Every finding on record at Riverview Healthcare Center

Based on observation, interview, record review, and policy review, the provider failed to develop and implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions, accurately assess and monitor refusals, and follow physician's orders for one of one sampled resident (13) identified at risk for developing pressure ulcers, and dependent on the staff assistance with repositioning, who developed an unstageable pressure ulcer to her right heel and a Stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to her coccyx (tailbone). Findings include:1. Observation and interview on 8/25/26 at 2:24 p.m. with resident 13 in her room revealed that she was in bed lying on her back, wearing a hospital gown. A blue foam heel support was on the floor at the end of her bed. Her face appeared thin, and her arms appeared to have reduced muscle mass. She said she was forgetful and was not out of bed yet because she had company. She did not know if she had an open area on her heel. 2. Observation and interview on 8/26/26 at 9:18 a.m. with resident 13 and contracted travel certified medication aide (CMA) EE in resident 13's room revealed resident 13 was in bed lying on her back wearing a hospital gown. A blue foam heel support was on the bed, but not under resident 13's heels. She was confused and asked, What's going on here? She became increasingly upset when she did not understand the surveyor's questions and the surveyor left the room. Contracted travel CMA EE remained in the room while the surveyor remained just outside the door. When contracted travel CMA EE exited resident 13's room, she stated that she did not know whether resident 13 had any pressure areas and that resident 13 was not repositioned while she was in the room because she did not want anything. 3. Observation and interview on 8/26/26 at 3:05 p.m. with resident 13 and certified nursing assistant (CNA) Q revealed that resident 13 was in bed, lying on her back, wearing a hospital gown. A blue foam heel support was on the floor at the end of her bed. Resident 13 was confused, stating that she needed to get home to get ready for a wedding and she had agreed to stay at this place for just one night. 4. Interview on 8/26/26 at 3:07 p.m. with CNA Q revealed that she worked primarily on the first floor, that resident 13 had moved to the first floor about one week ago, and that resident 13 was out of bed and dressed two times that week on the days that CNA QQ had worked. She felt that resident 13 was difficult to care for because resident 13 was confused and angry, yelled frequently, and refused to allow CNA Q to help her. She thought that resident 13 had sores on her bottom and her feet, but was not sure. CNA Q said that resident 13 sometimes allowed her to reposition her. 5. Observations on 8/27/26 from 8:35 a.m. to 2:05 p.m. revealed that resident 13 was in bed positioned on her left side. The blue foam heel support was on the floor at the end of her bed. 6. Interview on 8/27/26 at 2:05 p.m. with CNA U revealed that she was in resident 13's room four times that day to attempt to assist resident 13 to get dressed and out of bed. Resident 13 had refused her breakfast and her lunch; she was not bathed or dressed, said she was having pain, and did not want to be repositioned. CNA U stated that she told CMA V that resident 13 had refused her assistance and that she was in pain. She thought CMA V had reported resident 13's refusal to get dressed, eat, or to get out of bed to contracted travel licensed practical nurse (LPN) R. 7. Interview on 8/27/26 at 2:13 p.m. with contracted travel LPN R revealed that he was the nurse caring for resident 13 that day. No one reported to him that resident 13 had refused to get out of bed, be repositioned, was having pain, and did not eat her breakfast or lunch that day. He was aware that she frequently refused care and her meals. Resident 13 had refused to allow him to complete her heel dressing change that day. He stated that resident 13's physician was aware that resident 13 refused meals and personal care, and that the physician had recommended that the staff keep monitoring resident 13. 8. Review of resident 13's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes Mellitus, (a condition involving disruptions in how the body regulates blood sugar), hypomagnesemia (an electrolyte disorder defined by a low blood serum magnesium level), hypokalemia (a medical condition where the level of potassium in your blood drops below the normal range), sepsis (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection), anxiety, and fractures of her sacrum (tailbone) and left femur (leg). Her 8/11/26 Brief Interview for Mental Status (BIMS) assessment score was 6, which indicated her cognition was severely impaired. Resident 13's 6/10/26, 6/17/26, and 6/24/26 Braden Scale for Predicting Pressure Sore Risk (a tool used to assess the risk of developing pressure ulcers) scores indicated that resident 13 was AT RISK for developing a pressure ulcer. Her 7/2/26 Braden Scale score indicated that she was at MODERATE RISK for developing a pressure ulcer.A 6/10/26 admission Skin/Wound Evaluation revealed that resident 13 admitted to the facility with a right calf (back of lower leg) non-pressure injury and a left hip surgical incision. A 6/16/26 Weekly Wound Evaluation indicated she had a right calf non-pressure injury and that her left hip surgical incision was improving.There was no documentation that the left hip incision was assessed after 6/16/26 or when that incision was healed.The right calf non-pressure injury area was marked healed on 7/14/26. Resident 13's 6/16/26 Minimum Data Set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan (personalized plan that addresses a resident's care needs, goals, and interventions) to manage the resident's care needs) indicated resident 13 was at risk for pressure injuries, had a skin tear, and a surgical wound but did not have any unhealed pressure ulcers. Resident 13 had a pressure-reducing mattress, but no pressure-reducing device for the wheelchair, no turning and repositioning program, and no nutrition or hydration intervention was in place to manage skin problems. Resident 13 required maximum staff assistance with dressing, bathing, and toileting, and moderate staff assistance with transfers and bed mobility. Resident 13 was hospitalized after a fall on 6/21/26 and readmitted to the facility on [DATE] with a sacral fracture.A 6/24/26 admission Skin/Wound Evaluation indicated that resident 13 was readmitted to the facility with a right calf non-pressure injury and a pink blanchable (skin or a red mark that turns white or pale when you press on it and returns to its normal color when you release the pressure) non-pressure injury area to her coccyx.There was no documented response to the question Does the Resident present with a new Skin Impairment? (If yes, proceed to Weekly Wound Evaluation) on her 6/24/26 readmission Nursing Evaluation. A 6/25/26 [name of wound care provider redacted] wound assessment indicated that resident 13 admitted to the facility with a surgical incision to her left hip and a Non pressure injury [that was] superficial to her right lower calf. The primary diagnosis was Stage 2 [II] pressure ulcer to the right lower leg/shin. Resident 13's 6/30/26 significant change MDS assessment indicated resident 13 was at risk for pressure injuries, had a skin tear, and a surgical wound but did not have any unhealed pressure ulcers. Resident 13 had a pressure-reducing mattress and a pressure-reducing device for the wheelchair. No turning and repositioning program was in place, and no nutrition or hydration intervention was in place to manage skin problems. Resident 13 required maximum staff assistance with dressing and bathing and was dependent on staff for toileting, transfers, and bed mobility. A 7/2/26 Weekly Wound Evaluation indicated that she had a left buttocks non-pressure injury skin tear that was 4.5 centimeters (cm) long by 4 cm wide and an 11.4 cm by 4 cm non-pressure maceration (the softening, whitening, and breakdown of skin caused by prolonged exposure to moisture)/shearing and slit to her coccyx. The skin tear to her left buttocks was documented as healed on 7/7/26. A 7/7/26 Weekly Wound Evaluation indicated that she had a 2.5 cm long by 0.5 cm wide Stage II pressure ulcer to her coccyx that was 0.2 cm in depth and that the pressure ulcer was present on admission. A 7/7/26 [name of wound care provider redacted] wound assessment identified that resident 13 had a Stage II coccyx wound, that the age of the wound was unknown. Returned from [a] hospital stay on 6/24/26 - [The wound was] Noted by nursing on 7/2/26, that measured 3.0 cm long by 0.5 cm wide and 0.2 cm deep. The primary diagnosis was Stage 2 pressure ulcer to the right lower leg/shin. And Stage 2 pressure ulcer on the coccyx (tailbone). The treatment goal included to achieve wound closure through TIME principals [principles that provide a clinical framework for chronic wound bed preparation, standing for Tissue, Infection/Inflammation, Moisture, and Edge of wound healing, adequate offloading and [to] prevent recurrence]. A 7/8/26 Weekly Wound Evaluation indicated that she had a 2.5 cm long by 3.5 cm wide suspected deep tissue injury pressure ulcer to her right heel and that the pressure ulcer was present on admission. A 7/14/26 Weekly Wound Evaluation identified the wound site as Heel Right and had a Description Heel Left, which indicated that the wound was improving, and that the wound was not present on admission. The Stage II coccyx pressure ulcer marked present on admission was documented as healed. A 7/14/26 [name of wound care provider redacted] wound assessment indicated that resident 13's right lower calf and coccyx wounds were HEALED, and identified a pressure injury unstageable -fluid filled blister to her right heel that measured 2.5 cm in length by 3.0 cm wide. The treatment goal included resident 13 sleeping on a pressure-reducing mattress and using a pressure-reducing cushion in her wheelchair. Resident 13's 7/17/26 End of PPS (Perspective Payment System) Part A stay MDS assessment indicated resident 13 was at risk for pressure injuries and had one unstageable pressure injury that was not present on admission, refused to get dressed, and required maximum staff assistance with bathing and bed mobility. A 7/21/26 [name of wound care provider redacted] wound assessment indicated that resident 13's unstageable pressure ulcer to her right heel measured 3.0 cm long by 3.5 cm wide, and recommended repositioning every two hours to minimize shearing. A 7/22/26 Weekly Wound Evaluation identified the wound site as Heel left and a Description Heel Left that indicated that the pressure ulcer was unstageable, was not present on admission, measured 3.0 cm long by 3.5 cm wide, and was being monitored by the staff. A 7/28/26 Weekly Wound Evaluation identified the wound site as Heel Right and a