. *His care plan was updated to have at least two staff assist during transfers using the van wheelchair lift. 2. Interview and observation on 6/4/24 at 9:58 a.m. with resident 29 while in his room revealed: *He had arthritis and multiple sclerosis (MS). *He briefly mentioned about his recent fall off the van and explained the van buckled underneath him. -He fell , his wheelchair fell , and the staff fell . *His right hip was hurt, and he sustained two abrasions on his head. *His pointed out that his right wheelchair arm was bent. He stated that was because of the fall. Continued interview on 6/4/24 at 4:27 p.m. with resident 29 about his accident revealed: *He stated he was not taken back to the ER after his fall until about three or four days afterwards due to him having a lot of pain in his right hip. *He could not remember the results of his X-rays. *He talked about his upcoming orthopedic appointment to address his hip pain. *When describing the accident, he stated: -He was wheeled onto the ramp facing the van rather than facing out towards the parking lot. -He believed that something might not have been clipped into place. -He fell backward, his wheelchair fell on top of him, and the arm was bent, then the aide fell on top of both him and his wheelchair. *The resident explained he was still experiencing pain in his right hip, and he showed healing scabs on his head. -He explained he did not require stitches. -There were two scabs on his head. One scab on the back of his head was approximately 1 centimeter (cm) by 2cm, and another scab on the right side of his head was approximately the same size. 3. Observation and interview on 6/6/24 at 8:13 a.m. with maintenance director M revealed he: *Demonstrated how the van wheelchair lift operated. *Confirmed the lift was in good working condition at the time of the accident. 4. Observation and interview on 6/6/24 at 8:30 a.m. with director of nursing services (DNS) B and CNA L revealed: *CNA L transferred resident 29 to the ER via the facility van on 5/22/24 due to reports of nausea, vomiting, decreased appetite, diminished lung sounds, and difficulty breathing through his nose. *He was diagnosed with a UTI at the ER. *When CNA L brought him back to the facility, she noted he was acting confused and grabbing at random objects. *She wheeled him onto the wheelchair lift. He was facing the van's interior, with his back towards the outside. *She confirmed she had not locked his wheelchair wheels. *Resident 29 was trying to stand up from his wheelchair to grab at the lift frame rather than the lift handrails. *She confirmed the lift was partway in the air at the time he started to stand up and was approximately 1.5 to 2 feet off the ground. *With the lift remote still in her hand, she climbed onto the lift with the resident to try to calm him down and have him sit in his chair. *During that process, resident 29 flopped back down into his wheelchair. The momentum of the resident sitting back down caused him to tip backward off the wheelchair lift. -The lift was still lowering to the ground at that time. *The wheelchair landed on top of him. *She confirmed she also fell off the lift, on top of the resident and his wheelchair. *She immediately phoned for help. *Staff assessed him upon arrival and assisted him back to his wheelchair. 5. Interview on 6/6/24 at 10:20 a.m. with DNS B and Minimum Data Set (MDS) Coordinator N about resident 29's accident revealed: *DNS B confirmed that CNA L should have locked the resident's wheelchair before lowering the wheelchair lift. *She confirmed it was not normal procedure to have the staff on the wheelchair lift with a resident as the lift was moving. 6. Review of resident 29's current care plan revealed: *A problem area of [Resident 29] is High risk for falls r/t [related to] Gait/balance problems, MS dx [diagnosis], hx [history] of fall. Date initiated 3/4/24, revised on 3/12/24. *The associated interventions were as follows: -5/23/24- assist x2 for all transfers via facility van. Date initiated 5/23/24. -anti rollback wheelchair. Date initiated 5/22/24. -Cue and supervise as needed. Date initiated 3/12/24. -Educate the resident /family/caregivers about safety reminders and what to do if a fall occurs. Date initiated 3/4/24. -Follow facility fall protocol. Date initiated 3/4/24. -OT [occupational therapy] to evaluate and treat as ordered and PRN. Date initiated 3/4/24. -Pt [physical therapy] evaluate and treat as ordered or PRN. Date initiated 3/4/24. 7. Review of resident 29's progress notes revealed: *A nurse's Alert Charting: Fall/Accident/Injury progress note from 5/22/24 at 5:15 p.m. read in part: -Staff took [resident 29] to ER and had some difficulty having [him] keep hands in lap when using ramp to elevate [his] WC [wheelchair] into the facility van; Staff instructed Pt [patient] multiple times to keep hands in lap however Pt kept grabbing at multiple structures in reach. -On return from ER Pt was being wheeled onto ramp and continued to grab at different structures despite instruction to keep hands in lap. -Staff then got on ramp with Pt to assist in keeping Pt safe while ramp was lowering from back of van when ramp was approximately 2 feet off ground, Pt again grabbed at bar causing a wobble that tipped staff and Pt backwards over the lip of the ramp with ramp remote in staff hand. -Staff moved immediately to move Pt to safe position and removed wheelchair from where it had tipped onto Pt; Pt moved around on ramp attempting to grab bar and staff immediately called for assistance from nurses inside. -On arrival, Pt laying on platform with legs over side on ground, WC had been moved out of the way, staff was seated with Pt. -Pt states: 'We flipped off the ramp.' -Nurses immediately assess for injury and obtain vitals . -Pt reports being uncomfortable with lip of ramp at buttock. Nurses attempt to move Pt to a position to allow further assessment and have some difficulty when giving Pt directions to let go of bars of ramp as Pt kept putting hands back on bars and not letting go when asked to keep hands in lap. -It took multiple repetitions and gently disengaging Pt's hands from bar and returning them to Pt's lap so nursing able to position Pt. -Note 1.3cm abrasion to back of head. Note redness to right flank. -Nurse called out to Pt's niece [name redacted] to update on fall and on new order for antibiotic for UTI. -[Resident 29's physician] updated via fax. -Future transportation via van to have 2 staff for safety. -Pt's niece [name redacted] reports Pt has history of difficulty following instructions due to cognition at previous facility. *A nursing progress note from 5/23/24 at 3:05 p.m. indicated resident 29 was able to move all his extremities per his normal and continued to have a small lump of the back of head from the fall. *A nursing progress note from 5/29/24 at 10:20 a.m. read, Pt reporting increased bilateral hip pain rated 7/10 and reports increased difficulty standing self and transferring . Nurse called out to clinic to update and request instructions regarding this issue. Awaiting response. *An appointment progress note from 5/30/24 at 10:44 a.m. read, Res [resident] went to the [local clinic name] and had x-rays performed on bilateral hips, res was transported by staff in the company van, res returned to facility in same condition as leaving, x-ray results pending. *A follow-up appointment progress note from 5/31/24 at 2:02 p.m. indicated that resident 29 had significant arthritis and the clinic provider recommended a referral to orthopedics. 8. Review of resident 29's medical diagnoses revealed he had multiple sclerosis. 9. Review of resident 29's current physician's orders revealed he was prescribed the following pain medications: *Acetaminophen Oral Tablet 325 MG [milligrams]. Give 2 tablet by mouth every 4 hours as needed for pain, ordered on 4/8/24. *Acetaminophen Oral Tablet 500 MG, Give 2 tablet by mouth three times a day for Pain Do not exceed 3000 mg/24 hrs [hours], ordered on 3/4/24. *Diclofenac Sodium External Gel 1 %, ordered on 3/4/24. *Gabapentin Oral Capsule 100 MG, Give 2 capsule by mouth three times a day for increased leg pain 200mg TID [three times a day], ordered on 4/3/24. *Tramadol HCl [hydrochloride] Oral Tablet 50 MG, Give 1 tablet by mouth every 12 hours as needed for Pain, ordered on 4/12/24. 10. Review of resident 29's May 2024 medication administration record (MAR) revealed: *He was administered the scheduled doses of acetaminophen, gabapentin, and diclofenac gel as ordered. *He was administered a PRN (as needed) dose of acetaminophen on 5/23/24 at 12:57 a.m. with a pain level of 4/10 on a 0-10 pain scale. *He was administered a PRN dose of tramadol on 5/23/24 at 5:10 a.m., and again on 5/30/24 at 8:00 a.m. with a pain level of 4/10 on a 0-10 pain scale on both occasions. 11. Review of resident 29's June 2024 MAR through 6/6/24 revealed: *He was administered the scheduled doses of acetaminophen, gabapentin, and diclofenac gel as ordered. *He did not receive any PRN doses of acetaminophen. *He received a PRN dose of tramadol on 6/1/24 at 7:25 a.m. with a pain level of 5/10, and on 6/5/24 at 2:49 a.m. with a pain level of 2/10 on a 0-10 pain scale. 12. Review of resident 29's May and June 2024 treatment administration record (TAR) revealed: *Monitor abrasion to back of head until resolved. every shift. Start date 5/23/24. -The documentation indicated that the area was marked as monitored twice per day from 5/23/24 to 6/5/24. *Monitor redness to right flank every shift until resolved. every shift. Start date 5/23/24. -The documentation indicated that the area was marked as monitored twice per day from 5/23/24 to 6/5/24. 13. Review of resident 29's electronic and paper medical record revealed there was no evidence of wound or skin assessments regarding his abrasions. 14. Review of the Operator's Manual for the type of wheelchair hydraulic lift used by the provider revealed: *The manual was for the NL Millennium 2 Public Use Wheelchair Lift made by The [NAME] Corporation. *Page 4 included a diagram of the lift. The inboard direction was towards the van. The outboard direction was towards the outside. The pump side vertical arm was the area the resident was attempting to hold onto rather than the handrails. *Page 11 included several warnings, including Whenever a wheelchair passenger .is on the platform, the .wheelchair brakes must be locked, the passenger should grip both handrails (if able). *Page 12 included additional warnings, .Stop and brake wheelchair when loading onto the platform (manually stop and brake manual wheelchairs .). *Page 13 included additional warnings, Failure to follow these safety precautions may result in serious bodily injury . *Page 21 included a note about the handrails, Dual handrails are provided for wheelchair passenger .use.If able, passengers should grip both handrails when on the lift platform . *Page 22 included several notes about the lift attendant: -If you are an attendant operating the lift, it is your responsibility to perform safe loading and unloading procedures. -The lift operator .must keep clear of the area in which the lift operates. -The lift attendant should not ride on the platform with the passenger. *Page 22 included recommendations on positioning the passenger on the lift: -[NAME] NL-2 Series wheelchair lifts accommodate both inboard and outboard facing wheelchair passengers or standees. -Inboard facing of wheelchair lift passengers is not prohibited, but outboard facing of passengers is recommended by The [NAME] Corporation. *Page 24 included additional notes about ensuring the wheelchair brakes were locked prior to operating the lift. *Page 26 included a section about preventative maintenance: -General preventative lift maintenance consisting of careful inspections of the list system and cleaning the lift should be a part of your transit agency's daily lift service program. *Pages 28 and 30 included Lift Operating Instructions with pictures. There was a warning again to Load passenger onto platform and lock wheelchair brakes. 15. Review of the provider's Work History Report on the van for the past 12 months revealed: *The Vehicle Inspection: Safety Inspection was marked as completed each month. *On 6/30/23, a note read, Will schedule van for service. Needs new air filter and coolant topped off. *On 12/31/23, a note read, Van out for repairs. Will inspect upon return. *On 1/31/24, a note read, Van is out for repairs. Will inspect when it gets back before any resident transport. *On 4/30/24, a note read, Vehicle is out for service and repairs. Will inspect it when it gets back before next transport. 16. Review of the provider's documentation on their most recent wheelchair lift service revealed: *The van wheelchair lift was last serviced in December 2023. -The service estimate was printed on 12/4/23 and the invoice was printed on 12/28/23. *A multipoint vehicle inspection was completed. *A chief concern on the invoice read, The lift drops as soon as it is deployed, deemed unsafe for use. Diagnose and advise. -Cause: Found Hydraulics worn and leaking. -Correction: Removed and replaced lift cylinders, cylinder flap and gas springs. Verified repair. *The repair service indicated on the report that they performed service on the ramp & door. The service includes checking/ cleaning the vehicle's battery, battery terminals, ramp fasteners, and hardware for tightness - lubricating hinges, pinot points, door slides, and rollers.

Based on observation, interview, record review, and policy review, the provider failed to ensure necessary food safety guidelines were implemented and followed for appropriate storage and labeling of food items and for cleaning and sanitary maintenance of one of one kitchen and one of two kitchenettes. Findings include: 1. Observation on [DATE] from 2:43 p.m. to 3:38 p.m. during the initial kitchen tour revealed: *The water dispenser and ice machine in the dining room had a buildup of limescale in and around the machine, the metal grate was visibly rusty, and there was an unidentified black substance buildup in the catch tray. The machine was dripping water. *There were wooden storage cabinets in the dining room which contained the following outdated food items: -One bottle of caramel sauce with a Best if used by date of 15 [DATE], and an opened date of ,d+[DATE]. -A jar of instant coffee with a Sell by [DATE] . The year on the jar was smudged and appeared to have been either 2021 or 2024. -A shaker of Mrs. Dash brand seasoning with a Best by date of [DATE]. *In the service window area of the kitchen: -There was dust, food crumbs, and hair visible in the plate warmer drawers. -The storage area beneath the sink was stained with visible white and yellow residue. -There was a buildup of dust, garbage, and food crumbs beneath the serving equipment. -There was a visible burnt substance, food crumbs, and dust in the napkin dispenser. -The storage area beneath the cold holding table was scattered with food crumbs and garbage wrappers. *The ceiling vents had a visible buildup of dust. One of the vents was directly above the food prep area. *Regarding the gas range and flattop grill equipment: -The metal splash guard in between the flattop grill and the gas range was visibly soiled with layers of burnt food. -The grease trap drawer was not able to have been opened due to the amount of solidified grease and other food items in the drawer. -The backsplash on the gas range was visibly soiled with splashes of burnt food. -The catch tray beneath the gas range was soiled with layers of burnt food. *The top convection oven was soiled with splatters of burnt food and other food crumbs. The glass door was difficult to see through due to the amount of burnt particles. *There were several outdated and improperly stored food ingredient items in the baker's prep area in the kitchen: -A bottle of lemon juice concentrate was sitting at room temperature. The manufacturer's label indicated to Refrigerate after opening. The bottle was labeled as opened on ,d+[DATE]. -A bottle of imitation vanilla flavor with an opened date of [DATE] and an Best by date of [DATE]. -There was a brick of margarine sitting at room temperature and was not cool to the touch. The manufacturer's label indicated Perishable keep refrigerated. -A bottle of ground ginger with a label indicating Best by [DATE]. *Regarding the walk-in cooler: -There was at least two containers of sour cream with a manufacturer's label indicating Best By [DATE]. Those containers had a handwritten date of ,d+[DATE]. -There was at least one container of cottage cheese with a manufacturer's label indicating Best If Used By [DATE]. -There were several pitchers of various juices. Some of the labels did not match up with what was in the pitcher, and all the pitchers were past the handwritten Best By ,d+[DATE] date. --There was a pitcher of an amber liquid that appeared to have been apple juice that was labeled as water. --Some of the labels were missing from the pitchers and it was difficult to determine what the liquid was. *Regarding the dishwasher room: -It was a low-temperature chemical dishwasher. -There was significant grime buildup on the floor beneath the dishwasher. -The dishwasher was coated with limescale and food particle buildup. -The inside of the dishwasher appeared to be covered in limescale and food particle buildup. -The top of the dishwasher was covered in soap scum, limescale, and food particles. 2. Observation on [DATE] at 4:33 p.m. in the 200-hallway day room kitchenette cabinets revealed: *There was an opened package of candy that was sealed with a rubber band. -The rubber band was no longer elastic and crumbled when removed from the package. -There was a best by date from 2016. *A shaker of pepper had a printed date of 2015. *There was a package of individual pancake syrup that had turned rock solid. There was no manufacturer's date on the package. 3. Interview and observation on [DATE] at 3:20 p.m. with cook D in the kitchen revealed: *They did not use the flattop grill to cook food. -It was used as a prep table. -To clean the surface, he would sometimes scrape the food scraps into the grease trap drawer. -He had difficulties opening the grease trap drawer due to the amount of solidified grease. -He did not know when the drawer was last cleaned. *He confirmed the drip tray beneath the gas range should have been cleaned monthly and after each food spill. He confirmed it was unacceptable to have that much burnt food in the tray. *He indicated the convection ovens were deep cleaned with oven cleaner and a degreaser on a weekly basis. *There was a cleaning checklist binder and staff were supposed to initial when task items were completed. -He indicated the checklists might not have been filled out lately due to staffing shortages and their busy working schedules. -Observation of the cleaning checklist binder at that time revealed there had not been any cleaning checklists filled out since [DATE]. *He indicated they delimed the dishwasher weekly. 4. Interview on [DATE] at 4:20 p.m. with dietary manager C about food storage and kitchen cleanliness revealed: *Daily, he expected his staff to clean the trayline work area, wipe down the inside and outside of the steamer, sweep and mop, and clean the outside surfaces of the food preparation equipment. *The gas range grates were supposed to have been cleaned weekly. *He indicated he recently completed a deep clean of the kitchen which included cleaning the walls and ceiling pipes. -He was not able to clean all the burnt food particles on the gas range backsplash. He indicated the tin metal might have been discolored from use. *He expected staff to clean their work areas as they worked. *The ceiling vents and grease trap drawer probably should have been cleaned monthly. *He confirmed the dishwasher was delimed once per month as recommended by their dishwasher maintenance representative. *He was not aware of the state of the dishwasher with the buildup of limescale, soap scum, and food particles. *He was not aware of the expired foods in the cooler or the baker's prep area. -He indicated he reused the same bottle of vanilla extract and refilled the bottle from the larger jug of vanilla. -He did not indicate whether the reused bottle was washed in between refills. -He was not aware of the relabeling requirements when using refillable bottles. 5. Review of the provider's [DATE] Food Storage policy revealed: *Policy statement: Food storage areas are maintained in a clean, safe, and sanitary environment. *Procedure: -1. Food storage areas are kept clean at all times. - .4.Empty food cans are not reused. Only food grade reusable containers are used for food storage. - .11. The manufacturer's expiration date, when available is the use by date for unopened items. Review of the provider's [DATE] Food Labeling Reference Guide for Opened Items document revealed: *The manufacturer's expiration date, when available, is the 'use by' for unopened items. Use by dates should not exceed the manufacturer's expiration date. *Under the Refrigerator section: -Thickened milks, thickened juices, thickened water: use by date 7 days after opened. -Potentially hazardous cold foods, including but not limited to: milk, cottage cheese, hard cooked eggs, bacon: use by date 7 days after opened. -Fruit juice, canned fruit: use by date 7 days after opened. -Sour cream, buttermilk, yogurt, cream cheese: use by date 14 days after opened. -Bulk, non-potentially hazardous foods, including but not limited to .lemon juice . use by date 6 months after opened. *Under the Dry Storage section: -Spices, rice, sugar: use by date 1 year after opened. Review of the provider's [DATE] Cleaning and Sanitizing Work Surfaces policy revealed: *All surfaces must be cleaned and rinsed. This includes walls, storage shelves, and garbage containers. *All surfaces that are in contact with food must be cleaned rinsed and sanitized. This includes counter tops and work surfaces. *Process to Clean / Sanitize Work Surfaces. Work surfaces are cleaned: -1. After they are used. -2. Before handling a different type of food. Review of the provider's [DATE] Cleaning and Sanitizing Fixed Equipment policy revealed: *All surfaces must be cleaned and rinsed. This includes walls, storage shelves, and garbage containers. *All surfaces that are in contact with food must be cleaned, rinsed and sanitized. This includes, but not limited to, blender base, food processor base, slicer, mixer, can opener base, and microwave. *Process to Clean / Sanitize Work Surfaces. Work surfaces are cleaned: -1. After they are used. -2. Before handling a different type of food. Review of the provider's [DATE] Sanitation policy revealed: *Policy Statement: The food service area is maintained in a clean and sanitary manner. *Procedure: -1. Kitchens, kitchen areas, and dining areas are kept clean, free from litter and rubbish . -2. Utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas. - .4. Ice used in connection with food or drink is from a sanitary source and is handled and dispensed in a sanitary manner. - .7. Cleaning schedules are developed by the FANS [food and nutrition services] Manager or Person in Charge. -8. The FANS Manager or Person in Charge monitors compliance to the cleaning schedule. - .10. The FANS Manager maintains completed cleaning schedules for a minimum of 60 days. A policy and procedure for cleaning the dishwasher was requested on [DATE]. The provider indicated they did not have such a policy. 6. Review of the provider's daily, weekly, and monthly cleaning schedules for the past three months revealed that it appeared as though a base copy was drafted and photocopied for the past three months, with the different dates handwritten at the top of each page. The validity of the checklists could not be confirmed.

Based on observation, interview, and record review, the provider failed to ensure staff interactions and services were provided in a manner that maintained a resident's sense of dignity and respect by failing to: *Knock and ask permission to enter one of one sampled resident's (5) room. *Refer to one of one sampled resident (27) by a preferred nickname. *Follow two of two sampled resident (24 and 25) care plans for transfers in a dignified manner from their wheelchairs to their dining room chairs. *Provide incontinence care to one of one sampled resident (25) prior to being transferred into a dining room chair. *Maintain a homelike dining atmosphere by speaking loudly across the dining room to coworkers and other residents, and speaking about a resident (31) in front of that resident and others during two of two mealtime observations. Findings include: 1. Observation and interview on 6/3/24 at 3:27 p.m. with resident 5 in his room revealed: *He stated that workers bust in the door without knocking. *During the interview, certified nurse aide (CNA) E walked into the resident's room without knocking and interrupted the conversation. -The door was all the way open. 2. Observation on 6/3/24 at 5:39 p.m. in the dining room revealed: *CNA E sat down at one of the assisted dining tables and yelled across the room to another staff member. -Did [resident 36] eat? Did he eat? *CNA E and two other unidentified female staff members were also talking loudly to each other across the dining room, attempting to plan when they should take their respective breaks and where they were going to go. -CNA E said, Can you feed so these two can go on break? *CNA E was overheard asking a resident at the assisted dining table, Is it too hot for you, baby? *He was speaking with resident 16 in a child-like manner, exclaiming Good job! when she took a bite of food. 3. Observation on 6/4/24 from 11:13 a.m. to 11:51 a.m. in the dining room during the noon meal revealed: *CNA E transferred resident 25 from her wheelchair to a dining chair by grabbing her under her arm and the waistband of her pants and hoisted her up. *As resident 25 stood, her bottom was noticeably wet and soaked through, potentially with urine. -CNA E touched the soiled portion of her pants with his ungloved left hand and did not wash his hands. *CNA E sat resident 25 back down in her dining chair and walked away without assisting her out of the dining room to attend to her visibly wet pants. *He proceeded to touch other residents' wheelchairs and walkers, to place clothing protectors on residents, and to help other residents to transfer to their dining chairs with his unclean hands. *CNA E assisted resident 24 from his wheelchair to a dining room chair without first having locked his wheelchair brakes, grabbed his waistband to hoist him up and pivoted him into a chair. *CNA E then used hand sanitizer at 11:27 a.m. *CNA E was seated at one of the assisted dining tables and observed resident 34 walking out of the dining room. -CNA E yelled out the resident's name four times. -He then walked over to resident 34, and loudly said, You need to go sit back down because you haven't eaten yet! -Resident 34 walked back over to his table, appeared to have seen his food had not been served, and walked out of the dining room. *Resident 139 had propelled herself into the middle of the dining room as her oxygen cord dragged on the floor. CNA E yelled across the room, [Resident 139], you okay? *CNAs E and F were seated at an assisted dining table and had been helping residents eat their lunch. -CNA E asked CNA F, Have you seen her [resident 31] eat by herself? in front of that resident, other residents, and a guest. -CNA F responded, No she doesn't feed herself. I've never seen her feed herself. 4. Observation on 6/4/24 at 2:50 p.m. with CNA G and resident 27 while in her room revealed: *CNA G was by resident 27's bedside and had been preparing to obtain her vitals. *CNA G stated, Hey grandma, I'm going to take your vitals. *Resident 27 did not say any comments about having been called grandma. 5. Interview on 6/5/24 at 10:33 a.m. with CNA H regarding how she would have properly transferred a resident from their wheelchair to a dining room chair revealed: *She stated she would have first informed the resident that she would be helping them from their wheelchair to the dining room chair. *She would have then locked the wheelchair brakes and used a gait belt to have assisted the resident to stand and pivot to their chair. 6. Interview on 6/5/24 at 10:50 a.m. with nurse aide I regarding how to properly transfer a resident from their wheelchair to a dining room chair revealed: *She indicated she was in CNA training. *She stated she would have locked the resident's wheelchair breaks, used a gait belt, assisted the resident to stand, pivot, and sit in their dining chair, and then removed the gait belt. *She would have also explained to the resident what she would be doing before she did it. 7. Interview on 6/5/24 at 12:41 p.m. with social services designee/registered nurse (RN) J regarding resident dignity and privacy revealed: *She would have expected staff to knock, introduce themselves, and ask for permission before entering a resident's room. *She had provided staff with education and had reminded them to treat the residents with respect even if the staff were busy. 8. Interview on 6/5/24 at 1:58 p.m. with administrator A regarding resident dignity and privacy revealed: *She would have expected staff to knock on resident's doors before entering their rooms and introducing themselves before providing care to residents. *She would have expected staff to take residents back to their rooms if they need continence care before entering the dining room. 46453 9. Interview on 6/6/24 at 11:14 a.m. with licensed practical nurse (LPN) K regarding resident dignity in the dining room revealed: *When she assisted in the dining room, she would have expected staff to offer a clothing protector to the residents. *Staff should have made sure residents' hands and faces were clean. *Transfer belts and slings should have been removed. *She indicated it was not acceptable for staff to have yelled across the dining room at other staff members or residents. *She also indicated it was unacceptable for staff members to have spoken about a particular resident in front of that resident, or in front of other residents. 10. Interview on 6/6/24 at 11:25 a.m. with CNA H regarding resident dignity in the dining room revealed: *Staff should have covered the residents with a clothing protector so their clothes would stay clean. *She said, When they are a 'feeder' keep them clean. *She indicated it was not appropriate for staff to have talked about a resident when that resident is present. *She said when communicating with other staff members, staff should not have been yelling at each other across the dining room. 11. On 6/4/24 at 3:08 p.m., a policy on resident dignity was requested. The provider indicated they did not have a policy for resident dignity. 12. Review of resident 27's current care plan revealed: *There was an intervention which read, Prefers to be called: [resident's nickname]. Date initiated and revised on 6/3/22. *There was no mention of the word grandma in her care plan. 13. Review of resident 25's current care plan revealed: *Intervention of TRANSFER/AMBULATION: Assist x 2 and FWW for short distances. Wheelchair for long distance mobility as needed. Date initiated 9/26/22, revised on 5/28/24. *Intervention of Gait belt while ambulating, standing, transferring. Date initiated 11/9/22, revised on 2/23/24. 14. Review of resident 24's current care plan revealed there was an intervention of TRANSFER: assist x2 staff for transfers. Assist x2 staff due to behaviors. Date initiated 2/24/22, revised on 5/22/24. 15. Interview on 6/6/24 at 11:35 a.m. with director of nursing services B regarding maintaining resident dignity and respect revealed: *Staff should have engaged with the residents to foster a homelike environment. *It was inappropriate for staff to have spoken loudly across the dining room at other staff members or to other residents. *It was not appropriate for staff to have talked about the residents in front of that resident. *Staff should not have used pet names such as baby or grandma for residents unless that resident provided consent to do so. -She confirmed that resident 27 was not CNA G's grandma and he should not have been calling her that. -She indicated that some of their travel staff was from the southern region of the country, and it was a cultural thing for them to call each other by those pet names, but that was not necessarily the culture of the Midwest. *She had previously spoken to CNA E about his interactions with residents and other staff members but had not seen any improvement. *She confirmed residents 24 and 25 should have been transferred using a gait belt rather than by their waistband. *She confirmed CNA E should have performed hand hygiene after he had touched resident 25's soiled pants with his bare hand.