Description Heel Right that indicated that the pressure ulcer was unstageable, was not present on admission, measured 3.0 cm long by 3.0 cm wide, and was improving. A 7/28/26 [name of wound care provider redacted] wound assessment indicated that resident 13's unstageable pressure ulcer to her right heel measured 3.0 cm long by 3.5 cm wide, identified a New coccyx slit opening that was moisture associated, with a primary diagnosis of Stage 2 pressure ulcer on the coccyx, and recommended repositioning every 2 hours- side by [to] side. Resident 13 had a 7/29/26 physician's order to Clean skin tear to coccyx with wound cleanser and apply Zinc Oxide [a topical skin protectant that creates a barrier over the skin] to the area with each brief change. Do not scrub zinc oxide off. Contact provider if wound does not improve. An 8/6/26 Weekly Wound Evaluation identified the wound site as Heel Right and a Description Heel Right that indicated that the pressure ulcer was unstageable, was not present on admission, measured 2.0 cm long by 2.0 cm wide, and was improving. Resident 13 was admitted to the hospital on [DATE] and readmitted to the facility on [DATE]. There was no documentation that an admission Skin/Wound Evaluation was completed for resident 13 when she readmitted to the facility on [DATE]. An 8/13/26 Weekly Wound Evaluation identified the wound site as Foot Right and a Description Foot Right, indicated that the pressure ulcer was unstageable, was not present on admission, measured 2.0 cm long by 2.0 cm wide, and was improving. Resident 13's 8/13/26 significant change MDS assessment indicated that resident 13 was at risk for pressure injuries, had one unstageable pressure injury that was not present on admission, and had a pressure-reducing mattress and a pressure-reducing device for her wheelchair. She was not on a turning and repositioning program, and there was no nutrition or hydration intervention in place to manage skin problems. An 8/18/26 readmission Nursing Evaluation indicated that resident 13 did not have a new Skin Impairment. An 8/18/26 [name of wound care provider redacted] wound assessment indicated that resident 13 refused to allow the wound care provider to view the New coccyx slit opening that was identified on 7/28/26. Resident 13's unstageable pressure ulcer to her right heel, identified on 7/14/26, was open, Stage 2, and measured 2.5 cm long by 3.5 cm wide. This document referred to both left heel and right heel without identifying a new area of concern. An 8/20/26 Weekly Wound Evaluation indicated that resident 13 had a First Observation of a non-pressure injury wound on her coccyx that was not present on admission that measured 1.5 cm long x 0.0 cm wide. There was no documentation that a Weekly Wound Evaluation was completed on resident 13's right heel, foot, or left heel after 8/13/26. Resident 13's 6/10/26 through 8/26/26 weight documentation indicated that she had lost 29.1 pounds. On 6/10/26, she weighed 139.0 pounds. On 6/11/26, she weighed 132.7 pounds. On 6/28/26, she weighed 128.3 pounds. On 8/1/26, she weighed 125 pounds. On 8/21/26, she weighed 115.2 pounds. On 8/26/26, she weighed 109.9 pounds.On 8/27/26, resident 13's physician was notified of her 29.1-pound weight loss. 9. Interview and review of resident 13's Weekly Wound Evaluation and [name of wound care provider redacted] wound assessment documentation on 8/27/26 at 4:23 p.m. with director of nursing (DON) B and registered nurse (RN)/regional director C revealed there were several changes in who was responsible for overseeing wound care in the last few months. The most recent wound care nurse, previous RN/wound nurse FF no longer worked at the facility as of 8/25/26 and was unavailable for an interview. RN/regional director C was the acting DON from 7/8/26 until DON B started in that role at the facility on 7/27/26. DON B assumed the position of wound nurse, in addition to her position as DON, on 8/25/26, and was still learning about the residents. They did not know the location of resident 13's pressure ulcers and confirmed inconsistencies in the documentation regarding the ulcers staging, locations, and times of identification. 10. Observation and interview on 8/27/26 at 4:35 p.m. with DON B, RN/regional director C, and resident 13 in resident 13's room revealed that resident 13 was in bed. DON B and RN/regional director C confirmed resident 13 had a foam dressing on her right heel; there was no other wound or dressing on resident 13's right foot. There was no wound or wound dressing observed on resident 13's left heel. Resident 13 refused to allow DON B and RN/regional director C to assess her coccyx area at that time. DON B and RN/regional director C completed a dressing change to resident 13's right heel pressure ulcer and reported that the wound appeared to be healing. 11. Continued interview and review of resident 13's EMR on 8/27/26 at 4:50 p.m. with DON B and RN/regional director C revealed that resident 13 had a 7/28/26 physician's order for Cleanse right heel with wound cleanser, apply betadine solution, cover with telfa [a sterile, non-adherent wound dressing designed not to stick to healing tissue], cover with kerlix [gauze bandage rolls] and secure with medipore tape [a breathable, soft cloth medical tape used to secure wound dressings]. Change every 3 days. That dressing was not the dressing on resident 13's right heel on 8/27/26 at 4:35 p.m. when DON B and RN/regional director C completed the physician's ordered dressing change. RN/regional director C expected the physician's ordered dressing to be on resident 13's right heel, and that the nurse who completed the dressing change would have documented why there was a different dressing used. She was unable to locate any documentation of why the physician's order was not followed. Review of resident 13's Treatment Administration Record (TAR) revealed that dressing changes were documented as completed daily from 8/1/26 through 8/5/26, on 8/12/26, 8/13/26, 8/15/26, daily from 8/17/26 through 8/19/26, and daily from 8/21/26 through 8/25/26. Resident 13 was hospitalized from [DATE] to 8/11/26. RN/regional director C confirmed that the physician's order to change the wound dressing every three days was not followed, and that this could have impacted the healing process. RN/regional director C confirmed that there was no dressing or observed wound on resident 13's left heel or foot. RN/regional director C stated that if the wound care provider's 8/18/26 documentation revealed resident 13 had a primary diagnoses of Stage 2 pressure ulcer of the left heel, Stage 2 pressure ulcer to the right lower leg/shin, and Stage 2 pressure ulcer on the coccyx (tailbone), that she thought the reference to resident 13's left heel in the documentation was an error and that the document should have stated right heel. RN/regional director C stated that on 7/6/26, resident 13's pressure ulcer interventions included a pressure-relieving mattress on her bed and a cushion in her wheelchair, daily inspections of her skin during care, and to administer treatments as ordered. She confirmed that resident 13 was at risk for developing pressure wounds and that she did not have adequate interventions in place to prevent her coccyx and right heel pressure ulcers from developing. RN/regional director C expected that interventions, including heel boots, elevating the heels off the mattress, and turning and repositioning, would have been included in resident 13's care plan when she admitted to the facility to reduce her risk of developing pressure ulcers. RN/regional director C stated that if resident 13 refused those interventions, her refusal should have been documented. She confirmed that there were a limited number of documented days when resident 13 refused care. Resident 13's pressure injury on right foot, which was identified on 7/14/26, was added to the care plan on 7/21/26 with the intervention I have a heel elevator device in my room to help prevent pressure injury on [my] heels. I refuse to use it at times. Please encourage it's [its] use and position it appropriately. DON B expected the CNAs to report resident 13's refusals of care, including eating and repositioning when they occurred, to the nurse in charge of resident 13's care so that they could be documented. The nurse was to notify the resident's physician if needed, and alternative interventions should be attempted. RN/regional director C confirmed that the facility had an all-inclusive skin care policy and that there were no specific policies related to pressure ulcer prevention or wound care. 12. Interview on 8/28/26 at 9:20 a.m. with CNA W revealed that she used the resident's care plan to guide her care of the residents; she worked full-time and felt she knew most of the residents pretty well. She was unsure if there was information in resident 13's care plan related to her pressure ulcers, but stated that there were many contracted travel staff members who worked at the facility. She thought that information would be good to have in the resident's care plan since resident 13 often refused her meals and staff assistance with personal care. 13. Review of the provider's March 2025 CNA Job Description revealed the CNAs performed duties in caring for residents consistent with the plan of care and established long-term care standards. Essential functions included Turns and repositions bedfast residents, alone or with assistance, and utilizing proper body mechanics, to prevent pressure ulcers. The CNAs report to the Licensed Nurse directing and overseeing resident care on assigned unit. 14. Review of the provider's April 2022 Wound Care Certified Specialist Job Description revealed that the Wound Care Certified Specialist was Responsible for planning, coordinating, and documenting wound care. in conjunction with the center's clinical team, develops and implements a wound care plan that meets each patient's specific needs and reflects best practice acts as a consultant and educator to other staff regarding wound/skin care patients and practices. Performs ongoing, accurate and comprehensive wound/skin care assessments of each assigned patient.obtains physician's orders.develops and implements an evidence-based plan of care for each wound care patient.provides clear, concise documentation.provides supervision and mentorship related to wound care for skilled nursing, aides, and therapy staff. 15. Review of the provider's updated March 2026 Skin Integrity policy revealed It is the policy of this center that a resident who enters the center without pressure ulcers/injury does not develop pressure ulcers/injury unless the individual's clinical condition demonstrates that they were unavoidable and a resident having pressure ulcers/injury receives necessary treatment and services to promote healing, prevent infection, and prevent new sores from developing. Upon admission, the licensed nurse (LN) establishes a plan of care based on risk factors or presence of wounds.