Based on observation, interview, cleaning log review, and policy review, the provider failed to ensure: *One of one flattop grease trap drawer was maintained in a clean manner free from food and grease buildup. *One of three ceiling vent fans were free from dust. *Food items such as dill relish, tomatoes, apple cider vinegar, and red wine vinegar were discarded after the item was spoiled or expired. *One of one hand soap dispenser was functional. Findings include: 1. Observation on [DATE] from 3:37 p.m. to 3:58 p.m. in the kitchen revealed: *The grease trap drawer under the flattop grill had burnt bits of food, noodles, and burnt grease in it. -The grease trap hole that connected the flattop grill to the drawer was caked with a thick layer of black grease. -The drawer was difficult to open due to the amount of grease. *The ceiling vent fan near the food preparation area and the cooking equipment had a layer of dust on the vent grates, and streaks of dust spreading out on the ceiling from the vent. *In the walk-in cooler, there was: -A gallon jug of dill relish that had an unknown black slimy substance growing near the opening rim. --There was a label which read [DATE] opened. -A plastic tub of tomatoes. Several tomatoes had unknown white fuzzy and white slimy substances growing on them. --There was a label which read [NAME] ,d+[DATE]. *In the dry storage room, there was: -An opened gallon jug of apple cider vinegar with a handwritten date of ,d+[DATE]. --There was no year to indicate what year the product was opened. --The manufacturer's Best if used by date was [DATE]. -An opened gallon jug of red wine vinegar with a handwritten date of ,d+[DATE]. --There was no year to indicate what year the product was opened. --The manufacturer's Best if used by date was [DATE]. -There were two additional unopened gallon jugs of red wine vinegar with the same Best if used by date of [DATE]. *There was a handwashing sink near the coffee and juice machine. The hand soap dispenser was not functional. -The antibacterial foaming hand soap that was in the dispenser had an expiration date of EXP ,d+[DATE]. Observation on [DATE] at 11:23 a.m. revealed the kitchen equipment was still in the same condition as above and the spoiled/expired products were still there. Observation on [DATE] at 1:00 p.m. revealed the same as above. Interview on [DATE] at 1:03 p.m. with food and nutrition services (FANS) manager E about the above observations revealed: *She was not aware the ceiling fan was as dusty as it was. *She was aware of the grease trap drawer and agreed it needed to be deep cleaned more often. *Their process for discarding expired food was as follows: -The night cook was responsible to review the cooler and discard foods that were past its expiration date. -She was not aware there was a black slimy substance growing on the pickle relish jar. *She indicated they did not use tomatoes that often in their recipes. -She was not aware the tomatoes were starting to spoil. -They bought the tomatoes over one month ago. *She was not aware of the several jugs of vinegar in the dry storage room that had been there for years. -She indicated they did not use red wine vinegar or apple cider vinegar in their recipes. Review of the provider's 2018 Daily Cleaning Schedule template revealed the following items were included: *Range - Catch Pan *Grill *Handsink/Soap/Paper Towels *There were blank spaces to provide hand-written additions to the task list. Review of the provider's Daily Cleaning Schedule for [DATE] through [DATE] revealed: *The Range - Catch Pan and Grill were marked as completed on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. *The Handsink/Soap/Paper Towels were marked as completed on [DATE], [DATE], [DATE], and [DATE]. Review of the provider's 2018 Weekly Cleaning Schedule template revealed the following items were included: *Refrigerator - Clean/Organize *Store Room - Clean/Organize *Fans *There were blank spaces to provide hand-written additions to the task list. Review of the provider's Weekly Cleaning Schedule for [DATE] revealed: *The Refrigerator - Clean/Organize and Fans items were marked as being completed for Week 5. *The Store Room - Clean/Organize item was not marked as being completed that month. Review of the provider's 2018 Monthly Cleaning Schedule template revealed the following items were included: *Ceiling *Ceiling Lights and Covers - Clean *Drains - Clean *There were blank spaces to provide hand-written additions to the task list. Review of the provider's Monthly Cleaning Schedule for 2023 revealed: *Each task item on the list was initialed as being completed for Month 1 and Month 5. *The only items that were initialed for Month 2 and Month 3 were Ice Machine and FANS Manager Office - Clean. *For Month 4, the following items had initialed as being completed: -Ice Machine -Lowerator/Plate Warmers (Heavy Clean) -Fire Extinguishers - Wipe/Clean -Drains - Clean -FANS Manager Office - Clean. Review of the provider's 2017 Food Storage policy revealed: *Policy Statement: Food storage areas are maintained in a clean, safe, and sanitary environment. *Procedure: -1. Food storage areas are kept clean at all times. -5. Foods are dated with month and year of delivery to the Center. EXCEPTION: Food items with used by dates of less than 30 days (e.g. milk, cottage cheese, fresh bread, and produce) do not require labeling with the moth and year of delivery. -6. Food products are used within one year unless the manufacturer's expiration date is different. -10. Opened items have 'use by' dates indicated on them . May indicate date opened or date prepared if required by your survey agency. -11. The manufacturer's expiration date, when available, is the use by date for unopened items. Review of the provider's 2019 Sanitation policy revealed: *Policy Statement: The food service area is maintained in a clean and sanitary manner. *Procedure: -1. Kitchens, kitchen areas, and dining areas are kept clean, free from litter and rubbish, and protected from rodents, roaches, flies and other insects. -2. Utensils, counters, shelves, and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas. -7. Cleaning schedules are developed by the FANS Manager or Person in Charge. -8. The FANS Manager or Person in Charge monitors compliance to the cleaning schedule.

Based on interview and policy review, the provider failed to deliver mail daily to ten of ten residents (1, 4, 6, 7, 14, 16, 21, 22, 28, and 33) within twenty-four hours after it was delivered to the local post office. Findings include: 1. Interview on 3/8/22 at 2:30 p.m. during the resident group meeting revealed: *Ten of ten residents (1, 4, 6, 7, 14, 16, 21, 22, 28 and 33) agreed they did not get their mail daily. *Sometimes the mail was only delivered a few days a week, and the residents would then find a stack of mail had been delivered to their rooms. *One of the residents (6) was concerned that she was not getting her newspaper delivered daily. Interview on 3/8/22 at 3:27 p.m. with activity director B revealed: *Maintenance supervisor (MS) C, executive director A, or she would pick up the mail at the local post office. *MS C and she were certified nursing assistants (CNA) and helped out on the floor by working shifts as CNAs. *Working CNA shifts prevented them from going to get the mail at the post office. *At times, two to three days would pass before mail was picked up and delivered during the weekdays. *She worked Monday through Friday. *She could not confirm mail delivery on Saturdays. *She did confirm daily mail delivery had not happened, including on Saturday. *She needed to work on the problem with mail delivery. Review of the provider's 2015 Resident Mail Policy revealed Mail goes to the resident within 24 hours of postal service delivery.

Based on observation, interview, and record review, the provider failed to ensure 1 of 13 sampled residents (19) had received the appropriate incontinence care from the staff to ensure her dignity was maintained. Findings include: 1. Observation on 1/5/20 at 3:16 p.m. of resident 19 revealed: *She was sitting in her wheelchair in room and appeared to be sleeping. *Her pants were down around the middle of her thighs. *Her incontinence brief was exposed. *Her roommate was also in the room and could see resident 19 in her wheelchair. Observation on 1/6/20 at 4:03 p.m. of resident 19 revealed: *She was sitting in her wheelchair in an activity room, watching TV. *Her jeans were soiled with what appeared to be urine, had an odor like urine, and it was dripping underneath her wheelchair onto the carpet. Review of resident 19's medical record revealed: *She was admitted on [DATE]. *She had multiple [DIAGNOSES REDACTED].>-Type 2 diabetes mellitus without complications. -[MEDICAL CONDITION]. -Bladder-neck obstruction. -Mild intellectual disabilities. *She was on multiple medications including diuretics. Review of resident 19's most recent quarterly 11/27/19 Minimum Data Set (MDS) assessment revealed: *She had a brief interview of mental status score of 15, which indicated she was cognitively intact. *She was not currently on a bowel or bladder toileting program. *She was frequently incontinent of bladder and occasionally incontinent of bowel. *She needed extensive assistance of one person for toileting. Review of resident 19's 10/22/19 care plan revealed: *Staff would assist her to the toilet upon rising, before and after meals, at bedtime, and as needed. -They would assist her on routine night shift rounds. *Problem of: The resident has frequent bowel/bladder incontinence r/t(related to) diuretic use, bladder neck obstruction, history of UTI(urinary tract infection) and impaired Mobility. -Goal was: The resident will be clean, dry and free from odors through the review date. -Interventions: Brief use: The resident uses disposable briefs. Clean peri(perineal)-area 2x(two times) daily and with each incontinence episode. Ensure the resident is clean, dry and free from odor. Medications/labs/treatments as ordered. Monitor/document for s/sx(signs and symptoms) UTI: pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, Change in behavior, Change in eating patterns. Interview on 1/8/20 at 10:51 a.m. with the Director of Nursing(DON) and the minimum data set(MDS) coordinator revealed: *They encouraged routine toileting for their residents. *They had not tried any toileting programs. *There had not been a big push to try toileting programs. *They had used occupational therapy for help with toileting residents. *The DON agreed that a resident being soiled would be a dignity issue. *They agreed resident 19 would be an appropriate resident for a toileting program. Surveyor: 6. Interview on 1/6/20 at 10:20 a.m. with CNAs D and [NAME] regarding the observations above revealed: *The staff were to have assisted the residents with turning, repositioning, and toileting every two hours. -Those residents who had been at risk for skin breakdown should have been assisted more frequently than that. *Resident 19 had been capable of communicating her needs and would have asked them for assistance with toileting. 7. Observation and interview on 1/6/20 at 4:37 with the director of nursing (DON) and registered nurse (RN) consultant regarding residents 19 revealed: *The DON had taken resident 19 to her room and got a staff member to assist her with incontinence care. -The RN consultant had gone to let the maintenance supervisor know the carpet in the sitting room required cleaning. -They: --Were not aware of the incontinence concerns observed for that resident. --Would have expected residents to have been repositioned and assisted with toileting and incontinence care every one to two hours. --That time frame and frequency varied depending upon the resident's level of risk for skin breakdown. *The DON had assisted resident 19 with toileting and incontinence care at 11:30 a.m. that day. *The DON stated: -I helped her, because she was incontinent and needed her clothes changed. -She was stand-by assist and it was documented in PCC (Point Click Care). -She does have a history of refusing care, but yes, the staff should still check on her. -If (resident's name) has to urinate she will tell you but by then it's typically to late. *The DON was not aware if the resident had been assisted prior to 11:30 a.m. and between 11:30 a.m. and 4:00 p.m. Continued interview with the DON and RN consultant revealed: *The staff documented the resident's repositioning and toileting in PCC. -That documentation typically occurred once per shift. -The CNAs would have been expected to document any refusals of care from the residents. *They confirmed: -There were only three CNAs scheduled to work the evening shift. -The CNAs were to have assisted the residents with smoking. -All residents who used a mechanical lift for transfers required two staff members to assist them. *The did not have a policy and procedure in place for the staff to follow to ensure the residents' dignity had been maintained. Interview on 1/7/20 at 9:43 a.m. with licensed practical nurse (LPN) F revealed she: *Was the charge nurse that day, 1/7/20. *Would have expected the CNAs to have: -Completed incontinence care or repositioned all residents every two hours and as needed. -Checked on those residents that had been considered independent with their cares and toileting as well. *She stated: -(Resident 19's name) will usually put on her call light, but they should be checking on her as well. -We have sheets for them to sign, so they know when they were last taken care of. *Had not been aware of any concerns regarding toileting, checking and/or changing soiled incontinence products, and positioning.

Based on observation, interview, and record review, the provider failed to implement and follow the comprehensive care pan for 1 of 12 sampled residents (19) to ensure she had received the appropriate care and services she required. Findings include: 1. Review of resident 19's 10/22/19 care plan revealed: *She required extensive assistance by one staff person for toileting. *Staff would help and assist the resident to the toilet upon rising, before and after meals, at bedtime, and as needed, and on routine night shift rounds. *Problem: The resident has frequent bowel/bladder incontinence r/t(related to) diuretic use, bladder neck obstruction, history of UTI(urinary tract infections) and impaired Mobility. -Goal was: The resident will be clean, dry and free from odors through the review date. *Interventions were: -Brief use: The resident uses disposable briefs. -Clean peri(perineal)-area 2x(two times) daily and with each incontinence episode. Ensure the resident is clean, dry and free from odor. -Medications/labs/treatments as ordered. Monitor/document for s/sx UTI(signs and symptoms of urinary tract infections): pain, burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased pulse, increased temp, Urinary frequency, foul smelling urine, fever, chills, altered mental status, Change in behavior, Change in eating patterns. 1. Observation on 1/5/20 at 3:16 p.m. of resident 19 revealed: *She was sitting in her wheelchair in room and appeared to be sleeping. *Her pants were down around the middle of her thighs. *Her incontinence brief was exposed. *Her roommate was also in the room and could see resident 19 in her wheelchair. Observation on 1/6/20 at 4:03 p.m. of resident 19 revealed: *She was sitting in her wheelchair, in an activity room, watching TV. *Her jeans were soiled with what appeared to be urine, had an odor like urine, and it was dripping underneath her wheelchair onto the carpet. Review of resident 19's medical record revealed: *She was admitted on [DATE]. *She had multiple [DIAGNOSES REDACTED].>-Type 2 diabetes mellitus without complications. -[MEDICAL CONDITION]. -Bladder-neck obstruction. -Mild intellectual disabilities. *She was on multiple medications including diuretics. Review of resident 19's most recent quarterly 11/27/19 Minimum Data Set (MDS) assessment revealed: *She had a brief interview of mental status score of 15, which indicated she was cognitively intact. *She was not currently on a bowel or bladder toileting program. *She was frequently incontinent of bladder and occasionally incontinent of bowel. *She needed extensive assistance of one person for toileting. Interview on 1/8/20 at 10:51 a.m. with the director of nursing(DON) and the minimum data set(MDS) coordinator revealed: *They encouraged routine toileting for their residents. *They had not tried any toileting programs. *There had not been a big push to try toileting programs. *They had used occupational therapy for help with toileting residents. *The DON agreed that a resident being soiled would be a dignity issue. *They agreed resident 19 would be an appropriate resident for a toileting program.

A. Based on observation, interview, and record review, the provider failed to assess, develop, and implement interventions for pain management for one of one sampled resident (2) with uncontrolled pain during the resident's dressing change. Findings include: 1. Observation on 4/20/16 at 10:00 a.m. of resident 2's dressing change to her pressure ulcer on her coccyx with registered nurses (RN) C and N revealed: *RN N performed the dressing change while RN C assisted with the positioning of the resident. *The resident was repositioned two to three times during the dressing change. *She grimaced and called out when she was repositioned. Interview immediately after the above observation with RN C regarding resident 2 revealed: *She had assessed the resident for pain one half hour before the dressing change, and she had appeared comfortable. *She had not received extra pain medication prior to the scheduled dressing change. *She thought the resident's discomfort was due to repositioning her, and not the dressing change itself. Review of resident 2's medical record revealed: *She had been admitted on [DATE] and was placed on hospice care on 12/30/15 with the goal to keep her comfortable. *Her [DIAGNOSES REDACTED]. -The pressure ulcer started as a [MEDICAL CONDITION] on 6/15/15. -She was then admitted to the hospital for twelve days for treatment of [REDACTED]. -She was readmitted on [DATE] with a pressure ulcer to her coccyx. *She had a daily dressing change to her pressure ulcer. *There was no documentation from 2/24/16 up to 4/20/16 nursing pain assessments had been done before or after her dressing changes. *A nurse's note written by RN C from the day of the observed dressing change on 4/20/16 stated Resident noted to moan when repositioning to prepare for dressing change, no s/s (sign or symptom) of pain noted while performing dressing change. Review of resident 2's 3/16/15 annual Minimum Data Set (MDS) assessment revealed: *A Brief Interview for Mental Status score (BIMS) of six out of fifteen indicating moderately impaired thinking and judgement. *Her behaviors included refusing cares, verbal and physical. *She was independent in her functioning. Review of resident 2's 4/12/16 quarterly Minimum Data Set (MDS) assessment revealed: *A BIMS assessment had been performed by staff. *The resident had been unable to complete it, indicating severe cognitive impairment. *She had pain and showed it by facial grimacing and moaning. *She had received scheduled pain medication. Review of resident 2's Medication Administration Record [REDACTED] *Her scheduled pain medication was a [MEDICATION NAME] (a narcotic) pain patch that delivered continuous medication. *Her as needed (PRN) pain medication consisted of: -Tylenol: none had been given for that month. -[MEDICATION NAME] (a narcotic pain medication) to be given every hour PRN. It was used twice in April on 4/2/16 and 4/6/16. Review of resident 2's current 4/19/16 care plan revealed: *She had chronic pain due to arthritis. *Interventions were: -11/2/15, I know nurse will assess for pain prior to dressing changes and provide pain medication . -1/7/16, [MEDICATION NAME]/[MEDICATION NAME]/[MEDICATION NAME] as ordered for comfort. *There was no documentation about the dressing change nor any interventions for pain control before the dressing change was done. Interview on 4/21/16 at 11:00 a.m. with RN O regarding the dressing change on resident 2 revealed: *She said ow for everything. *She holds her breath when she's having pain. *When asked what she would do if she noticed the resident having pain during a dressing change, she had no response. Interview on 4/21/16 at 1:40 p.m. with the director of nursing services and the administrator regarding resident 2 revealed: *They did not believe she was having pain during the dressing change. *The hospice nurse came to see the resident last night to reassess her for pain at their request. *Per the hospice note, hospice came per the request of the facility due to state surveyors being there. *They stated hospice had recommended: -The dose of the resident's [MEDICATION NAME] be increased. -To use the PRN [MEDICATION NAME] more often as needed. *They confirmed no routine pain assessments had been done by the provider. *A policy had been requested from the provider, none was provided by the time of exit. B. Based on record review, interview, and policy review, the provider failed to combine the hospice plan of care with the provider's plan of care to specify who was responsible for care for three of three sampled hospice residents (2, 6, and 11). Findings include: 1. Review of resident 2's medical record revealed an admission date of [DATE]. Hospice care had started on 12/30/15. Review of resident 2's current 4/19/16 provider's care plan revealed: *It was located in a care plan binder. The hospice agency's care plan was located in the resident's chart along with the hospice visitation notes. *The provider's care plan revealed: -The resident started hospice on 12/29/15. -Hospice to evaluate and to help keep comfortable. -See hospice care plan in resident chart 1/26/16. *No documentation was made on the provider's care plan to indicate who was responsible for what care the resident was to have received. 2. Review of resident 6's medical record revealed: *On 1/27/16 she had been placed on hospice services with [DIAGNOSES REDACTED]. *The 2/2/16 significant change Minimum Data Set (MDS) assessment was marked for hospice services. *The 2/2/16 care plan revealed: -1/11/16: Hospice ordered. -1/21/16: Started on hospice. *There was no further documentation on the care plan regarding hospice services. Interview on 4/20/16 at 10:00 a.m. with the MDS registered nurse regarding resident 6 confirmed and revealed: *They had received a physician's orders [REDACTED]. *Hospice services had begun on 1/27/16. *The hospice care plan was located in the resident's chart. *The care plan was located in a seperate binder. *The resident did not have an integrated care plan with hospice. *Any resident who had been receiving hospice services did not have an integrated care plan. *The resident's care plan had been updated on 2/2/16 when the MDS significant change assessment had been completed. *She agreed hospice information should have been written on the resident's care plan. *The staff would not know what hospice services were provided by looking at the 2/2/16 care plan. 3. Review of resident 11's medical record revealed: *On 12/31/15 she had been placed on hospice services with a terminal [DIAGNOSES REDACTED]. *The 1/12/16 significant change MDS assessment was marked for hospice services. *The above assessment had included she had: -Pain present, almost constantly. -That pain was coded as moderate. Review of resident 11's revised 2/5/16 care plan revealed: *On 12/29/15: -Under the discharge planning focus Hospice to evaluate and to help keep comfortable. -Under the mental health focus Hospice comfort care. *Under the activity focus Hospice and staff 1:1 (one-to-one). *Under the religion focus Visits w/ (with) hospice chaplain. *The resident had chronic (persisting for a long time) pain related to gout (severe pain, redness, and tenderness in joints). -The above pain was located in multiple areas. -Interventions included medications and laboratory tests as ordered, [MEDICATION NAME] (a narcotic pain medication) increased, and to have reported signs and symptoms of pain to the charge nurse. *There was no further documentation on the care plan for hospice services for pain or any other areas. *The care plan had not: -Addressed why she was on hospice. -Identified all the services hospice provided to the resident. -Identified how pain management was achieved. -Identified what care was to have been provided by the provider and by hospice. Further review of resident 11's medical record revealed the hospice care plan was separated from the provider's care plan. Interview on 4/21/16 at 10:05 a.m. with the MDS coordinator regarding resident 11 revealed: *They had received a physician's orders [REDACTED]. *Hospice services had begun on 12/31/15. *She did not have an integrated care plan with the hospice care plan, and that was an area that could be improved. *The hospice care plans were always placed in the residents' charts, and the provider's care plans were placed in a separate binder. *Any resident who had been receiving hospice services did not have an integrated care plan. Interview on 4/21/16 at 11:05 a.m. with the director of nursing (DON) and the MDS coordinator regarding resident 11 revealed they confirmed she had needed to have the hospice care plan integrated with the provider's care plan. Surveyor: Interview on 4/21/16 at 10:00 a.m. with the DON regarding the integration of resident's care plans with hospice care plans revealed: *She had been unaware the resident's care plans should have been integrated with the hospice care plans. *She confirmed they did not have integrated hospice care plans. Surveyor: Interview on 4/21/16 at 2:05 p.m. with hospice registered nurse K regarding the integration of resident care plans with hospice care plans and staff training revealed: *Her main goals for hospice had included resident's pain level and comfort. *She was unaware of any hospice training to staff. *She had been unaware the residents' care plans had not been been integrated with the residents' hospice care plans. *She confirmed there needed to have been integrated care plans with hospice care plans. *It was the responsibility of the provider to integrate the care plan provided by the hospice agency into the provider's care plan. Interview on 4/21/16 at 2:35 p.m. with the administrator regarding the above revealed: *There had needed to have been integrated care plans with hospice care plans. *Hospice training online for all staff had been mandatory on the provider's Care to Learn program in May 2015. *Hospice training was important for all staff to have been provided for care for those residents on hospice. Review of the provider's revised 6/20/13 Hospice Services Agreement revealed: *Hospice was to have provided appropriate training to the provider's personnel who were providing care to residents receiving hospice services. *Hospice gave the provider a copy of the resident's plan of care. -That plan of care specified the resident's services that were provided. -The provider agreed to comply with the hospice plan of care. *There was to have been coordination of care between the provider's staff and hospice services. Review of the provider's 11/6/15 Care Plans-Comprehensive policy revealed an individualized comprehensive care plan would have been developed to meet each resident's medical, nursing, mental, and psychological needs.