Based on observation, interview, record review, and policy review, the facility failed to identify and implement interventions promptly to aid in the prevention of significant weight loss and failed to notify the resident's physician of the significant weight loss for one of one sampled resident (13), who lost 29.1 pounds within two months. Findings include:1. Observation and interview on 8/25/26 at 2:24 p.m. with resident 13 in her room revealed she was in bed wearing a hospital gown. Her face appeared thin, and her arms appeared to have reduced muscle mass. She asked the surveyor if it was lunchtime, indicated she was unsure whether she had eaten anything that day because she was forgetful, stated she was not hungry, and that she would ask for a snack if she became hungry. 2. Review of resident 13's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes Mellitus, (a condition involving disruptions in how the body regulates blood sugar), hypomagnesemia (an electrolyte disorder defined by a low blood serum magnesium level), hypokalemia (a medical condition where the level of potassium in your blood drops below the normal range), sepsis (a life-threatening medical emergency that happens when the body has an extreme, harmful response to an infection), anxiety, and fractures of her sacrum (tailbone) and left femur (leg). Her 8/11/26 Brief Interview for Mental Status (BIMS) assessment score was 6, which indicated her cognition was severely impaired. A 6/10/26 physician's order for Monthly Weights & [and] Vital Signs [measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate]. A 6/11/26 physician's order for Daily weight. Once a day. Notify MD [medical doctor] of wt [weight] change equal to or > [greater than] 3 lbs [pounds] in 2 days or = [equal to] or >5 lbs in a week. Check to see what previous weights have been, with an end date of 6/14/26.A 6/26/26 physician's order for daily weight x 3 [for three] days was marked complete. A 7/1/26 physician's order for Monthly Weights. was discontinued on 8/3/26. An 8/3/26 physician's order for Monthly Weights. was discontinued on 8/5/26. On 6/10/26, resident 13 weighed 139.0 pounds. On 6/11/26, she weighed 132.7 pounds. There was no documentation that resident 13 was weighed on 6/12/26 or 6/13/26 as ordered or that her physician was notified of her 6.3-pound weight loss. There was no documentation that resident 13 was weighed weekly between 6/11/26 and 6/28/26, or that resident 13 was weighed on 6/26/26 or 6/27/26 as ordered. On 6/28/26, she weighed 128.3 pounds. There was no documentation that resident 13's physician was notified of her 10.7-pound weight loss. On 8/1/26, resident 13 weighed 125 pounds. There was no documentation that resident 13's physician was notified of her 14-pound weight loss since her admission to the facility. On 8/21/26, resident 13 weighed 115.2 pounds. There was no documentation that resident 13's physician was notified of her 23.8-pound weight loss since admission to the facility. On 8/26/26, resident 13 weighed 109.9 pounds. She had lost 29.1 pounds. A 6/16/26 Nutrition Evaluation Form indicated that resident 13 weighed 139.0 pounds (her 6/10/26 most current documented weight), had a non-pressure injury to her right lower leg, a surgical wound on her left hip, was at risk for skin breakdown, preferred to eat in her room, and ate between 25-75% (percent) of her meals. Registered dietitian (RD) J recommended Pro Heal supplements daily to aid in wound healing, that her weights were stable, and indicated that those supplements could be discontinued if resident 13 refused them or her meal intakes improved. A 6/30/26 Nutrition Evaluation Form indicated that resident 13 readmitted to the facility from the hospital (on 6/24/26) after a fall, weighed 128.3 pounds, had a 7.7% weight loss in the past 30 days, and that there was no edema (swelling) noted at this time nor at admission. RD J recommended discontinuing the Pro HEAL supplements and starting Calorie Dense Medication Pass supplements for more calories [and] to encourage stable weights. An 8/3/26 Nutrition Evaluation Form indicated that resident 13 acquired a right unstageable heel pressure ulcer that measured 3.0 cm (centimeters) by 3.0 cm and a left unstageable heel ulcer that measured 3.0 cm by 3.5 cm. weighed 125.0 pounds, had a 5% weight loss in 30 days, and a 7.5% weight loss in the past 90 days. Resident 13 was independent with eating her meals in her room, and RD J recommended restarting the Pro HEAL supplements, continuing the Calorie Dense Medication Pass supplements, and to encourage PO (oral) intake at meals. An 8/13/26 Nutrition Evaluation Form indicated that resident 13 readmitted to the facility from the hospital on 8/12/26 related to a urinary tract infection and sepsis. She weighed 125.0 pounds (her 8/1/26 documented weight). Resident 13 was independent with eating her meals in her room, had multiple [meal] refusals over the past 14 days, had a pressure ulcer on her right heel, and RD J recommended increasing the Calorie Dense Medication Pass supplement and that she would continue to monitor for a new weight and monitor PO intakes. An 8/25/26 Nutrition Evaluation Form indicated that resident 13 weighed 115.2 pounds, had a 7.5% weight loss in the past 90 days, and that her weight loss [was] r/t [related to] sepsis while hospitalized , PO intakes are baseline for resident before hospitalization. Resident 13 had pressure ulcers on her right foot and heel, and acquired a non-pressure injury on her coccyx (tailbone) on 8/20/26. RD J requested another weight and indicated, RD [J] recommends keeping current interventions in place to give them time to be effective. Resident 13's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated that on 7/8/26, the Nutrition Hydration focus area was updated to include her risk of losing weight. Interventions included that resident 13 was on a regular diet, she was independent at meals, her dining preferences would be honored, she took Pro HEAL Liquid Protein one time a day, she did not have religious, ethnic, or cultural food preferences, and that the staff members were to observe for signs and symptoms of dehydration. There was no documentation of resident 13's repeated meal refusals, significant weight losses, changes to RD J's recommendations for meal supplements, or when to notify her physician. Resident 13's Nutrition-Meal Monitor documentation indicated that from 8/2/26 through 8/27/26, resident 13 was offered three meals a day on twelve days, two meals a day on six days, and one meal a day on two days. Resident 13 was hospitalized from [DATE] through 8/11/26. Resident 13 refused 12 of 50 meals offered between 8/2/26 and 8/27/26. There was no documentation that the staff consistently reported those refusals, and there were no documented care plan interventions addressing her frequent meal refusals. 3. Interview on 8/25/26 at 10:51 a.m. with RD J revealed that she was aware resident 13 had lost 29.1 pounds since her admission to the facility. She thought the weight loss was due to resident 13 being in the hospital recently. She requested the staff to obtain another weight after her 8/25/26 assessment but thought resident 13 had refused to be reweighed. She expected the nursing staff members to obtain a resident's weight and reweigh that resident on the same day or the next day if there was more than a five-pound weight change since the last weight. She confirmed that resident 13 was not reweighed whenever there was a weight loss of more than 5 pounds.RD J stated that the nurse in charge of resident 13's care was responsible for notifying the physician of any weight loss for additional recommendations and interventions. RD J recommended adding supplements because resident 13 was losing weight. RD J stated resident 13 had reported that her appetite was great and that she liked the meal supplements. The documentation RD J had reviewed supported that resident 13 was eating well and was offered additional food if she slept through a meal. She thought that resident 13's weight would bounce back after she returned from the hospital. 4. Interview on 8/26/26 at 3:06 p.m. with certified nursing assistant (CNA) Q revealed that resident 13 was independent with eating and did not need to be fed. She had refused her breakfast and lunch trays to be left in her room that day (8/26/26) and did not eat those meals. CNA Q did not report resident 13's breakfast and lunch refusals to the nurse because she thought the nurses knew resident 13 was refusing to eat her meals, and she refused to get out of bed. She thought that resident 13 ate better in the evening. 5. Interview on 8/27/26 at 2:05 p.m. with CNA U revealed that she thought that resident 13 was alert and oriented and made the choice to eat all her meals in her room. Resident 13 had refused to eat her breakfast and lunch that day (8/27/26). CNA U did not report to anyone that resident 13 refused her breakfast and lunch that day because she thought that certified medication aide (CMA) V had reported it to contracted travel licensed practical nurse (LPN) R. 6. Interview on 8/27/26 at 2:13 p.m. with contracted travel LPN R revealed that he was the nurse caring for resident 13 that day. No one reported to him that resident 13 did not eat her breakfast or lunch that day, but he was aware that she refused her meals frequently and had experienced some weight loss since her admission to the facility. He was unsure how much weight resident 13 had lost, but he would receive an alert in the EMR when a resident with weight loss needed to be reviewed. He stated that resident 13's physician was aware of her weight loss, that resident 13 refused meals and personal care, and that the physician had recommended that the staff to keep monitoring resident 13. 7. On 8/28/26 at 8:00 a.m., a request was made to registered nurse (RN)/ regional director C for all notifications sent to resident 13's provider regarding her weight loss since her admission to the facility and interventions added or attempted. 8. Interview on 8/28/26 at 9:20 a.m. with CNA W revealed that she used the resident's care plan to know how to care for the residents; she worked full time and felt like she knew most of the residents well. She was unsure if there was information in resident 13's care plan related to her weight loss but stated that there were many contracted travel staff members who worked at the facility. She thought that information would be good to have in the resident's care plan since resident 13 often refused her meals and staff assistance with personal care. 9. Interview and review of resident 13's weight documentation and physician notifications on 8/28/26 at 11:18 a.m. with director of nursing (DON) B and RN/regional director C revealed that resident 13 was last weighed on 8/26/26 and weighed 109.9 pounds. Resident 13 had lost 29.1 pounds between 6/10/26 and 8/26/26. She thought that RD J was aware of resident 13's weight loss and recommended supplements because resident 13 was not eating well.RN/regional director C expected resident 13 to be weighed following the physician's orders, to be reweighed when she had a weight loss of five pounds or more in a week, and her physician to be notified of the weight loss. She confirmed that resident 13 was not weighed according to the physician's orders, nor was she reweighed on the same day she had lost five or more pounds in a week. Resident 13's physician was notified on 8/27/26 of her 29.1-pound weight loss, but RN/regional director C did not hear back from the physician at that time. There was no other documentation indicating that resident 13's physician was notified of weight losses greater than 5 pounds per week, which could have resulted in a lack of timely medical evaluation and contributed to continued significant weight loss. 10. Review of the provider's May 2026 Weights policy revealed that The Center uses weights as one component of data collection to evaluate the resident's nutritional status. Newly admitted residents were weighed on admission, then weekly for 4 weeks. If weights and nutritional status are stable after 4 weeks, weigh the resident once per month.Re-weigh criteria included any weight with [a] 5-lb [pound] variance is re-weighed. After a re-weigh has been completed, that weight is recorded in PCC [Point Click Care, the provider's EMR] on the same day [it was] taken. If a significant variance is verified after the re-weigh, the nurse: Documents the weight variance in the medical record. Revises the care plan, as appropriate. Refers to the RD for evaluation, as indicated. Notifies the medical provider and resident/resident representative.