Based on observation, interview, record review, and policy review, the provider failed to ensure five of eight interviewed sampled residents (1, 2, 3, 5, and 7) were free from verbal, emotional, and physical abuse, related to: *Staffing concerns. *Activities of Daily Living (ADLs) (toileting, dressing, bathing, moving from one surface to another). *Pressure (injury to skin usually from pressure and over a bony area) ulcers. Findings include: 1. Review of resident 1's most current 8/16/15 Minimum Data Set (MDS) assessment revealed: *She had scored a fifteen on her Brief Interview for Mental Status (BIMS) (testing for mental function) evaluation indicating she was alert and able to answer questions. *Her ADL assessment indicated she needed extensive weight bearing support assistance with one staff member. Interview on 10/21/15 at 5:15 a.m. with certified nursing assistant (CNA) B and licensed practical nurse (LPN) C revealed resident 1 required staff assistance of one with ADLs. The above MDS indicated she had: *Been at risk for developing a pressure ulcer. *Not been on a toileting program. *Not been on a repositioning (turning and changing position) program. *Not been on a nutrition or hydration (fluid replacement) intervention program. Review of her 8/16/15 Braden (assessment for risk of skin breakdown) Score assessment revealed a score of eighteen indicating she had been at risk for a pressure ulcer. Review of the 10/11/15 at 2:22 p.m. nurses notes revealed: *Skin abrasion (scraping off of skin) noted per staff to inner buttock d/t (due to) excoriation (wearing off the skin)/incontinence (unable to control bladder). *Resident states 'no one will believe me' when she says that the sores always happen d/t the pull ups (disposable briefs) she wears, that she is allergic to them. Surveyor Review of the 10/11/15 at 2:26 p.m. nurses notes revealed: *Irritated abrasion to left upper buttock (bottom) . nurse further observed and area is what appears to be an old skin abrasion that has healed and the outer layer of skin peeled off. *After discussing the 'pull ups' it was discovered that yes resident has been wearing the inserts not the pullups to prevent this 'nylon allergy' that resident has. *Resident emotional this afternoon, crying at times when nurse talking to her regarding staff issues. Surveyor Review of the provider's 10/21/15 following reports revealed: *The Moisture Associated Skin Damage (MASD) report indicated she had skin impairment caused by moisture. *The Urinary Continence report indicated she had been frequently (seven or more episodes in seven days) incontinent. *The Urinary Tract Infections [MEDICAL CONDITION] from April through October 2015 report indicated she had been on antibiotic therapy for a UTI. -Review of the medical record revealed she had been treated for [REDACTED]. Surveyor: Interview and observation on 10/19/15 at 7:45 p.m. with resident 1 and the local ombudsman revealed the resident stated: *CNA A was ornery. *When she had told staff about her incontinent brief allergies and the sores she obtained from them she was told It was her imagination. *She had been left wet. *Night staff did not want to get her up and take her to the bathroom during the night. *She had been instructed by the night CNAs to Pull her pad (incontinent brief) out of the way and urinate in the bed, because it is easier to change the pad instead of bring her to the bathroom. *Staff did not always wear their name tags. *A nurse had said Don't ring your bell again, it won't be answered. *Night staff had jerked on the shoulder she had surgery on (right arm). *That concern had been reported, and that was why there was a sign above her bed. -Observation at that time revealed a sign posted at the head of her bed instructing staff not to pull on her right arm. Surveyor Surveyor 2. Review of resident 2's most current 8/10/15 MDS assessment revealed: *She had scored a fourteen on her BIMS evaluation indicating she was alert and able to answer questions. *Her ADL assessment scores indicated she needed extensive assistance of one to two staff members. *She had limitations in movement in both of her legs. *She had been at risk for developing a pressure ulcer. *She had not been on a toileting and repositioning program. *She had not been on a nutrition or hydration intervention program. Review of her 10/15/15 Braden score revealed a score of seventeen indicating she was at risk for pressure ulcers. Review of the provider's 10/21/15 following reports revealed: *The Urinary Continence report indicated she had been frequently incontinent. *She had not been included on the provider's MASD list. *The UTI from April through October 2015 report revealed she had been on antibiotic therapy for a UTI. -Review of her medical record revealed she had been treated for [REDACTED]. Interview on 10/20/15 at 9:00 a.m. with resident 2 revealed: *CNA A had a violent temper. -She had cursed at her and raised her voice at her. -She had also refused to assist her and walked out of the resident's room. *LPN C had a mouth on her. -She can put you through the grinder. -She has walked out on her when she had asked for care. 3. Review of resident 3's most current 7/27/15 MDS assessment revealed: *He had scored a fifteen on his BIMS evaluation indicating he was alert and able to answer questions. *His ADLs indicated he needed limited to extensive (some weight bearing to full weight bearing) assistance of one staff member. *He had limitations in movement to one of his legs. *He had been at risk for developing a pressure ulcer. *He had not been on a toileting and repositioning program. *He had not been on a nutrition or hydration intervention program. Review of his 7/27/15 Braden score revealed a score of seventeen indicating he was at risk for pressure ulcers. Review of the provider's 10/21/15 following reports revealed: *The Urinary Continence report indicated he had been frequently incontinent. *The Bowel Continence report indicated he had been occasionally incontinent. *He had not been included on the provider's MASD list. *The Pressure Sores list revealed he had a facility acquired (developed while in the facility) pressure ulcer. Review of resident 3's 9/1/15 physician's orders [REDACTED]. The physician had ordered a medication for that rash. Review of the provider's skin assessment book revealed resident 3 had: *On 3/13/15: A pinpoint open area on his scrotum from moisture and friction. -That area was now healed. *On 8/6/15: A rash on the inner back of both legs. -The right leg rash measured 10 centimeters (cm; unit of measurement 2.5 cm equals 1 inch) X (by) 11 cm with no drainage. -The left leg rash measured 15 cm X 12 cm with no drainage. -The left leg rash had been healed on 9/29/15. Interview on 10/20/15 at 8:50 a.m. with resident 3 revealed the night CNAs: *Leave me on the toilet so now I don't use it anymore. *They had walked out on him when he had asked for assistance. *They had raised their voices at him. *He had hollered at them to come back, but they don't come back. *He stated he had been unable to control his bladder. *He said sometimes they changed his incontinent product, and sometimes they did not. *He has had sores on his bottom from being left sitting on the stool and being wet. *He had reported his concerns to the charge nurses. 4. Review of resident 5's most current 7/6/15 MDS assessment revealed: *She had scored a thirteen on her BIMS evaluation indicating she was alert and able to answer questions. *Her ADLs assessment indicated she needed extensive to total assistance (full weight bearing, staff to complete all of the task) of two staff members. *She had limitations in movement to both of her arms and legs. *She had been at risk for developing a pressure ulcer. *She had not been on a toileting program and repositioning program. *She had not been on a nutrition or hydration intervention program. Review of her 7/6/15 Braden score revealed it was seventeen indicating she was at risk for pressure ulcers. Interview on 10/20/15 at 9:50 a.m. with resident 5 revealed the following regarding the night CNAs: *One night (she was unable to determine the exact date), two of the night CNAs got mad at her roommate, and they swore at her roommate. Her roommate was unable to make her wants and needs known. *CNA A acted as if she can't stand me. *The night CNAs acted as if they just need the money. *She asked to go to the bathroom at 4:10 p.m. on one day (she could not remember the exact day). CNA A had told her there were only two of us on, you will have to wait. She was finally able to go to the bathroom at 9:00 p.m. after they had put all the other residents to bed. *Some days CNA A was sweet and some days she is very mouthy. *The resident was able to verbalize she had told the interim administrator (now the director of nursing) and the social services designee (who no longer was employed at the facility) of the above abuse. 5. Review of resident 7's most current 9/20/15 MDS assessment revealed: *He had scored a fifteen on his BIMS evaluation indicating he was alert and able to answer questions. *His ADL assessment indicated he needed limited to extensive assistance of one staff member. *He had limitations in movement to one of his legs. *He had been at risk for developing a pressure ulcer. *He had not been on a toileting program and repositioning program. *He had not been on a nutrition or hydration intervention program. Review of his 9/23/15 Braden score revealed it had been fifteen indicating he was at risk for developing pressure ulcers. Review of the provider's 10/21/15 following reports revealed: *The Urinary Continence report indicated she had been occasionally incontinent. *The MASD report indicated he had skin impairment caused by moisture. Interview on 10/20/15 at 9:25 a.m. with resident 7 revealed the CNAs were: *Rough in using the gait belt. He had pain in his left upper rib area because of that gait belt use. *He was afraid to push his button (call light). *The CNAs don't give me time when getting me up, they hurry me. *There was a CNA on the night before last (10/18/15) when asked to empty his urinal (container for men to urinate into) stated to him Where do you want me to put it, on you? *Some of the CNAs grabbed and threw me on the bed. They grab my hands to drag me out of bed. They also grab my leg to pull me in and out of the bed. *He had a CNA swat at him. He stated it was Very frightening. During that interview he stated the following regarding the nurses: *One of the nurse said to him Why are you shaking, I'm the good nurse? *One of the nurses told him she was Afraid to work with the night CNAs. *He had reported the rough behavior to the charge nurses. 6. Review of CNA A and B's employee files revealed: *CNA A had signed the Reporting and Investigating of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Personal Property policy on 1/10/15. *CNA B had signed the Reporting and Investigating of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Personal Property policy on 8/6/13. Review of the provider's June 2005 Reporting and Investigating of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Personal Property policy revealed: *The Policy statement: -It is the policy of (facility name) to provide an environment free from abuse, mistreatment, neglect, and misappropriation of personal property. - If a violation occurs or is suspected, it is the policy of the facility to investigate the alleged violation and take the appropriate action according to the results. *The General statement: -The resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal (physical) punishment, involuntary seclusion, or misappropriation of property or funds. -The facility staff is to be aware of the definitions of abuse as defined by the Federal Government and the State of South Dakota, Department of Health, Office of Health Care Facilities Licensure and Certification. -All staff is to be aware of this policy and procedure and their legal responsibility for following the guidelines. -Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents, consultants, or volunteers, staff of other agencies serving the individual, family members, legal guardians, friends, or other individuals. -(facility name) ensures that incidents of possible abuse and neglect are investigated promptly with reports sent to proper regulatory agencies within the state and federal guidelines. Review of the provider's January 2007 Procedure for Incident Reports revealed attached to it was a form titled Nursing Facility Incident Reporting Flowsheet from the South Dakota Department of Health, Office of Licensure and Certification that was not the current form the facilities was to have been using, and the following link to the website (http://doh.sd.gov/documents/Providers/Licensure/Reporting_Instructions.pdf) for reference to the reporting flow diagram was provided to the interim administrator on 10/21/15. Review of the provider's 1/1/09 Resident Rights policy revealed: *Employees shall treat all residents with kindness, respect, and dignity. *Orientation and in-service training programs are conducted to assist our employees in understanding our residents' rights. *Inquiries concerning residents' rights should be referred to the social services director. Review of the provider's undated Resident Rights form provided to all residents upon admission revealed: As a resident, you have the right to: -Be treated with respect and dignity. -Be free from physical/mental abuse. -Trained staff. -Voice grievances. -Be informed of your rights. Review of the provider's last formal abuse group education revealed: *It was provided on 12/23/14. *CNA A had attended. *CNA B had not attended. 7. Review of the provider's 10/10/15 through 10/25/15 staffing schedule revealed: *CNA A had worked: -10/10 and 10/11 the evening and night shift (2:00 p.m. until 6:30 am). -10/12 from 8:00 p.m. through 6:00 a.m. -10/15 from 8:00 p.m. through 6:00 a.m. -10/17 and 10/18 2:00 p.m. through 6:00 a.m. -10/19 from 6:00 p.m. through 6:00 a.m. *CNA B had worked: -10/11, 10/12, 10/14, 10/19, and 10/20 from 10:00 p.m. through 6:30 a.m. -She had been designated as the CNA to assist the residents in the special care unit (SCU). *LPN C had worked: -10/14, 10/16, 10/17, and 10/20 from 6:45 p.m. through 7:00 a.m. Review of the provider's CNA staff schedule for the dates of the survey (10/19/15 through 10/21/15) revealed the following positions needed to have been filled when the schedule had been posted: *10/19/15: Three evening and two night positions. *10/20/15: One evening from 6:00 p.m. through 10:00 p.m. along with one day and one night position. *Posting a schedule with open positions notified staff of the needs of the facility for potential overtime hours. Review on 10/19/15 at 7:30 p.m. of the provider's 10/19/15 daily staffing sheet revealed: *10/19/15 had not been updated to indicate the registered nurse (RN) had called in ill and had been replaced by LPN C. Interview at that time with LPN C revealed she was going to be working 6:45 p.m. until 11:00 p.m. The director of nursing would be working 11:00 p.m. until 4:00 a.m. The administrator (an RN) would be working from 4:00 a.m. until 5:00 a.m. until the next nurse arrived early. Review on 10/20/15 at 4:45 a.m. of the provider's 10/20/15 daily staffing sheet revealed: *The posting for 10/20/15 had not been updated to indicate the RN had called in ill and had not been replaced. *The posting did not reflect the shorter shifts worked by CNAs on the evening shift. Review of the provider's 2015 Turnover report listed the following number of employees had been terminated or quit: *January: One. *February: Two. *March: Three. *April: Five. *May: Four. *June: Three. *July: Two. *August: None. *September: Three. *October 1 through 20: Four. Review of the provider's job descriptions revealed: *CNA summary: Performs the functions of a nursing assistant in carrying out all assignments given by the RN or LPN in charge of the facility. Is accountable for all residents' care he/she is assigned during a shift. He/she is responsible for promoting teamwork among co-workers and personal self-development. Maintain confidentiality of information regarding residents, families, health care personnel and (facility name). Consequences of Action: Failure to comply with department and or (facility name) policies will result in disciplinary action as outlined in our employee handbook. *Charge Nurse RN/LPN: The primary responsibility of this position is to take responsibility for supervision and providing quality care to our residents in a friendly home-like atmosphere, while allowing them to make choices. This is done in accordance with our policies, procedures, and the state and federal guidelines and your scope of practice. *The last page of the job description number 31 stated Report any resident abuse IMMEDIATELY (that was bolded and capitalized). Interview on 10/21/15 at 7:20 a.m. with the staff development coordinator revealed: *The instructional manual used to train staff was How to Be a Nursing Assistant by the American Health Care Association. -Abuse prevention had been included in this manual. *Direct care giver staff had sixteen hours of classroom education before going to the floor and within those sixteen hours abuse and neglect was covered along with the facility's policy. Review of the staff education revealed the last time abuse training was provided to all staff members had been December 2014. That educational session had been provided by the social service designee (she was no longer employed at the facility). 8. Interview on 10/21/15 at 10:00 a.m. with the interim administrator confirmed the following: *The social services position had been unfilled since June 2015. *The resident abuse policy was to have been followed by all staff members. *CNAs were supervised by the licensed staff members. -Licensed staff should have been aware of resident concerns. *She was not aware of the new flow diagram from the South Dakota Department of Health, Office of Licensure and Certification for reporting abuse. *She was not aware of the above residents' concerns.

br>Based on record review, interview, and policy review, the provider failed to thoroughly investigate 11 of 15 sampled residents' (1, 2, 3, 5, 7, 9, 10, 11, 12, 14, and 15) reports to determine no abuse or neglect had occurred. Findings include: 1. Review of resident 1's medical record and interview with resident on 10/19/15 at 7:45 p.m. revealed concerns of abuse and neglect. Refer to F223, finding 1. 2. Review of resident 2's medical record and interview with resident on 10/20/15 at 9:00 a.m. revealed concerns of abuse and neglect. Refer to F223, finding 2. 3. Review of resident 3's medical record and interview with resident on 10/20/15 at 8:50 a.m. revealed concerns of abuse and neglect. Refer to F223, finding 3. 4. Review of resident 5's medical record and interview with resident on 10/20/15 at 9:50 a.m. revealed concerns of abuse and neglect. Refer to F223, finding 4. 5. Review of resident 7's medical record and interview with resident on 10/20/15 at 9:25 a.m. revealed concerns of abuse and neglect. Refer to F223, finding 5. 6. Review of resident 9's medical record revealed concerns of neglect relating to pressure ulcers (injury to skin usually from pressure and frequently over a bony area). Refer to F314, finding 4. 7. Review of resident 10's medical record revealed concerns of neglect relating to pressure ulcers. Refer to F314, finding 5. 8. Review of resident 11's medical record revealed concerns of neglect relating to pressure ulcers. Refer to F314, finding 6. 9. Review of resident 12's medical record revealed concerns of neglect relating to pressure ulcers. Refer to F314, finding 7. 10. Review of resident 14's medical record revealed concerns of neglect relating to pressure ulcers. Refer to F314, finding 8. 11. Review of resident 15's medical record revealed concerns of neglect relating to pressure ulcers. Refer to F314, finding 9. 12. Interview with multiple staff who wish to remain confidential revealed they had concerns about neglect. They did not feel concerns had been resolved after reporting. Refer to F224, findings 8 and 9. 13. Review of the provider's June 2005 Reporting and Investigating of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Personal Property policy revealed: *Policy statement: -It is the policy of (facility name) to provide an environment free from abuse, mistreatment, neglect, and misappropriation of personal property. - If a violation occurs or is suspected, it is the policy of the facility to investigate the alleged violation and take the appropriate action according to the results. *General statement: -The resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal punishment, involuntary seclusion, or misappropriation of property or funds. -The facility staff is to be aware of the definitions of abuse as defined by the Federal Government and the State of South Dakota, Department of Health, Office of Health Care Facilities Licensure and Certification. -All staff is to be aware of this policy and procedure and their legal responsibility for following the guidelines. -Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents, consultants, or volunteers, staff of other agencies serving the individual, family members, legal guardians, friends, or other individuals. -(facility name) ensures that incidents of possible abuse and neglect are investigated promptly with reports sent to proper regulatory agencies within the state and federal guidelines. 14. Interview on 10/21/15 at 10:00 a.m. with the interim administrator revealed: *She was unaware of the above residents' concerns. *She was unaware the staffs' concerns.

br> Based on record review, interview, and policy review, the provider failed to ensure dignity had been maintained for four of eight sampled residents (1, 3, 5, and 7). Findings include: Surveyor 1. Review of resident 1's medical record and interview on 10/19/15 at 7:45 p.m. with the resident revealed dignity had not been maintained in regards to toileting. Refer to F223, finding 1. 2. Review of resident 3's medical record and interview on 10/20/15 at 8:50 a.m. with the resident revealed dignity had not been maintained in regards to toileting. Refer to F223, finding 3. 3. Review of resident 5's medical record and interview on 10/20/15 at 9:50 a.m. with the resident revealed verbal respect and dignity had not been maintained. Refer to F223, finding 4. 4. Review of resident 7's medical record and interview on 10/20/15 at 9:25 a.m. with the resident revealed verbal respect and dignity had not been maintained. Refer to F223, finding 5. 5. Review of the provider's revised 4/2/12 Dignity policy revealed: *Each resident shall receive care in a manner and in an environment that maintains or enhances dignity and respect in full recognition of his or her individuality. *Interaction between facility staff and residents will demonstrate that each resident's self-worth is maintained or enhanced, as by the following: -7. Residents will be addressed by name of each resident's choice. Staff will speak with courtesy, listen with care, and treat residents with respect. Interview on 10/21/15 at 10:00 a.m. with the interim administrator revealed: *Residents 1, 2, 5, and 7 were alert. *She agree those examples provided by the residents were examples of breeches of dignity. *She had not been aware of those residents' concerns.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure skin integrity (normal condition) was maintained for 8 of 15 sampled residents (3, 8, 9, 10, 11, 12, 14, and 15) who had skin breakdown after moving into the facility. Findings include: 1. Review of the provider's 10/20/15 Pressure Sores list revealed nine out od forty-two residents currently residing in the facility were listed as having facility acquired (caused after admission to the facility) pressure ulcers (injury to skin from pressure and frequently over a bony area). That was a 21.43 percent (%) rate. About one in four residents had obtained a pressure ulcer while living in the facility. 2. Review of resident 3's medical record revealed the most current Minimum Data Set (MDS) assessment had been completed on 7/27/15 and revealed: *He scored a fifteen on his Brief Interview for Mental Status (BIMS) evaluation (interview to determine ability to reason) indicating he was alert and able to answer questions. *His Activities of Daily Living (ADL)(daily tasks including dressing, grooming, getting in and out of bed, bathing, eating) evaluation indicated he needed limited to extensive assistance of one staff member. *He had limitations with one of his legs. *He had been at risk for developing a pressure ulcer. *He had not been on a toileting and repositioning program. *He had not been on a nutrition or hydration (fluid)intervention program. *His 7/27/15 Braden score (assessment for predicting pressure ulcer development) had been seventeen indicating he was at risk for developing pressure ulcers. Review of the provider's following reports revealed: *The 10/21/15 Urinary Continence one indicated he had been frequently incontinent (loss of control). *The 10/21/15 Bowel Continence one indicated he had been occasionally incontinent. *He had not been included on the provider's 10/21/15 moisture associated skin damage (MASD) list. Review of the physician's orders [REDACTED]. The physician had ordered a medication for that rash. Review of the revised 5/20/15 care plan revealed: *Focus area: The resident has an ADL (activities of daily living, dressing, toileting, personal hygiene, and bathing) self-care performance deficit r/t (related to) stroke, dementia (unable to think well enough to do normal activities; forgetful). *Goal had been: The resident will maintain current level of function through the review date. *Interventions were: -I require extensive assistance of 1 for dressing, toileting, personal hygiene, bed mobility, transfers, and bathing. -Hand written and dated 5/20/15 I prefer to change clothes Q (every) 3 days and resist changing when clothes are soiled. *Focus area: The resident has potential for impairment to skin integrity r/t urinary incontinence and diabetes (lack of blood sugar control). *Goal had been The resident will maintain or develop clean and intact skin by the review date. *Interventions were: -Report skin changes to charge nurse. -Assist resident to reposition Q 2 hours. -9/4/15 [MEDICATION NAME] (prescription) cream to MASD as ordered -9/21/15 [MEDICATION NAME] (specific type of dressing) to P.U. (pressure ulcer) change Q 3 days and PRN. Review of the provider's skin assessment book revealed resident 3 had: *On 3/13/15 a pinpoint open area on his scrotum (posterior(back)) from moisture and friction. That area had healed on 4/2/15. *On 8/6/15 a rash on inner back of both legs. The right leg rash measured 10 centimeters (cm; unit of measurement, and 2.5 cm equals one inch) X (by)11 cm with no drainage. The left leg rash measured 15 cm X 12 cm with no drainage. -According to the documentation that rash took one and one-half months to heal. Interview on 10/20/15 at 8:50 a.m. with resident 3 revealed the night CNAs (certified nursing assistant): *Leave you on the toilet so now I don't use it anymore. *He stated he was unable to control his bladder. *Sometimes they changed his incontinent product (disposable brief) and sometimes they did not. *He had sores on his bottom from being left sitting on the stool and being wet in the past. 3. Review of resident 8's medical record revealed the most current MDS assessment completed on 9/16/15 revealed: *A Braden score of sixteen indicating she was at risk for a pressure ulcer. *No toileting or repositioning program. *No nutrition intervention program. Review of the provider's skin assessment book revealed resident 8 had: *A pressure ulcer on her left buttock noted on 8/19/15. -It had been a stage two (partial loss of skin causing a shallow open ulcer) when found. -Measured 1.4 cm X 0.7 cm X 0.1 cm. -Nutritional/hydration status for food intake had been below 50% (percent). -Preventative measures were: -Turned q (every)1-2 hours. -Duoderm (specialized dressing) to the area. -Lay down in bed on right side in am and pm. *On 8/25/15 that ulcer: -Continued to be a stage two. -Measured 1.1 cm X 1.4 cm X 0.1 cm. -Nutritional/hydration status for food intake had been below 50%. -Preventative measures: --Turned q 1-2 hours. --Lay on side while in bed between meals et (and) noc (night) as allows/cooperates. *On 9/10/15 the ulcer: -Continued to be a stage two. -Measured 0.9 cm X 0.6 cm X 0.1 cm. -Nutritional/hydration status for food intake had been below 50%. -Preventative measures: --Repositioning side to side in bed. --Laying down between meals when resident allows. *On 9/17/15 the ulcer: -Continued to be a stage two. -Measured 1.1 cm X 0.8 cm X 0.1 cm. -The nutrition/hydration status had not been evaluated. -Preventative measures remained the same as above. -Response to treatment stated Area cleansed polymem (specialized dressing) applied. *On 9/24/15 the ulcer: -Continued to be a stage two. -Measured 0.6 cm X 0.7 cm X (symbol meaning less than) 0.1 cm. -The nutritional/hydration status revealed resident losing weight and food intake below 50%. -Preventative measures remained the same. *On 10/1/15 the ulcer: -Continued to be a stage two. -Measured 0.5 cm X 0.5 cm X (symbol for less than) 0.1 cm. -Response to treatment: Area decreasing in size. Resident lays down in bed between meals on right side. -The nutritional/hydration status revealed food intake below 50%. -Preventative measures: --Lays in bed on right side between meals et (and) at noc (night). --Repo (reposition) Q 1-2 hrs (hours). *On 10/8/15 the ulcer: -Continued to be a stage two. -Measured 0.8 cm X 0.5 cm X 0.1 cm. -Response to treatment: Area larger since last week. Duoderm replaced - Rolls off moist skin easily. -Preventative measures: --Turned q 1-2 hours. --Enc (encouraged) to lay on side after meals. -The nutritional/hydration status stated Food intake had been 50-75% and below 50%. *On 10/15/15 the ulcer: -Continued to be a stage two. -Measured 0.5 cm X 0.5 cm X (symbol for less than) 0.1 cm. -The nutritional/hydration status: --Actual weight-losing. --Food intake-50-75% and below 50%. -Preventative measures: --Turned q 1-2 hrs. Repos (repositions) self at times. --Rest after ea (each) meal on side. On 10/1/15 an open area on coccyx (end of the spine; tail bone) crease had been identified. -It was a stage two when found. -It measured 0.5 cm X 0.4 cm X (symbol for less than) 0.1 cm. -Duoderm (specific dressing) applied. -Nutritional/hydration status: food intake below 50%. -Preventative measures: --Turned q 1-2 hrs. --Resident to lay down on side while in bed. Between meals et noc. --Repo Q 1-2 hrs. *On 10/8/15 the ulcer: -Continued to be a stage two. -It measured 0.7 cm X 0.3 cm X (symbol for less than) 0.1 cm. -Nutritional/hydration status not addressed on that evaluation. -Preventative measures: --Turn q 1-2 hrs as allows (hand written). --Encouraged to lay down after both am et noon meals. *On 10/15/15 the sheet had been completed and then a diagonal line had been drawn through it and stated omit. As in the information place on 10/15/15 was incorrect. Review of the following 10/21/15 provider's reports revealed: *The MASD indicated she had skin impairment caused by moisture. *The Urinary Continence one indicated she had been frequently incontinent. *The Pressure Sores one indicated she had a facility acquired pressure sore. 4. Review of resident 9's medical record revealed: the most current MDS assessment had been completed on 8/27/15 revealed. *The ADLs indicated she needed extensive assistance of two staff members. *She had limitations with one of her legs. *She had been at risk for developing a pressure ulcer. *She had not been on a toileting and repositioning program. *She had not been on a nutrition or hydration intervention program. Resident 9's 8/27/15 Braden score had been seventeen indicating she was at risk for pressure ulcers. Review of the following 10/21/15 provider's reports revealed: *The Urinary Continence one indicated she had been occasionally incontinent. *She had not been included on the provider's 10/21/15 MASD list. *The Pressure Sores indicated she had a facility acquired pressure sore. Review of the provider's skin assessment book revealed resident 9 had a pressure ulcer on her right outer ankle: *Onset 9/24/15. -The size was 0.6 cm X 0.8 cm. -Unstageable (unable to determine depth) due to dark purple and black in color. -Interventions: --Reposition every one to two hours. --Float (keeping the pressure off) heels. --No shoe to be worn. *On 10/1/15 the ulcer: -Was 0.5 cm X 0.7 cm in size. -Continued to be unstageable. -treatment of [REDACTED]. *On 10/8/15 the ulcer: -Was 0.5 cm in diameter. -Continued to be unstageable. -No change in the treatment. *On 10/15/15 the ulcer: -Was 0.5 cm X 0.7 cm in size. -Continued to be unstageable. -No change in the treatment. Resident 9's care plan had been requested on 10/21/15 at 7:30 a.m. from the director of nursing . It had not been received prior to exit of the survey on 10/21/15 at 12:00 noon. 5. Review of resident 10's medical record revealed the most current MDS assessment had been completed on 7/6/15. *The ADLs indicated he needed supervision. *He had not been at risk for developing a pressure ulcer. *He had not been on a toileting or repositioning program. *He had not been on a nutrition or hydration intervention program. Resident 10's 7/6/15 Braden score had been twenty indicating he was not at risk for developing pressure ulcers. Review of the 10/21/15 provider's following reports revealed: *The Urinary Continence one indicated he had been continent. *The MASD report indicated he did not have skin impairment caused by moisture. *The Pressure Sores one indicated he had a facility acquired pressure sore. Review of the provider's skin assessment book revealed a pressure ulcer on the top of resident 10's his left foot. *Onset 9/7/15. -It had been a stage two (partial loss of skin causing a shallow open ulcer). -It measured 0.5 cm X 0.4 cm. with depth zero with a line through it. -Interventions were switch shoes and use grippy socks. *On 9/14/15 the ulcer: -Continued to be a stage two. -Measured 0.4 cm in diameter and a zero with a line through it for depth. -Interventions: awaiting new shoes. *On 9/21/15 the ulcer: -Continued to be a stage two. -Measured 0.3 cm with a dash (-) in the depth measurement column. -No change in the interventions. *On 9/28/15 the ulcer: -Continued to be a stage two. -Measured 0.3 cm with a dash in the depth measurement column. -No change in the interventions. *On 10/5/15 the ulcer: -Continued to be a stage two. -Measured 0.3 cm X 0.3 cm with a dash in the depth measurement column. -No change in the interventions. *On 10/12/15 the ulcer: -Continued to be a stage two. -Measured 0.3 cm X 0.3 cm with a dash in the depth measurement column. -No change in the interventions. Review of resident 10's care plan revealed: *A revision on 10/1/15 for a Stage II (2) P.U. (pressure ulcer) L (left) foot near great toe - new shoes-observe for friction. *A revised 5/5/15 focus area of The resident is occasional incontinence r/t Dementia. I will occasionally urinate in inappropriate places. -Goal had been: The resident will be continent during waking hours through the review date of 7/6/15. -Interventions were: --Incontinent: Check resident and assist him to the bathroom every 2-3 hours while awake and as required for incontinence. Assist with peri-care (cleaning of bottom) 2 x daily and as needed. Change clothing PRN (as needed) after incontinence episodes. --W/P (whirlpool) bath weekly, report changes in skin to the charge nurse. 