Based on South Dakota Department of Health ( SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to maintain effective pain management for one of one resident (20) who was prescribed a Butrans (buprenorphine) transdermal patch (controlled narcotic skin patch that slowly releases an opioid medicine to treat severe pain), which was received from the pharmacy and unaccounted for, resulting in a replacement patch being ordered and subsequently administered late to resident 20. Findings include:1. Review of the provider's 6/13/26 SD DOH FRI revealed that on 6/12/26, resident 20's ordered Butrans transdermal patch was unaccounted for. The patch was delivered to the facility on 6/8/26 by PharMerica (pharmacy), signed by registered nurse (RN) S, and taken to the medication cart. It was not documented or secured in the locked narcotic storage box within the medication cart.The Butrans transdermal patch was scheduled to be applied on the evening of 6/12/26. RN X reported that when she attempted to retrieve the medication, it was not available and could not be found in the medication treatment cart. RN X notified licensed practical nurse (LPN) Y and resident 20's physician. Assessment of resident 20's skin confirmed she did not have an extra patch applied. A facility-wide search did not locate the patch, and PharMerica confirmed the patch was delivered to the facility.Lumina Care (virtual clinical care service that provided after-hours telehealth) and PharMerica prescribed a replacement Butrans transdermal patch, which was received on 6/13/26 and administered to resident 20 by RN X.The provider's investigation revealed that the loss of the Butrans transdermal patch resulted from the staff's failure to document and secure the controlled substance when it was received from the pharmacy. The medication was never documented in the narcotic count book or placed in the medication cart's narcotic lock box.2. Review of the PharMerica shipping manifest confirmed resident 20's Butrans 15 microgram (mcg)/hour (hr) transdermal patch was delivered on 6/8/26.3. Review of resident 20's electronic medical record (EMR) revealed she admitted to the facility on [DATE] and had diagnoses including chronic pain (ongoing pain), osteoporosis (weak bones), phantom limb pain (pain from a body part that has been amputated), sciatica pain (sharp pain through your buttock and down one leg), and rheumatoid arthritis (pain, swelling, or stiffness in joints). Her 7/21/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had a 7/23/26 physician's order for a Butrans 15 mcg/hr transdermal patch to be applied every 7 days. The medication administration record (MAR) verified RN S administered the patch on 6/14/26 at 1:27 a.m.4. Interview on 8/27/26 at 8:31 a.m. with resident 20 revealed she had chronic back pain following multiple surgeries to her back. She reported there have been times when her pain medications were administered late, and she relied on them for pain relief.5. Interview on 8/27/26 at 3:52 p.m. with RN S revealed she received the Butrans transdermal patch on 6/8/26 but believed it was in a box rather than a plastic bag. She did not open the box, left it in the medication room, and did not follow any process for securing the medication. She stated she did not know the facility's narcotic policy or what was expected when receiving controlled medications.6. Interview on 8/27/26 with RN X revealed that on 6/12/26 around 6:00 p.m., she attempted to retrieve the resident's Butrans transdermal patch, but it was not in the narcotic lock box. RN X contacted RN S, who could not recall where she had placed the medication. When the second Butrans transdermal patch was delivered by PharMerica, they delivered one patch, and it is placed in a small clear plastic bag. RN X stated the facility did not have a policy on how to receive narcotic medications from the pharmacy at the time of the incident.7. Interview on 8/28/26 at 9:29 a.m. with director of nursing (DON) B revealed she did not audit the controlled narcotic sheets. She stated the staff was required to use PharMerica's controlled narcotic book to document the narcotic medication counts and that signing the controlled narcotic sheet in the book verified the count was accurate. She expected two nurses to sign PharMerica's shipping manifest upon receiving controlled medications, place the medication in the locked narcotic box in the medication cart, and complete the controlled narcotic book entry.8. Interview on 8/2/26 at 9:35 a.m. with RN/regional director C, revealed that the Butrans transdermal patch was left on top of the medication cart in the narcotic book by RN S. Previous DON CC, who was no longer employed at the facility, had informed RN/regional director C about the missing patch's location. 9. Previous administrator LL, previous DON CC, and previous LPN Y, who were employed at the facility at the time of the incident, were no longer employed at the facility and not available for an interview. 10. Review of the provider's January 2025 Controlled Medication Storage policy revealed that Medications included in the Drug Enforcement Administration (DEA) or state classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. A controlled medication accountability record is prepared when receiving inventory of any controlled substance to establish a record of receipt and disposition in sufficient detail to enable accurate reconciliation. The following information is completed: name of resident, prescription number, name, strength (if designated), and dosage form of medication, date received, quantity received, and name of person receiving medication. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken. 11. Review of the provider's May 2025 Resident Handbook revealed that Medications require a physician's order and are administered on a routine basis. Pain management: You have an important role in managing your pain. Our policy is to respect and support your right to appropriate pain assessment and management. If you are in pain, your doctor or nurse may ask you to describe your pain in order to determine the appropriate action to take to minimize and manage your pain. 12. Review of the provider's March 2025 Registered Nurse policy revealed Under general supervision, provides general nursing care to residents in the Community in compliance with state and federal regulations. Works collaboratively with members of the healthcare team. Maintains standards of professional nursing practice. Obtains and administers prescribed medications and treatments in accordance with approved nursing techniques. Documents same according to Community policy and standards of practice. Interprets, implements, and enforces Community policies and procedures to promote quality of care and to assure resident safety. Demonstrates knowledge of nursing process, particularly as it relates to geriatric residents, long-term care, and rehabilitation

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 controlled substances were secured and accounted for regarding one of one Butrans (buprenorphine) transdermal patch (controlled narcotic skin patch that slowly releases an opiod medicine to treat severe pain) not being secured or available for administration for one of one resident (20) who had chronic pain, and for two of two observed residents (11 and 25) whose controlled medications were missing. Findings include: 1. Review of the provider's 6/13/26 SD DOH FRI revealed that on 6/12/26, resident 20's ordered Butrans transdermal patch was unaccounted for. The patch was delivered to the facility on 6/8/26 by PharMerica (pharmacy), signed by registered nurse (RN) S, and taken to the medication cart. It was not signed or secured in the locked narcotic storage box within the medication cart. The Butrans transdermal patch was scheduled for application on the evening of 6/12/26. RN X reported that the patch was not available and could not be located on the medication cart. RN X reported that the patch was not available and could not be located on the medication cart. She notified previous licensed practical nurse (LPN) Y, resident 20's physician, and resident 20, who was her own power of attorney (POA) (legal document that gives someone else authority to act on your behalf). Resident 20's skin was assessed and revealed that she did not have an extra Butrans (buprenorphine) transdermal patch applied. The medication was confirmed to be missing after a facility-wide search was completed. PharMerica confirmed the medication was sent to the facility. Lumina Care (virtual clinical care service that provides after-hours telehealth) and PharMerica prescribed a replacement Butrans transdermal patch for resident 20, which was received on 6/13/26 and administered to the resident by registered nurse (RN) S. The investigation concluded that the loss resulted from the staff's failure to properly document and secure the controlled medication when it was received from the pharmacy. It was never documented in the narcotic count book or secured in the narcotic lock box in the medication cart as required. 2. Review of the PharMerica shipping manifest confirmed resident 20's Butrans 15 microgram (mcg)/hour (hr) transdermal patch was delivered on 6/8/26. 3. Review of resident 20's electronic medical record (EMR) revealed she admitted to the facility on [DATE] and had diagnoses including chronic pain (ongoing pain), osteoporosis (weak bones), phantom limb pain (pain from a body part that has been amputated), sciatica pain (sharp pain through your buttock and down one leg), and rheumatoid arthritis (pain, swelling, or stiffness in joints). Her 7/21/26 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. She had a 7/23/26 physician's order for a Butrans 15 micrograms per hour to be applied once every 7 days for pain management, with the previously placed patch to be removed at the time of the new application. Her medication administration record (MAR) indicated that the Butrans transdermal patch was administered on 6/14/26 at 1:27 a.m. by RN S. 4. Interview on 8/27/26 at 8:31 a.m. with resident 20 revealed she had chronic back pain following multiple surgeries to her back. She reported there have been times when her pain medications were administered late, and she relied on them for pain relief. 5. Interview on 8/27/26 at 3:52 p.m. with RN S revealed she received the Butrans transdermal patch from PharMerica on 6/8/26 for resident 20. She thought the patch was in a box and not a plastic bag. She did not know exactly what was labeled on the box or what was in it, as she did not open the box. She left the box in the medication room and did nothing else with the medication. RN S did not know the provider's policy on narcotics or what was expected of her when she received a narcotic from the pharmacy. 6. Interview on 8/27/26 with RN X revealed that on 6/12/26 around 6:00 p.m., when she went to retrieve the Butrans (buprenorphine) transdermal patch for resident 20, she found it was not in the locked box within the medication cart. She had checked the treatment cart, and it was not there either. She called RN S to ask where she had put the Butrans (buprenorphine) transdermal patch, but the nurse could not recall what she had done with it. She stated the facility did not have a policy for receiving controlled narcotic medications from the pharmacy when this incident had occurred. 7. Interview on 8/28/26 at 9:29 a.m. with director of nursing (DON) B revealed she did not conduct audits of the controlled narcotic sheets. She stated that the staff was required to use PharMerica's controlled narcotic book to document narcotic medication counts, ensuring the medication quantities matched the recorded totals. She stated that signing the controlled narcotic sheet verified the narcotic count. She expected that when narcotic medications arrived from the pharmacy, two nurses were to sign the shipping manifest, and place the narcotic medication in the locked narcotic box within the medication cart. The nurse who received the narcotic medication would then complete the corresponding entry in the controlled narcotic book. 8. Interview on 8/2/26 at 9:35 a.m. with RN, regional director C, revealed that the Butrans transdermal patch was left on top of the medication cart in the narcotic book by RN S. Previous DON CC, who was no longer employed at the facility, had informed RN/regional director C about the missing patch's location. 9. The previous administrator LL, previous DON CC, and LPN Y, who were employed at the facility at the time of the incident, were no longer employed at the facility and not available for an interview. 10. Review of the provider's January 2025 Controlled Medication Storage policy revealed that Medications included in the Drug Enforcement Administration (DEA) or state classification as controlled substances are subject to special handling, storage, disposal, and recordkeeping in the nursing care center in accordance with federal, state, and other applicable laws and regulations. A controlled medication accountability record is prepared when receiving inventory of any controlled substance to establish a record of receipt and disposition in sufficient detail to enable accurate reconciliation. The following information is completed: name of resident, prescription number, name, strength (if designated), and dosage form of medication, date received, quantity received, and name of person receiving medication. Medication storage conditions are monitored on a regular basis as a random quality assurance (QA) check. As problems are identified, recommendations are made for corrective action to be taken. 11. Observation and review of the provider's Controlled Substance Book on 8/27/26 at 1:59 p.m. with contracted travel licensed practical nurse (LPN) T revealed nurses and certified medication aides (CMAs) reconciled scheduled and as-needed controlled medications (the process of comparing the medical record against an inventory of medication to prevent errors such as omissions, duplications, or incorrect dosages) at the beginning and end of the day, evening, and night shifts. After verifying the available quantity of the controlled medications, the nurses and CMAs signed the provider's Controlled Substance Book to accept accountability of the medications during their shift. Each medication cart (A and B) had two signature books, one for scheduled medications and one for as-needed medications. All four signature books were missing multiple staff signatures during the months of June, July, and August 2026. Contracted travel LPN T stated that the process of signing the Controlled Substance Book varied among the staff, depending on preference. Some staff sign it at the beginning of their shift, but I like to sign it at the end of my shift to make sure everything is correct. She did not know who was responsible for ensuring that the staff signed the book on each shift. 12. Observation, review of the Controlled Substance Book, and EMR review on 8/27/26 at 4:41 p.m. with CMA V revealed that the medication count for resident 11's as-needed Lorazepam (a medication used to treat anxiety) was off by one pill. According to the Controlled Substance Book, there should have been 16 Lorazepam 0.5 milligram (mg) pills in the resident's medication card, but there were only 15. The medication count for resident 25's scheduled Hydrocodone Acetaminophen (a medication used to manage moderate to severe pain) was off by one pill. According to the Controlled Substance Book, there should have been 29 Hydrocodone Acetaminophen 5-325 mg pills in the resident's medication card, but there were only 28. 13. Interview on 8/27/26 at 5:14 p.m. with CMA V revealed that if the medication counts were off, she would search the entire medication cart to see if any pills came loose from the medication card. She did this and did not find resident 11 and 25's missing pills. She stated she would tell the charge nurse or director of nursing (DON) B about the discrepancy. CMA V said that when counting medications, she would say the number of counted pills in the medication card while the other nurse or CMA verified the number in the Controlled Substance Book. She said she had verified the medication count with registered nurse (RN) S at the start of her shift that day (8/27/26). To my knowledge, it was accurate this morning. 14. Interview and EMR review on 8/27/26 at 6:06 p.m. with DON B revealed she had identified a clerical error that resulted in the medication count discrepancy for resident 25's Hydrocodone Acetaminophen. The error occurred on 8/26/26 at 5:00 p.m. when RN S administered a Hydrocodone Acetaminophen to resident 25, documented it in the resident's EMR, but did not document it in the Controlled Substance Book. 15. Interview and EMR review on 8/28/26 at 9:30 a.m. with DON B revealed she had identified a second clerical error that resulted in the medication count discrepancy for resident 11's Lorazepam. The error occurred on 8/27/26 at 8:00 a.m. when CMA V administered a Lorazepam to resident 11, documented it in the resident's EMR, but did not document it in the Controlled Substance Book. DON B felt that if she did not investigate the medication count discrepancy for these two medications, the clerical errors would have eventually been noticed by the evening shift staff. She stated that it was a frustrating system and that incorrect medication counts have happened one other time that she knew of. There were 10 nursing staff members who attended an in-service education meeting by PharMerica (pharmacy provider) on 8/20/26 to learn about safe medication administration and controlled substance reconciliation processes. Aside from the pharmacy in-service meeting, DON B said she did not perform competency testing for controlled substance reconciliation. She felt the process could improve if both nurses have eyes on the number of pills in the resident's medication pack and the count documented in the Controlled Substance Book. They need to take accountability of both numbers. DON B said the resident care manager is responsible for auditing the Controlled Substance Book to ensure the staff are correctly counting medications and signing the book each shift. The facility did not currently have anyone hired for that role, so DON B assumed those responsibilities. 16. Review of the provider's January 2026 Medication Administration Policy revealed that each medication administration is documented in the resident's EMR or medication administration record (MAR) (a log used to track all the medications given to a patient) by the person administering the medication. The staff's initials on each resident's MAR were verified with a full signature in the space provided in the Controlled Substance Book or on the nursing care center's master employee signature log.