6. Review of resident 11's medical record revealed: the most current MDS assessment had been completed on 8/10/15 and revealed: *The ADLs indicated he had been independent except for bathing. *He needed limited assistance of one staff member for bathing. *He had not been at risk for developing a pressure ulcer. *He had not been on a toileting or repositioning program. *He had not been on a nutrition or hydration intervention program. The 8/10/15 Braden score had been twenty-two indicating he had not been at risk for a developing pressure ulcer. Review of the 10/21/15 provider's following reports revealed: *The Urinary Continence one indicated he had been continent. *The Bowel Continence one indicated he had been continent. *The MASD one indicated he did not have skin impairment caused by moisture. *The Pressure Sore one indicated he had a facility acquired pressure ulcer. Review of the provider's skin assessment book regarding resident 11 revealed: *Pressure ulcer onset 9/15/15 on his right ankle at a stage two. -The ulcer measured 0.4 cm X 0.6 cm with no depth documented. -Duoderm had been applied. -Intervention had been Turned q 1-2 hrs. *On 9/25/15 the ulcer: -Continued to be a stage two. -Measured 0.4 cm X 0.6 cm with unknown as depth. -Response to treatment: --Has scabbed area. --Dark purple/red area dry. --Duoderm in place. -Preventive measures: --Turned q 1-2 hrs. --Encouraged to reposition self to keep pressure off area. --Float heels/ankles in bed. *On 10/8/15 the ulcer: -Continued to be a stage two. -Response to treatment: --Patient reports (symbol to indicate increase) pain with this area. --Fax sent requesting scheduled pain relief. -Preventive measures: --Turned q 1-2 hrs. --Float heels/ankles. --Repos self at times. *On 10/15/15 the ulcer: -Continued to be a stage two. -Measured 0.8 cm X 0.8 cm X 0.1 cm. -Response to treatment: Removed Duoderm wash area et placed new Duoderm. -Preventive measures were Turned q 2 hrs. *The skin assessment pressure book revealed a pressure ulcer on 9/18/15 on his left ankle at a stage two. -It measured 0.5 cm X 0.5 cm X (symbol indicating less than) 0.1 cm. -Response to treatment: --Circular area difficult to visualize sl (slight) posterior of left ankle bony prominence, cream/white/sl yellow wound bed. --Denies pain. --Edges sl macerated (soft) post bath. --Likely from laying on left side to relieve pressure on right ankle area. -Preventive measures were Turned q 2 hrs. *On 9/25/15 the ulcer: -Continued to be a stage two. -Measured 0.5 cm X 0.5 cm X (symbol indicating less than) 0.1 cm. -Response to treatment: --Area unchanged. --Yellow/cream colored wound bed. --Duoderm on place. -Preventive measures: --Turned q 1-2 hrs. --Encourage resident to keep pressure off area. --Floating ankles/heels. *On 10/9/15 the ulcer: -Continued to be a stage two. -Measured 0.5 cm X 0.4 cm X (symbol indicating less than) 0.1 cm. -Response to treatment: Little change. -Preventive measures: --Turned q 1-2 hrs. --Repos self at times. --Float heels/ankles. *On 10/15/15 the ulcer: -Continued to be a stage two. -Measured 0.5 cm X 0.5 cm X 0.1 cm. -Response to treatment: Removed old Duoderm washed et dried area then place new Duoderm. -Preventive measures: Turned q 2 hrs. Review of the 8/12/15 care plan revealed: *Focus area: The resident has potential impairment to skin integrity. Hand written below that was 9/18/15 Pressure sores to left and right ankle. *Goal: The resident will maintain or develop clean and intact skin by the review date. *Interventions: -Report changes in skin to charge nurse. -Assist me with peri care 2 x daily as I allow. -Duoderm (symbol for change) q with a line over it (every) 3 days & (and) PRN. 7. Review of resident 12's medical record revealed the most current MDS assessment had been completed on 9/24/15. The ADLs indicated she needed extensive assistance with ADLs *She had been at risk for developing a pressure ulcer. *She had not been on a toileting and repositioning program. *She had been on a nutrition or hydration intervention program. The 10/17/15 Braden score had been fifteen indicating she had been at risk for developing a pressure ulcer. Review of the 10/21/15 following reports revealed: *The Urinary Continence one indicated she had been frequently incontinent. *The Bowel Continence one indicated she had been frequently incontinent. *The MASD one indicated she had skin impairment caused by moisture. *The Pressure Sore one indicated she had a facility acquired pressure ulcer. Review of the provider's skin assessment book revealed: *A pressure ulcer on 6/27/15 on her coccyx. -It was a stage three to four (full thickness tissue loss with possible exposed bone, tendon, or muscle). -It measured 7 cm X 5 cm X 2.5 cm with serous scant exudate (small amount of thin watery drainage). -No odor. -The wound bed was pink, moist. -Response to treatment: --[DEVICE] (vac; device to drain a wound) to area. --Noted scant serous drainage prior to applying treatment. -Nutritional status: food intake 50-75%. -Preventive measures: --Turned q 1-2 hrs. --Pressure relieving interventions mattress. Supplements TID (three times a day)). -High protein supplements had been checked. *On 7/31/15 the ulcer: -Was a stage three to four. -Measured 7 cm X 5 cm X 2.0 cm with serous small exudate. -Had no odor. -The wound bed was pink, moist. -Response to treatment: --Wet to dry dressing to area. --Changed after bath. --Nutritional supplements TID. -Preventive measures: --Turned q 1-2 hrs. --Pressure relieving interventions mattress. -High protein supplements had been checked. *On 7/10/15 the ulcer: -Was a stage three to four. -Measured 6 cm X 4.5 cm X 2 cm. -It had small serous exudate an had no odor. -The wound bed was pink et moist. -Response to treatment: --Wet-to-dry dressing changed BID (twice a day). --Area (down arrow) (decrease) in size. --Wound pink et moist with small area that has tan drainage. --No odor. --Does have reddened surrounding area d/t moisture from wet-to-dry. --Cream applied. -Nutritional status: food intake had been 50-75%. -Preventive measures: --Turned every 1-2 hours as allows. --Pressure relieving interventions mattress. --High protein supplements. *On 7/20/15 the ulcer: -Was a stage three to four measuring 6 cm X 5 cm X 2 cm. -It had small purulent (containing pus) exudate. with no odor. -The wound bed was pink/white moist. -The response to treatment: --Wet to dry dressing changed BID. --Area moist. --Patient tolerated ok. -Nutritional status: food intake had been 50-75%. -Preventive measures: --Turned every 1-2 hours as allows. *On 7/29/15 the ulcer: -Was a stage four measuring 5 cm X 3.5 cm X 3.5 cm. -There was yellow, sm (small) amt (amount) exudate with no odor. -The wound bed was pink, white, scant yellow plaques (build up). -Response to treatment: --Wet to dry dressing cont. (continued) BID. --Interior of wound moist. --No heat, swelling or odor. --Area reduced in size. --TAC (special prescription cream) to areas of buttocks surrounding wound. --Area improving. -Nutritional status had not been addressed. -Preventive measures: --Turned every 1-2 hours as allows. --Pressure relieving interventions, mattress. *On 8/4/15 the ulcer: -Was a stage four measuring 4 cm X 3 5 cm X 3 cm (standing) and 4.5 cm X 4 cm X 2 cm (laying on R (right) side. -There was no odor. -The wound bed was pink moist, some slough (dead tissue separating from living tissue) to (L) (left) inner side. -Response to treatment: --Wet to dry dressing being changed BID. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions mattress, W/C (wheelchair) cushion (pressure redistributing) --High protein supplements. --Multivitamins *On 8/10/15 the ulcer: -Was a stage four. -It measured standing 4.2 cm X 4 cm X 3.7 cm at deepest area of tunneling (creating a channel). -There was mod (moderate) yellow slough with no odor. -The wound bed was red, pink, yellow slough in places. -Response to treatment: --Note wet to dry dressing (zero with a line through it) (none) remove dry (capitalized) remains wet (c with a line over it) (with) slough present also. -- Patient (resident) only partially coop (cooperative) during measurements. --(Zero with line through it, no) C/O (complaints of) pain regarding area. --At times uncoop (uncooperative) with repo (reposition) et cares. -Nutritional status: food intake 50-75% checked and below 50% with 'at times' hand written below circled. -Preventive measures: --Turned every 1-2 hours as allows. --Pressure relieving interventions mattress, W/C cushion. --High protein supplements and multivitamins. *On 8/18/15 the ulcer: -Was a stage four measuring 3.8 cm X 4.0 cm X 3.6 cm. -There was yellow dng (drainage) small amt exudate. -There was 1.8 cm tunneling -The box titled odor had a diagonal line drawn through it. -The wound bed was red (c with a line over it) (with) scant yellow slough. -Response to treatment: --Area reducing in size slightly. --(Zero with a line through it) (No) C/O pain. --Packing to area falls out easily. --[MEDICATION NAME] placed over 2nd (second) packing place this date. -- Notably fewer areas of yellow slough noted to wound bed. -Nutritional status had not been addressed. -Preventive measures: --Turned every 1-2 hours as allows. --Pressure relieving interventions air mattress, WC (wheelchair) cushion. --High protein supplements hand written above it was frequent refusals. --Multivitamins hand written beside it was DC'd (discontinued) 8/18/15. *On 8/24/15 the ulcer: -Was a stage four measuring 3.8 cm X 4.0 cm X 2.8 cm. -It had brownish mild to mod (moderate) exudate. -There had been 1.2 cm tunneling.-(Zero with a line through it) C/O pain. -The wound bed was red (c with a line over it) scant yellow slough. -Response to treatment: --Depth reducing requiring less packing. --(Zero with a line through it) C/O pain during packing (triangle with an 's) (changes). --Difficulty keeping packing in place with [MEDICATION NAME] due to moisture in crease area. -Nutritional status had not been addressed. -Preventive measures: --Turned every 1-2 hours as allows. --Pressure relieving interventions air mattress, WC cushion. --High protein supplements hand written above it was frequent refusals. --Multivitamins hand written beside it was DC'd (discontinued) 8/18/15. *On 8/31/15 the ulcer: -Was a stage four measuring 2.5 cm X 3.0 cm X 2.4 cm. -It had yellow/small exudate with faint foul odor. -The tunneling had not been addressed. -The wound bed had been red (c with line over it) with areas of white/yellow slough. -Response to treatment: --Area decreasing in size. --Dressing packing changed after bath. --No C/O pain (c with line over it) with dressing change. -Nutritional status: food intake stated 50-75%. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions mattress, WC cushion. --High protein supplements.*On 9/10/15 the ulcer: -Was a stage four measuring 2.5 cm X 3.0 cm X 2.4 cm. -It had yellow/small exudate with foul odor. -The tunneling had not been addressed. -The wound bed had been red (c with line over it) with yellow edges. -Response to treatment: --Area decreasing in size. --Packed with [MEDICATION NAME] (specialized dressing) after bath (c with line over it) with dressing applied. --No pain (c with line over it) with dressing placement. -Nutritional status, Food intake stated 50-75%. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions mattress, WC cushion. --High protein supplements. *On 9/17/15 the ulcer: -Was a stage four measuring 2.5 cm X 3.0 cm X 2.4 cm. -It had yellow/small exudate. -The tunneling had not been addressed. -The odor box had a zero with a line through it (no). -The wound bed had been red/yellow plaques. -Response to treatment: --Area decreasing in-depth et overall dimensions. --Repacked with [MEDICATION NAME] AG (p with line over it) (after) bath it clear dressing applied over. --Zero with line over it (no) pain with dressing change. -Nutritional status: food intake stated 50-75%. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions air mattress. --High protein supplements hand written above it was occ (occasional) refuses. *On 9/24/15 the ulcer: -Was a stage four measuring 2.0 cm X 2.5 cm X 2.2 cm. -It had yellow/small exudate with faint odor. -The tunneling had not been addressed. -The wound bed stated pink with tan patches. -Response to treatment: --Area decreasing in size. --Dressing changed as ordered. -Nutritional status: food intake stated 50-75%. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions were repo onto side when in bed. --High protein supplements. *On 10/1/15 the ulcer: Was a stage four measuring 2.0 cm X 2.5 cm X 2.2 cm. -It had yellow/small exudate. -The tunneling had not been addressed. -The odor box stated none. -The wound bed stated pink/moist with white/tan patches. -Response to treatment, Area unchanged from last measurement. -Nutritional status: food intake stated 50-75%. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions were: --Mattress. --Reposition onto right side while on bed. --Lay down between meals. *On 10/8/15 the ulcer: -Was a stage four measuring 2.0 cm X 2.5 cm X 2.3 cm. -It had small amt brownish exudate. -The tunneling had not been addressed. -The odor box stated mild. -The wound bed stated pink/light brown. -Response to treatment: --Little change. --Replaced gauze dressing. -Nutritional status: food intake stated 50-75%. -Preventive measures: --Turned every 1-2 hours. --Pressure relieving interventions were: --Mattress. --Repo to sides in bed. --Laying down between meals. *On 10/11/15 the ulcer: -Was a stage four measuring 3.0 cm X 4.0 cm X 3.0 cm. -It had green purulent exudate with foul odor. -The tunneling had not been addressed. -The wound bed stated pink and brown-tan areas X 3. -Response to treatment: --Assessment done wide open while resident standing with easy stand (mechanical lift). --Necrotic (dead) brown area inside right wound edge 1.4 cm X 0.5 cm with occ (occasional) drip of bl.ing (bleeding) noted from site. --Left inside of wound edge 0.7 cm X 0.5 brown eschar --Inside to back of wound tan eschar area 1.2 cm in diameter. --Rest of inside wound pink in color. --Repacked with gauze. --No pain expressed. -Nutritional status: --Food intake: 50-75%. --Hand written in by actual weight was loss the past week. -Preventive measures: --Turned every 2 hours. --Pressure relieving interventions were: --Air mattress on bed. --Repo in bed and lay down after meals or in recliner to her side. --High protein supplements. Review of the 4/29/15 care plan revealed: * Focus: I am on a regular diet and once weighted close to 300 lbs (pounds). -Goal: I will maintain my weight between 150-155 # (pound) this quarter. -Interventions: --On 6/26/15 NIP (nutrition intervention program) d/t weight loss. --Offer me substitutes if I am not eating. --I like to look out window at meals. --Weigh weekly, monitor for [MEDICAL CONDITION]. *Focus: I have an ADL (activities of daily living, dressing, toileting, walking, locomotion (moving), and personal hygiene) self-care performance deficit r/t dementia. -Goal: The resident will maintain current level of function in adls through the review date. -Interventions: Extensive assist of 2 for bed mobility, transfer, walk in room/corridor, loc (locomotion) on/off unit, dressing, toilet and personal hygiene. *Focus: Skin and hand written on 6/26/15 Stage III-IV (three to four) pressure ulcer to sacrum. -Goal: I will maintain clean and intact skin by the review date. -Interventions: --On 7/21/15 Redistributing pressure cushion/mattress. --7/21/15 Supplements TID (three times a day) between meals. --Remind me of the importance of repositioning Q (every) 2 hours. I am able to make major/frequent changes in position independently. --Whirlpool bath weekly. --Skin changes to be reported to charge nurse. *Focus: Bowel/Bladder: I am incontinent of bowel and bladder. I have constipation. -Goal: The resident will have no skin breakdown r/t incontinence. -Interventions: --I wear incontinent products. --On 7/3/15 Pericare 2 X daily and PRN. Review of the provider's nursing notes revealed she had recently been hospitalized for [REDACTED]. Those notes revealed: *10/17/15 admitting [DIAGNOSES REDACTED]. -Resident has catheter (tube in bladder to drain urine) and is incontinent of bowel. -Changes to wound treatment, now hydrogen peroxide diluted with saline. -Returned with PICC (intravenous catheter for antibiotic therapy) line to right arm with IV (intravenous) antibiotics BID. *10/19/15 nurses note stated: -Resident is post hospitalization for debridement of coccyx wound that was showing signs of necrosis. Random observations from 10/19/15 at 7:30 p.m. through 9:30 p.m. revealed resident 12 sat in her wheelchair and had not been repositioned in over two hours. Interview at that time with CNA B and LPN C revealed: *She was one of the last residents to go to bed because she was loud at times when in bed. *She sat at the nurses station from after supper to bedtime to watch the happenings while other residents were put to bed. She sat from 5:30 p.m. until 9:30 p.m. before she had been repositioned. Review of the dining times revealed supper had been served at 5:30 p.m. 8. Review of resident 14 medical record revealed: *The most current MDS assessment had been completed on 7/6/15. *ADLs indicated he had needed extensive assist

br> Based on observation, record review, interview, and policy review the provider failed to maintain adequate staff to prevent resident care issues related to abuse, neglect, and dignity, and meet basic care needs to ensure the well-being of all residents in the facility. Findings include: 1. Interview with staff who wish to remain confidential during the survey revealed they did not believe there was enough staffing to properly care for residents. Refer to F224, findings 8 and 9. 2. Residents had not been free of abuse and neglect. Refer to F223, all findings. 3. Residents' dignity had not been maintained. Refer to F241, all findings. Surveyor: 4. Review of the provider's 2015 Turnover report listed the following number of employees had been terminated or quit: *January: One. *February: Two. *March: Three. *April: Five. *May: Four. *June: Three. *July: Two. *August: None. *September: Three. *October 1 through 20: Four. January through October 20, 2015, twenty seen employees had either been terminated or quit. Surveyor 5. Interview on 10/21/15 at 10:00 a.m. with the administrator revealed: *Staffing was hard to find in rural areas. *Current staff had stepped up to fill in the gaps. *She had implemented a program to cross train staff into multiple departments. *Licensed nursing staff were responsible for monitoring aides and reporting any issues back to management. *Licensed nursing staff were expected to take any issues with staff to that person right away. *When looking at hiring someone, administration looked at the board of nursing website and did a background check to make sure they qualified. *She tried to place staff into groups where they worked with residents they got along best with. -That was to help with staff burnout. -Residents could form closer relationships with staff in many departments. *Staff had preceptors they could talk to if they became frustrated about work. *Staff were monitored every two months for how much overtime they worked to watch for burnout. *She did not feel there were not enough staff to take care of all the residents' needs. Review of the provider's undated Resident Rights policy given to all residents on admission revealed residents had the right to: *Be treated with respect and dignity. *Be free from physical/mental abuse. *Have reasonable accommodation made. *Trained staff. *Voice grievances.

br> Based on interviews, observations, record reviews, and policy reviews throughout the course of the survey from 10/19/15 through 10/21/15 revealed the administration had not ensured all residents attained and/or maintained their highest practicable physical, mental, and psychosocial well-being. Findings include: 1. Refer to F223, F224, F226, F278, F280, F314, and F353. 2. Review of the provider's job descriptions revealed: *CNA summary-Performs the functions of a nursing assistant in carrying out all assignments given by the RN or LPN in charge of the facility. Is accountable for all residents' care he/she is assigned during a shift. He/she is responsible for promoting teamwork among co-workers and personal self-development. Maintain confidentiality of information regarding residents, families, health care personnel and (facility name). Consequences of Action: Failure to comply with department and or (facility name) policies will result in disciplinary action as outlined in our employee handbook. *Charge Nurse registered nurse (RN)/ licensed practical nurse (LPN)-The primary responsibility of this position is to take responsibility for supervision and providing quality care to our residents in a friendly home-like atmosphere, while allowing them to make choices. This is done in accordance with our policies, procedures, and the state and federal guidelines and your scope of practice. *The last page of the job description number 31 stated Report any resident abuse IMMEDIATELY (That was bolded and capitalized). *An administrator job description had been requested but was not provided by the time of the survey exit at 12:00 noon on 10/21/15. Surveyor: Review of the provider's 1/1/09 Hiring policy revealed: *The following criteria will be considered in determining whether an applicant is qualified for a particular job position: -Ability to perform the essential functions of the job (with or without reasonable accommodations); -Skill, knowledge, training, efficiency, ets.; and -Certifications and licenses. The administrator will determine how to seek applicants from outside the facility.

br>Based on record review, interview, and policy review, the provider failed to ensure an effective quality assurance (QA) program had been maintained to identify concerns within the facility and to develop and implement corrective action for issues involving pressure ulcers (injury to the skin usually from pressure and over bony area), abuse, neglect, dignity, and staffing concerns. Findings include: 1. Interview on 10/21/15 at 10:00 a.m. with the administrator revealed: *The facility was transitioning from their traditional QA plan to a different Quality Assurance and Performance Improvement (QAPI) program. *They would keep their current QA plan in place until QAPI was fully implemented. *They had started QAPI activities such as using performance improvement projects (PIP) to address quality issues. *They had done falls and were currently working on a pressure ulcer PIP. Review of the provider's 1/15/13 Quality Assessment and Assurance Committee policy revealed: *The purpose of the QA committee was to ensure the facility maintains a high level of quality care of its residents. *The committee was responsible for identifying issues and concerns related to quality deficiencies and develop plans to improve them. Refer to all findings in F223, F224, F226, F241, F278, F314, F353, and F490. Surveyor: An Attempt was made to reach the medical director for a phone interview on 10/21/15 however he was not in the office.

br> Based on interview, job description review, and policy review, the provider failed to implement policies to prevent neglect for four of eight interviewed sampled residents (1, 2, 3, and 5). Findings include: 1. Interview with resident 1 on 10/19/15 at 7:45 p.m. revealed there had been times when staff had refused to provide services when she requested. Refer to F223, finding 1. 2. Interview with resident 2 on 10/20/15 at 9:00 a.m. revealed there had been times when staff had refused to provide services when she requested. Refer to F223, finding 2. 3. Interview with resident 3 on 10/20/15 at 8:50 a.m. revealed there had been times when staff had refused to provide services when he requested. Refer to F223, finding 3. 4. Interview with resident 5 on 10/20/15 at 9:50 a.m. revealed there had been times when staff had refused to provide services when she requested. Refer to F223, finding 4. 5. Interview during the survey with anonymous staff revealed: *The director of nursing (DON) and the administrator did not regularly help on the floor and pass medications. *Staff worked short handed if no one offered to pick up overtime hours. *Staff were told to just work faster and were fed up. *Residents had constant complaints about CNA A and B during the night shift. *They would come in the morning and residents would cry to them, because they had not been changed at night. *One anonymous staff had come in for morning shift and found at least eight residents' beds that had not been changed and were soaked with urine. -Beds had been double-padded (with a second soaker pad to soak up urine) instead of being changed. *They had brought resident complaints to the director of nursing (DON) and administrator and nothing was done. *If they complained about the night shift they were asked well do you just want to work that shift. *No one they report to will do anything. *One anonymous staff person had been threatened by night staff to physically harm her, because she had brought up complaints to the DON and administrator. *One anonymous staff person had been text messaged threatening statements to her personal cell phone, because they found out she had reported complaints. Interview with an staff who wish to remain confidential revealed: *That staff felt they had to get out of here. *Residents were being neglected, because they (staff) can't keep up. *She could not sleep at night, because she was worried about if residents were getting taken care of. *Residents were not getting toileted, because were are so short handed. -Residents that were usually pretty continent were having multiple pairs of pants show up daily in laundry, because they were not getting toileted. *One resident's bed had been left without a pad, and she had been laying in puddles of urine. *That staff person had tried talking to the administrator, and nothing had been done. Review of the provider's job descriptions revealed: *CNA summary-Performs the functions of a nursing assistant in carrying out all assignments given by the registered nurse (RN) or licensed practical nurse (LPN) in charge of the facility. Is accountable for all residents' care he/she is assigned during a shift. He/she is responsible for promoting teamwork among co-workers and personal self-development. Maintain confidentiality of information regarding residents, families, health care personnel and (facility name). Consequences of Action: Failure to comply with department and or (facility name) policies will result in disciplinary action as outlined in our employee handbook. *Charge Nurse RN/LPN-The primary responsibility of this position is to take responsibility for supervision and providing quality care to our residents in a friendly home-like atmosphere, while allowing them to make choices. This is done in accordance with our policies, procedures, and the state and federal guidelines and your scope of practice. *The last page of the job description number 31 stated Report any resident abuse IMMEDIATELY (that was bolded and capitalized). 6. Review of the provider's June 2005 Reporting and Investigating of Resident Abuse, Mistreatment, Neglect, and Misappropriation of Personal Property policy revealed: *Policy statement: -It is the policy of (facility name) to provide an environment free from abuse, mistreatment, neglect, and misappropriation of personal property. - If a violation occurs or is suspected, it is the policy of the facility to investigate the alleged violation and take the appropriate action according to the results. *General statement: -The resident has a right to be free from verbal, sexual, physical, and mental abuse, corporal (physical) punishment, involuntary seclusion, or misappropriation of property or funds. -The facility staff is to be aware of the definitions of abuse as defined by the Federal Government and the State of South Dakota, Department of Health, Office of Health Care Facilities Licensure and Certification. -All staff is to be aware of this policy and procedure and their legal responsibility for following the guidelines. -Residents must not be subjected to abuse by anyone, including but not limited to: facility staff, other residents, consultants, or volunteers, staff of other agencies serving the individual, family members, legal guardians, friends, or other individuals. -(facility name) ensures that incidents of possible abuse and neglect are investigated promptly with reports sent to proper regulatory agencies within the state and federal guidelines. Surveyor: 7. Review of the gray folder at the nurses station titled Grievance forms and policy revealed in the folder were forms to file a grievance. However there was no policy in the folder for staff to refer to. Review of the provider's 1/1/09 Grievance Procedure revealed: *There were specific time frames the grievance form needed to follow. *An employee must follow, in order, each step of this grievance procedure until the grievance is resolved. And employee is not allowed to skip any step of this procedure. *Despite any implementation of this policy, the facility reserves the right to administer disciplinary action against any employee for any reason so long as such disciplinary action is not in retaliation (in response to) for employee's use of the grievance procedure. 8. Review of the provider's 1/1/09 Workplace Violence policy revealed: *It is the policy of this facility that all employees, residents, family members, visitors, contractors, vendors, etc., enjoy a positive, respectful productive, and safe environment while on our premises. *1. Our worksite environment shall remain free of behavior, actions, or language causing or contributing to workplace harassment or bullying. *2. Violence, the treat of violence, or harassment or bullying by or against an employee will not be condoned. *8. Employees who, in good faith, report what they believe to be workplace violence or who cooperate in any investigation will not be subject to retaliation. 9. Interview on 10/21/15 at 10:00 a.m. with the interim administrator confirmed the following: *The social services position had been unfilled since June 2015. The administrator, the director of nursing, and the Minimum Data Set (MDS) nurse had split the responsibilities of that position. *Resident abuse and dignity policies were to have been followed by all staff members. *CNAs were supervised by the licensed staff members. *She was not aware of the residents' concerns. *She was not aware of staff-to-staff retaliation that had been occurring. *She was not aware of the new flow diagram from the South Dakota Department of Health, Office of Licensure and Certification for reporting of abuse and/or neglect.