Based on South Dakota Department of Health (SD DOH) complaint review, interview, observation, documentation review, and policy review, the provider failed to ensure that food was palatable (having a pleasant taste or being acceptable and easy to accept), appetizing, and warm when served to all residents who ate meals in their rooms and in the dining room. Findings include: 1. Review of the 7/9/26 SD DOH complaint revealed that the complainant was a resident at the facility in May and June of 2026. The complainant stated that there was a large outbreak of diarrhea that may or may not have been related to food not being served at appropriate holding temperatures, that the food was frequently served cold, and that the food was placed on carts and sat too long before it was served. The complainant indicated that the second floor was served first and the first floor was served last. 2. Interview on 8/25/26 at 11:25 a.m. with residents 50 and 51 in their shared room revealed that they ate their meals in their room. They felt the food was cold, the meat was often tough, and sometimes it was undercooked. Resident 51 stated they often received lunch at 1:15 p.m. and wondered how long their meals waited on the cart to be served. 3. Interview on 8/25/26 at 12:25 p.m. with resident 28 revealed that he did not like the meat and mashed potatoes, so he only ate the bread pudding dessert. He said he rarely liked the noon meal, so at breakfast he ordered two egg sandwiches, hot cereal, and three glasses of chocolate milk to stay full until supper. 4. Observation on 8/25/26 at 12:32 p.m., in the main dining room, revealed that the dietary staff loaded twelve plates of food with insulated tops and bottoms onto an open wheeled cart. At the bottom of the cart were beverages, including juice and milk, covered with a tray. These meals were delivered to the first floor at 12:35 p.m. The last of those plates of food and a beverage were delivered to a resident at 12:52 p.m. 5. Observation on 8/25/26 at 12:48 p.m. in the main dining room revealed that resident 28, who appeared frustrated, was leaving the dining room. He stated to a staff member that the chicken was terrible, that he was going to his room, and that he wanted to be left alone. 6. Interview on 8/25/26 at 2:38 p.m. with resident 28 in his room revealed that he thought the food was awful, that everyone knew it, and stated, Go talk to the other residents, and you will hear the same thing. He did not want to discuss his concerns because nothing will come from it. 7. Interview on 8/25/26 at 3:44 p.m. with resident 44 in his room revealed he ate most of his meals in the dining room. He stated, The food is not good. He stated that the food was bland and cold, and the meat was hard to chew. He believed the dietary staff was aware of the residents' concerns about the food because residents complained to one another all the time. He did not report his concerns to the dietary department. 8. Review of the monthly 2/24/26 through 8/24/26 resident council minutes revealed that on 2/24/26, twelve residents (1, 2, 3, 7, 25, 29, 34, 36, 57, 71, 72, and 73) and dietary supervisor (DS) E, activities director (AD) G, and previous administrator LL, attended the resident council meeting. Resident concerns included cold food and tough and dry meat. Discussion of new business related to the dietary department indicated, Things are better. Depends on [the] cook for [the] temp [temperature] of [the] food. On 3/31/26, nine residents (1, 3, 9, 15, 25, 29, 31, 34, and 57) and AD G attended the resident council meeting. Resident 3 indicated he did not care for certain cooks' food. On 7/28/26, thirteen residents (1, 2, 3, 7, 9, 15, 25, 29, 33, 34, 36, 42, and 57) and AD G attended the resident council meeting. Discussion of new business related to the dietary department indicated Cold Food. On 8/24/26, fourteen residents (1, 2, 8, 9, 15, 20, 24, 25, 31, 34, 38, 42, 57, and 61) and AD G attended the resident council meeting. Resident concerns included still cold food. Discussion of new business related to the dietary department indicated, No meal of the month for [the] last two months.want real butter and in a bigger pack, more food options. 9. Review of the provider's February 2026 through August 2026 grievance forms revealed that on 5/20/26, resident 68 completed a grievance form indicating that he wanted a microwave for his room because his food was always cool to cold. The action taken was that maintenance director DD explained to resident [68] that it was not possible. Regional vice president of operations (RVPO) D discussed resident 68's concerns with DS E and followed up with resident 68 on 5/26/26 and 5/27/26, indicating, Resident [68's] food [was] hot [for the] last 3 meals. On 5/6/25, resident 68 completed a grievance form indicating that he was receiving cold room trays and not receiving the items he requested. The actions taken included DS E meeting with resident 68 to set up his menu for the week. He was offered the option to eat meals in the dining room and declined, indicating he would prefer to eat in room, and that he would be served first at all meals. On 6/12/26, residents 50 and 51 completed a grievance form indicating they got a cold dessert on top of a hot meal, and that the Jell-O was placed under the dome lid and was melted onto the main dish. The actions taken included DS E educating the dietary aides not to place cold desserts under the dome lid and to be mindful of quality when delivering the resident's meals. 10. Interview on 8/26/26 at 10:00 a.m. with the resident council group revealed that nine residents (1, 15, 20, 24, 25, 29, 34, 57, and 61) who regularly attended the facility resident council meeting were present. All residents present confirmed that they were frustrated about the meals they were served. One resident stated, The food is cold, it tastes bad, and there is no choice. All residents confirmed they had concerns about receiving cold food when they ate in their room and in the dining room. Their concerns were occurring for several months, and they had shared their concerns at the resident council meetings. The food would get better for a few days, and then the food would be cold again. One resident who did not want to be identified stated she was served mashed potatoes so cold they seemed like they came directly from the refrigerator. Another resident who did not want to be identified stated he was served chicken last night so tough I couldn't cut it, never mind chew it. The resident council group agreed that hot meals were colder when served in their rooms, but that some hot meals were served cold even in the dining room. They acknowledged that the new DS E met with the resident council group for a Chef Talk recently, but felt that they continued to receive meals in their rooms that were cool or cold when they received them. 11. Interview on 8/26/26 at 11:14 a.m. with AD G confirmed that she facilitated the resident council meetings, that the residents had many concerns about the meals they were served, and that food was brought up more than once recently. The resident council minutes were approved by administrator A each month. AD G indicated that more than one administrator was made aware of the resident council group's concerns with the food. DS E attended a resident council meeting a few months ago, but resident concerns about cold food and tough meat were discussed again at the August meeting. 12. Observation on 8/26/26 at 5:30 p.m. revealed that the chicken strips that were served for supper were hard and slightly burned. Many of the residents chose not to eat the chicken strips and left them on their plates. 13. Observation on 8/27/26 at 8:24 a.m. revealed that 10 breakfast meals were delivered to the first floor for the residents who resided on the first floor. A test breakfast meal was ordered by the surveyor to contain one serving of each item served to the residents, and to be brought to the surveyor after the last resident's breakfast meal was delivered. The last resident breakfast meal was delivered at 8:56 a.m. The test breakfast meal temperatures were checked on the food delivery cart on the first floor and included French toast that was 104 degrees Fahrenheit (F), hot cereal that was 119 degrees F, eggs that were 98 degrees F, sausage that was 89.7 degrees F, and milk that was 55 degrees F. 14. Interview and review of the food temperatures observed above on 8/27/26 at 10:17 a.m. with DS E and registered dietitian (RD) J revealed that they were aware of resident concerns about cold food and had attended a resident council meeting a few months ago, where residents shared concerns about the food temperatures and the meat. DS E stated that a cook they thought was having a hard time meeting performance standards no longer worked at the facility and believed the issue was improving. She monitored the temperature of the food in the steam table but felt she had little control over its temperature once it left the steam table. She expected the hot resident meals to be served hot. The nursing staff was responsible for delivering the resident meal plates once the dietary staff members delivered the cart to the floor. DS E and RD J were not aware of the temperature of the food when it was served to the residents and agreed that the above-temperature foods were not palatable, were surprised how quickly the foods had lost their initial temperature, and expected the meat to be warmer than that and the milk to be cold. They were unsure what temperature the food should have been when it was served. DS E stated that she had requested that the facility purchase a plate warmer and the thermal inserts for the insulated plate base and thought they were ordered. 15. Interview and Performance Improvement Plan (PIP) document review with DS E on 8/27/26 at 2:51 p.m. revealed that she was working on improvements in the kitchen but did not document those efforts until that day (8/27/26). She confirmed the documented dietary department PIP areas were not directly related to the resident's food temperatures or to addressing the residents' concerns about receiving cold food in their rooms. 16. Interview and email documentation review on 8/28/26 at 10:49 a.m. with RVPO D revealed that on 8/18/26 RVPO D received an email from divisional dietitian JJ that stated, Is it possible to get [provider's initials redacted] a plate warmer? I have been trying since I started to get one. They have cold food complaints in [resident] rooms. RVPO D replied, Yes, I just need a couple Bids. RVPO D stated that she knew there were resident complaints about receiving cold food a while ago, had thought that those complaints were resolved, and did not order the plate warmer. 17. Review of the provider's December 2025 Resident Handbook revealed Our center provides at least three meals a day, and supplemental snacks are available between meals and at bedtime. We encourage all residents to eat in the dining room, which is designed for a pleasant dining experience. Our nutrition program provides menus featuring fresh and nutritious meals. You will be provided with regular, well-prepared meals, as ordered by your physician and in accordance with established national guidelines. 18. Review of the provider's October 2017 Food Temperature policy revealed that Food Temperatures are taken and documented daily prior to meal service and monitored periodically throughout the meal service. The policy did not include monitoring the temperatures of the resident meals served in their rooms. 19. Review of the provider's July 2008 Serving Food policy revealed that Food is prepared and served in a manner that meets the needs of the resident. The procedure of Residents Eating in Their Rooms was that The Dietary Department prepares the food cart for delivery. The nursing staff takes [the] food trays into the resident's room. Nursing Services picks up the resident's food tray after each meal and returns the food cart to the Dietary Department. Tray setup is done by nursing and assistance [is] provided as needed. The policy did not include monitoring the temperatures of the resident meals served in their rooms.

Based on record review, interview, and policy review, the provider failed to develop a person-centered baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) that included the minimum healthcare information necessary to care for one of four sampled newly admitted resident (13) and that the baseline care plan was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for two of four sampled newly admitted residents (13 and 67). Findings include: 1. Review of resident 13's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. Her diagnoses included Type 2 Diabetes Mellitus (a condition involving disruptions in how the body regulates blood sugar), anxiety, and fractures of her sacrum (tailbone) and left femur (upper leg). Her 8/11/26 Brief Interview for Mental Status (BIMS) assessment score was 6, which indicated her cognition was severely impaired. Resident 13's 6/10/26 Braden Scale for Predicting Pressure Sore Risk (a tool used to assess the risk of developing pressure ulcers) scores indicated that she was AT RISK for developing a pressure ulcer. A 6/10/26 admission Skin/Wound Evaluation revealed that resident 13 was admitted to the facility with a right calf (back of lower leg) non-pressure injury and a left hip surgical incision. Her Treatment Administration Record (TAR) indicated that on 6/10/26, her baseline plan of care was offered to her or her representative. Her baseline care plan did not contain the level of staff assistance she required for bathing, dressing, or eating, her social services needs, or interventions to prevent the development of pressure ulcers. 2. Interview and review of resident 13's care plan on 8/28/26 at 9:40 a.m. with licensed practical nurse (LPN)/Minimum Data Set (MDS) I revealed the baseline care plan was triggered automatically in the EMR when the resident's admission assessment was completed. He expected the nurse who completed the resident's admission assessment to answer the questions correctly to trigger each area that needed to be included in the baseline care plan and to document in the TAR that it was offered to the resident or their representative. He expected all of the required areas to be on the resident's baseline care plan but was unsure which areas were required. He was unable to determine whether all the required areas were included in resident 13's baseline care plan because it appeared that not every area was triggered. He expected the resident's baseline care plan to be reviewed with the resident and/or their representative when the admission nursing assessment was completed, and a copy of the baseline care plan to be printed for the resident or their representative if they requested one. He confirmed that the TAR did not indicate what information was on the baseline care plan when it was reviewed with the resident, or if the resident or their representative was provided a copy. 3. Review of resident 67's electronic medical record revealed she admitted to the facility on [DATE]. Her 6/22/26 BIMS assessment score was 14, which indicated her cognition was intact. Her TAR indicated that on 8/3/26 her baseline plan of care was offered to her or her representative. 4. Interview on 8/26/26 at 4:02 p.m. with registered nurse (RN)/regional director C regarding the resident's baseline care plan revealed that the documentation indicating the baseline care plan was developed and offered to the resident or their representative within 48 hours of admission was documented on the residents' TAR. She indicated that if the +/- was documented, it meant that the baseline care plan was offered to the resident or their representative or that it was refused by the resident or their representative. Regarding resident 56's documented y she believed that also meant that the resident or their representative was offered the baseline care plan. She confirmed there was no documentation in the residents' 11, 56, and 67's EMRs to confirm who had received the baseline care plan. 5. Review of the provider's July 2025 Baseline Plan of Care policy revealed: The facility develops the baseline plan of care for each resident, within 48 hours of admission. A summary or a copy of all components of the baseline plan of care, and the initial goals of the resident, is offered to the resident/Representative. The licensed nurse initials on the TAR, indicating that the BPOC was offered and either accepted or declined.

Based on interview and record review, the provider failed to ensure registered nurse (RN) KK staff received necessary guidance, provider direction, and competency support for the care of a resident with a peripherally inserted central catheter (PICC) that could not be accessed, for one of one resident (67) reviewed for vascular access device care. This failure resulted in a lack of appropriate and timely nursing intervention and had the potential to compromise the resident's safety and treatment needs. Findings include: 1. Review of resident 67's closed electronic medical record (EMR) revealed she admitted to the facility on [DATE]. She went to a clinic appointment on 6/22/26 and was admitted to the hospital from that appointment, as she refused to return to the provider's facility. Resident 67's diagnoses included right artificial knee joint, right knee infection, cellulitis of right lower limb, type 2 diabetes, and sepsis. Resident 67's 6/17/26 physician orders included ceftriaxone sodium-dextrose (antibiotic) intravenous (IV) (within a vein) solution to be administered every 24 hours for infection of prosthetic knee joint until 6/23/26. Resident 67 had a PICC line for this to be administered through. Review of resident 67's 6/17/26 hospital notes revealed that the hospital did not administer the antibiotic before discharging resident 67 to the provider's care. Review of the provider's documentation revealed that resident 67's admission medications did not arrive at the facility until 6/18/26 at 12:03 a.m. There was no documentation that resident 67 received her 6/17/26 dose of antibiotic. On 6/18/26, RN KK documented in resident 67's nurse progress notes, unable to flush PICC line after infusion of IV antibiotic. Antibiotic infused without difficulty. Call placed to [redacted name] Infectious disease for further direction. On 6/19/26 a RN S Resident on IV antibiotic. PICC line unable to be flushed due to being plugged. No return call back from [redacted name] ID [infectious disease]. States she [resident 67] does not want to be here. Resident 67 complained of a burning sensation when her mouth was dry. An appointment was made 6/22/26 for resident 67 to be evaluated for the burning sensation by a medical professional. There were no further documented attempts to contact resident 67's physician regarding her PICC line being obstructed. 2. Interview and review of resident 67's EMR on 8/27/26 at 2:21 p.m. with RN KK, RN/regional director C, and administrator A regarding resident 67's antibiotic medication revealed that RN KK stated that when the lumen (a hollow space inside a tube-like structure or medical device) of the PICC line did not flush after administering the antibiotic, she called an infectious disease doctor and left a message. That doctor did not return her phone call. She reported to the evening shift nurse that the lumen would not flush. RN KK indicated that when the infectious disease doctor did not respond to her message, she should have called the previous DON CC or a nurse case manager regarding care of the obstructed lumen. She stated she did not know if the provider's PICC line policy would explain how to care for the lumen, as she was not familiar with the policy. RN KK confirmed that resident 67's MAR included documentation that on the 6/19/26, 6/20/26, and 6/21/26, a different nurse administered the antibiotic through the PICC line. The MAR included that Ceftriaxone 2000 IM was also administered. RN KK indicated that the provider seldom admitted a resident who had a PICC line. She was unable to remember if she had annual education regarding IV access or PICC lines. 3. Interview with previous contracted travel RN MM on 8/27/26 at 6:14 p.m. verified that she administered resident 67's IV antibiotic intravenously via the PICC line, as there were two lumens and one was obstructed. She stated that she was able to flush one side of the lumen attached to the PICC line after she put new caps on the PICC line and was able to flush that same lumen after administering the antibiotic. 4. Interview on 8/28/26 at 11:30 a.m. with administrator A revealed there were no documented PICC line or IV care competencies for RN KK. 5. Interview and review of resident 67's EMR on 8/28/26 at 11:41 a.m. with RN X regarding resident 67's antibiotic administration revealed that on 6/21/26 she attempted to administer the antibiotic through her PICC line. She stated she tried both lumens in the PICC line, and both were occluded. She contacted resident 67's physician and obtained an order to have the antibiotic administered IM. She confirmed resident 67's MAR documentation indicated she had received the antibiotic twice on 6/21/26 and should have received it once. RN X indicated she did not have much experience with the care of PICC lines. RN X stated, [Resident 67] told me she didn't think the nursing staff was taking good care of her and she wanted to go home. 6. Review of the provider's Maintaining Patency of Peripheral and Central Vascular Access Devices IV Flush policy revealed: Vascular access devices are aspirated for blood return and flushed prior to each infusion to assess catheter function and prevent complications. Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. Each lumen of a multi-lumen catheter must be flushed individually. To succeed with saline flushing, a needleless connector with an anti-reflux design must be placed on the hub of EVERY lumen of EVERY vascular access device/catheter. Never inject against resistance. A pulsatile flushing technique of short boluses interrupted by brief pauses may be effective in better catheter clearance. Repeat for each individual lumen as needed. There was no indication in the provider's policy of the process for removing the obstruction of the PICC line. B. Based on observation, record review, interview, and policy review, the provider failed to ensure controlled substances were secured and accounted for by RN S and certified medication aide (CMA) V, regarding two of two observed residents (11 and 25) whose controlled medications were missing. Findings include: 1. Observation and review of the provider's Controlled Substance Book on 8/27/26 at 1:59 p.m. with contracted travel licensed practical nurse (LPN) T revealed nurses and certified medication aides (CMAs) reconciled scheduled and as-needed controlled medications (the process of comparing the medical record against an inventory of medication to prevent errors such as omissions, duplications, or incorrect dosages) at the beginning and end of the day, evening, and night shifts. After verifying the available quantity of the controlled medications, the nurses and CMAs signed the provider's Controlled Substance Book to accept accountability of the medications during their shift. Each medication cart (A and B) had two signature books, one for scheduled medications and one for as-needed medications. All four signature books were missing multiple staff signatures during the months of June, July, and August 2026. Contracted travel LPN T stated that the process of signing the Controlled Substance Book varied among the staff, depending on preference. Some staff sign it at the beginning of their shift, but I like to sign it at the end of my shift to make sure everything is correct. She did not know who was responsible for ensuring that the staff signed the book on each shift. 2. Observation, review of the Controlled Substance Book, and EMR review on 8/27/26 at 4:41 p.m. with CMA V revealed that the medication count for resident 11's as-needed Lorazepam (a medication used to treat anxiety) was off by one pill. According to the Controlled Substance Book, there should have been 16 Lorazepam 0.5 milligram (mg) pills in the resident's medication card, but there were only 15. The medication count for resident 25's scheduled Hydrocodone Acetaminophen (a medication used to manage moderate to severe pain) was off by one pill. According to the Controlled Substance Book, there should have been 29 Hydrocodone Acetaminophen 5-325 mg pills in the resident's medication card, but there were only 28. 3. Interview on 8/27/26 at 5:14 p.m. with CMA V revealed that if the medication counts were off, she would search the entire medication cart to see if any pills came loose from the medication card. She did this and did not find resident 11 and 25's missing pills. She stated she would tell the charge nurse or director of nursing (DON) B about the discrepancy. CMA V said that when counting medications, she would say the number of counted pills in the medication card while the other nurse or CMA verified the number in the Controlled Substance Book. She said she had verified the medication count with registered nurse (RN) S at the start of her shift that day (8/27/26). To my knowledge, it was accurate this morning. 4. Interview and EMR review on 8/27/26 at 6:06 p.m. with DON B revealed she had identified a clerical error that resulted in the medication count discrepancy for resident 25's Hydrocodone Acetaminophen. The error occurred on 8/26/26 at 5:00 p.m. when RN S administered a Hydrocodone Acetaminophen to resident 25, documented it in the resident's EMR, but did not document it in the Controlled Substance Book. 5. Interview and EMR review on 8/28/26 at 9:30 a.m. with DON B revealed she had identified a second clerical error that resulted in the medication count discrepancy for resident 11's Lorazepam. The error occurred on 8/27/26 at 8:00 a.m. when CMA V administered a Lorazepam to resident 11, documented it in the resident's EMR, but did not document it in the Controlled Substance Book. DON B felt that if she did not investigate the medication count discrepancy for these two medications, the clerical errors would have eventually been noticed by the evening shift staff. She stated that it was a frustrating system and that incorrect medication counts have happened one other time that she knew of. There were 10 nursing staff members who attended an in-service education meeting by PharMerica (pharmacy provider) on 8/20/26 to learn about safe medication administration and controlled substance reconciliation processes. Aside from the pharmacy in-service meeting, DON B said she did not perform competency testing for controlled substance reconciliation. She felt the process could improve if both nurses have eyes on the number of pills in the resident's medication pack and the count documented in the Controlled Substance Book. They need to take accountability of both numbers. DON B said the resident care manager is responsible for auditing the Controlled Substance Book to ensure the staff are correctly counting medications and signing the book each shift. The facility did not currently have anyone hired for that role, so DON B assumed those responsibilities. 6. Review of the provider's January 2026 Medication Administration Policy revealed that each medication administration is documented in the resident's EMR or medication administration record (MAR) (a log used to track all the medications given to a patient) by the person administering the medication. The staff's initials on each resident's MAR were verified with a full signature in the space provided in the Controlled Substance Book or on the nursing care center's master employee signature log. C. Based on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent. The facility failed to prevent a medication error involving two inhalers (a small, handheld medical device that delivers medication directly into your lungs when you breathe) for one of one observed resident (55) when contracted travel licensed practical nurse (LPN) T and certified medication aide (CMA) V left the inhalers on a dining room table for the resident to self-administer. Resident 55 did not have a physician's order to self-administer either inhaler. This practice resulted in a medication error rate of 6.25 percent. Findings include: 1. Observation and interview on 8/27/26 at 7:50 a.m. with contracted travel LPN T revealed she brought a cup of medication and two inhalers to resident 55 as he sat in his wheelchair eating breakfast at a dining room table. She placed the cup of medication and two inhalers on the table beside resident 55 and returned to the medication cart approximately 20 feet away. Contracted travel LPN T stated resident 55 had a rigid routine for how and when he preferred to take his medication, saying, we don't hover over him. She said he knew to take his medication after he finished breakfast. She performed hand hygiene and proceeded to administer medications to other residents in the dining room. At 7:57 a.m., after resident 55 finished eating breakfast, he took one puff from each inhaler and swallowed the tablets in the medication cup, then self-propelled his wheelchair away from the table and left the dining room, leaving the two inhalers on the table. At 7:59 a.m., contracted travel LPN T administered medication to residents on the north side of the dining room with her back turned to the table where resident 55's two inhalers remained. Approximately 12 residents were eating breakfast in the dining room, and several residents passed by the table with the two inhalers. At 8:14 a.m., contracted travel LPN T administered medications to a resident sitting adjacent to the table with resident 55's inhalers. At 8:17 a.m., she collected resident 55's two inhalers and returned them to the medication cart. 2. Review of resident 55's electronic medical record (EMR) revealed he had a diagnosis of chronic obstructive pulmonary disease (COPD) (a progressive, long-term lung disease that makes it difficult to breathe). He had a 7/22/26 physician's order for Breo Ellipta Inhalation Aerosol Powder (a brand-name prescription dry powder inhaler used for long-term maintenance treatment of asthma and COPD), inhale one puff orally once daily, and a 5/1/25 physician's order for Combivent Respimat Aerosol Solution (a prescription inhalation spray that helps open the airways in the lungs for adults with COPD), inhale two puffs orally once daily. He had physician's orders to self-administer Icy Hot (a topical pain cream) and AutoShield Duo (an insulin pen), but he did not have orders to self-administer any other medications, including the two inhalers. 3. Interview with contracted travel LPN T revealed she normally picked up resident 55's inhalers as soon as he left the dining room, but she was behind schedule today. 4. Observation on 8/28/26 at 7:50 a.m. revealed resident 55 was sitting in his wheelchair eating breakfast at a dining room table. CMA V was administering medications to other residents. At 8:41 a.m., resident 55's two inhalers were sitting on his dining room table while he was not present in the dining room. CMA V was assisting resident 31 and her back was to the inhalers. Eight residents were eating breakfast in the dining room. At 8:43 a.m., director of nursing (DON) B walked past the table, collected the two inhalers, and gave them to CMA V. 5. Interview on 8/28/26 at 8:44 a.m. with DON B revealed she expected the nurses and med aides to wait next to resident 55 while he used the inhalers, then collect the inhalers and return them to the medication cart. She stated they could collect an inhaler later for residents with a physician's order to self-administer their inhaler, but since resident 55 did not have such an order, she felt it was unacceptable to observe his two inhalers sitting unattended on his dining room table. 6. Review of the provider's January 2026 Medication Storage Policy revealed medications were to be stored properly to maintain their integrity and support safe drug administration. Medication carts, rooms, cabinets, and medication supplies were to remain locked when not in use or when not attended by authorized personnel. 7. Review of the provider's January 2026 Medication Administration Policy revealed residents were allowed to self-administer medications only when specifically authorized by the prescriber, the nursing home's interdisciplinary team (IDT), and in accordance with facility procedures for self-administration.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to investigate a staff-reported incident of potential resident abuse regarding one of one previous contracted travel certified nursing assistant (CNA) (BB) who allegedly pulled one of one residents' (56) wheelchair backward into the bathroom with resident (56) sitting in it, causing the resident's leg to get caught under the wheelchair wheel, which caused her to have pain.Findings include: 1. Review of the provider's 6/9/26 SD DOH FRI revealed alleged abuse between previous contracted travel CNA BB and resident 56 occurred on 6/8/26 at 8:30 p.m. The report was completed by previous director of nursing (DON) CC.According to the FRI, previous contracted travel CNA BB yelled at resident 56 while they pulled the resident backward in their wheelchair to the bathroom. The resident had yelled ow, my leg, and previous contracted travel CNA BB yelled back, stop fighting me. CNA GG had intervened and fixed the resident's leg, which was stuck under the front wheel of the wheelchair, and placed it back on the foot pedal. Resident 56's range of motion was assessed and was within normal limits, and the resident denied having any pain during the assessment. The staff was provided with abuse and neglect education to ensure they reported abuse and neglect incidents on time.2. Review of the provider's investigation file included a copy of the FRI submitted to SD DOH, handwritten statements from previous contracted travel CNA BB and CNA GG, a Rehab Communication to Nursing dated 6/10/26 regarding resident 56 and to change her transfer technique to an EZ [a mechanical stand used to assist someone from a seated position to an upright standing posture] stand with the assistance of three staff members. There was no other information provided regarding the alleged abuse.The written statement from previous contracted travel CNA BB indicated she was getting resident 56 into a nightgown. Previous contracted CNA BB denied yelling at anyone or saying anything wrong.The written statement from CNA GG indicated that previous contracted travel CNA BB was the perpetrator, and registered nurse (RN) X came into the room during the time of the alleged incident.There were no statements or interviews from other staff members on duty, including RN X, or from any residents.3. Review of resident 56's electronic medical record (EMR) revealed her 6/5/26 Brief Interview of Mental Status assessment score was a three, indicating that her cognition was severely impaired. There was no documentation in her EMR indicating that she was assessed for injury by RN X after the incident on 6/8/26.4. Interview and review of the 6/9/26 SD DOH FRI on 8/27/26 at 3:02 p.m. with director of nursing (DON) B and RN/regional director C regarding investigating allegations of abuse revealed the nurse was to complete an initial assessment of the residents and document the information into the provider's risk management system. DON B would complete an internal investigation. This would include interviewing residents who were cognitively aware, nurses, and anyone else who may have been involved in the incident. She would call the police department, Ombudsman, and the South Dakota Department of Health. The employee would be suspended until the investigation was complete. They were not aware of why this process was not followed for this incident, as neither of them were employed at that time.5. Interview on 8/26/26 at 3:28 p.m. with administrator A regarding resident 56's 6/8/26 incident revealed administrator A was not employed at the time of the incident. She stated that the investigation file she provided was the only information available regarding the incident.6. Review of the provider's October 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation policy revealed that a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source, in accordance with state and federal regulations. (Refer to Abuse Investigation Policy)7. Review of the provider's October 2022 Abuse Investigation policy revealed that The Center conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents .The Executive Director is the designated abuse coordinator and is responsible for assigning and overseeing staff that are to assist with investigations. The Center identifies and interviews involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. Through investigation, the Center works to determine if the abuse, neglect, exploitation, misappropriation of property, and/or mistreatment, has occurred and to determine the extent and cause. The Center maintains complete and thorough documentation of the investigation.

Based on observation, interview, and policy review, the provider failed to ensure the residents' right to privacy and confidentiality of protected health information (an individual's health, treatment, and payment information, also known as PHI) was protected by registered nurse (RN) S, who left two of two residents' (31 and 59) medication administration records (MARs) visible on an unattended computer in an area accessible to anyone who passed by. Findings include:1. Observation on 8/26/26 from 3:25 p.m. to 3:34 p.m. of RN S standing at the east hall medication cart outside of resident 11's room revealed she gave two Ibuprofen tablets to resident 31 as he sat in a wheelchair next to the cart. After resident 31 swallowed the two tablets, RN S locked the medication cart and walked around the corner to a sink near the kitchen to wash her hands, leaving the computer screen on the medication cart open with resident 31's MAR visible to four guests who were talking to resident 31 next to the cart. At 3:26 p.m., RN S returned to the cart, noticed the visible MAR, and said, Oh, I forgot. She then closed the MAR on the screen. At 3:30 p.m., RN S placed two Acetaminophen tablets in a medicine cup and walked to resident 59's room, leaving the bottle of Acetaminophen and the computer screen displaying resident 59's MAR unattended on the cart. RN S gave the two tablets to resident 59, who was in her bed, washed her hands in the room, and returned to the cart. She clicked on the computer screen and said, Oh, I forgot to get her pain rating. RN S walked back to resident 59's room, leaving the bottle of Acetaminophen resident 59's visible MAR unattended. She asked resident 59 to rate her pain, then walked past the unattended cart to the nurse's station to speak with RN X. At 3:34 p.m., RN S returned to the medication cart, documented resident 59's pain rating, locked the computer screen, and placed the Acetaminophen bottle back into the medication cart. 2. Interview on 8/26/26 at 4:42 p.m. with RN S indicated she normally closed or locked the computer screen and secured all medication before walking away from the medication cart. She stated, I just forgot today. 3. Interview on 8/28/26 at 10:00 a.m. with director of nursing (DON) B revealed she expected the staff to lock the computer screen when stepping away from the medication cart. She said it was not acceptable to leave medication or open computer screens on an unattended cart. 4. Review of the provider's January 2026 Medication Administration policy revealed that medication administration records containing resident health information must not be visible when not in direct use (paper MAR closed, electronic health record information hidden).

Based on observation, interview, and policy review, the provider failed to ensure the staff protected the residents' sense of dignity for three of four sampled residents (37, 56, and 67) by assisting them with bathing once per week. Findings include: 1. Observation on 8/18/26 at 3:36 p.m. of resident 37 in the dining room revealed she had long hair that reached just below her shoulders. Her hair appeared greasy and was stuck to the top of her head.2. Review of resident 37's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her documented bathing record indicated she preferred Fridays as her bath day and required the assistance of one staff member. There was no documentation of bathing care for her from 5/29/26 through 6/12/26 (12 days), and from 8/7/26 through 8/21/26 (14 days).3. Review of resident 56's EMR revealed she admitted to the facility on [DATE]. Her documented bathing record indicated she preferred Fridays as her bath day and required the assistance of three staff members. There was no documentation of bathing care for her from 6/19/26 through 7/3/26 (14 days).4. Review of resident 67's EMR revealed she admitted to the facility on [DATE] and discharged on 6/22/26. Her preference for the day of bathing was not documented, and there was no documentation of bathing care during her stay at the facility.5. Interview on 8/28/26 at 9:14 a.m. with registered nurse (RN)/regional director C stated that there was no documentation that resident 67 received bathing care during her stay. She stated that there may be more information regarding the residents' baths being completed and that she would provide that information. There was no additional information provided that was different from the above documented bathing records.6. Review of the provider's March 2026 Skin Integrity policy revealed there was no information regarding bathing care.

Based on observation, interview, review of the daily nurse staffing posting form, and policy review, the provider failed to ensure the daily nurse staffing information form was posted in a location where residents and visitors could easily view it and that it included the resident census.Findings include: 1. Observation from 8/27/26 at 9:43 a.m. of the daily nurse staffing posting on the second floor of the building revealed it was located above eye level behind the nurse's desk and did not include the daily census.2. Interview and review of the daily staffing information form on 8/27/26 at 9:46 a.m. with director of nursing (DON) B revealed she was not aware there was a daily nurse staffing posting form. She thought business office manager (BOM) F completed the form.3. Observation, interview, and review of the daily nurse staffing information form posted on 8/27/26 at 1:10 p.m. with BOM F revealed that the night shift nurse completed the daily nurse staffing information form. BOM F keeps a copy of the completed forms in her office. There was a space on the form to document the resident census. She confirmed that none of those forms had the resident census documented on them.She thought the form was posted at the nurses' station by the residents' sign-out book, so they would be able to see it easily. After reviewing where the form was located behind the nurses' desk, she agreed it would be difficult for residents and visitors to see the information on the nursing staff daily posting. She stated the form must have been recently moved.4. Interview on 8/27/26 at 1:54 p.m. with administrator A revealed the daily nurse staffing posting form was previously taped to a post next to the nurses' station at a level that someone in a wheelchair would be able to see. She had moved it from the post to the wall behind the nurses' desk. She confirmed residents and visitors would not be able to easily view the form in its current location. Administrator A indicated there was no daily nurse staffing information form located on the first floor. She had not thought about posting one there.5. Review of the provider's July 2012 Daily Nurse Staffing Information policy revealed A designated individual records the following information on the Daily Nurse Staffing Information Form and posts daily: .d. Resident census at the beginning of each shift. Posting Requirements a. The Center posts the nurse staffing data on a daily basis at the beginning of e3ach shift [.] b. Data is posted as follows: .In a prominate place readily accessible to residents and visitors.

Based on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent. The facility failed to prevent a medication error involving two inhalers (a small, handheld medical device that delivers medication directly into your lungs when you breathe) for one of one observed resident (55) when contracted travel licensed practical nurse (LPN) T and certified medication aide (CMA) V left the inhalers on a dining room table for the resident to self-administer. Resident 55 did not have a physician's order to self-administer either inhaler. This practice resulted in a medication error rate of 6.25 percent. Findings include: 1. Observation and interview on 8/27/26 at 7:50 a.m. with contracted travel LPN T revealed she brought a cup of medication and two inhalers to resident 55 as he sat in his wheelchair eating breakfast at a dining room table. She placed the cup of medication and two inhalers on the table beside resident 55 and returned to the medication cart approximately 20 feet away. Contracted travel LPN T stated resident 55 had a rigid routine for how and when he preferred to take his medication, saying, we don't hover over him. She said he knew to take his medication after he finished breakfast. She performed hand hygiene and proceeded to administer medications to other residents in the dining room. At 7:57 a.m., after resident 55 finished eating breakfast, he took one puff from each inhaler and swallowed the tablets in the medication cup, then self-propelled his wheelchair away from the table and left the dining room, leaving the two inhalers on the table. At 7:59 a.m., contracted travel LPN T administered medication to residents on the north side of the dining room with her back turned to the table where resident 55's two inhalers remained. Approximately 12 residents were eating breakfast in the dining room, and several residents passed by the table with the two inhalers. At 8:14 a.m., contracted travel LPN T administered medications to a resident sitting adjacent to the table with resident 55's inhalers. At 8:17 a.m., she collected resident 55's two inhalers and returned them to the medication cart. 2. Review of resident 55's electronic medical record (EMR) revealed he had a diagnosis of chronic obstructive pulmonary disease (COPD) (a progressive, long-term lung disease that makes it difficult to breathe). He had a 7/22/26 physician's order for Breo Ellipta Inhalation Aerosol Powder (a brand-name prescription dry powder inhaler used for long-term maintenance treatment of asthma and COPD), inhale one puff orally once daily, and a 5/1/25 physician's order for Combivent Respimat Aerosol Solution (a prescription inhalation spray that helps open the airways in the lungs for adults with COPD), inhale two puffs orally once daily. He had physician's orders to self-administer Icy Hot (a topical pain cream) and AutoShield Duo (an insulin pen), but he did not have orders to self-administer any other medications, including the two inhalers. 3. Interview with contracted travel LPN T revealed she normally picked up resident 55's inhalers as soon as he left the dining room, but she was behind schedule today. 4. Observation on 8/28/26 at 7:50 a.m. revealed resident 55 was sitting in his wheelchair eating breakfast at a dining room table. CMA V was administering medications to other residents. At 8:41 a.m., resident 55's two inhalers were sitting on his dining room table while he was not present in the dining room. CMA V was assisting resident 31 and her back was to the inhalers. Eight residents were eating breakfast in the dining room. At 8:43 a.m., director of nursing (DON) B walked past the table, collected the two inhalers, and gave them to CMA V. 5. Interview on 8/28/26 at 8:44 a.m. with DON B revealed she expected the nurses and med aides to wait next to resident 55 while he used the inhalers, then collect the inhalers and return them to the medication cart. She stated they could collect an inhaler later for residents with a physician's order to self-administer their inhaler, but since resident 55 did not have such an order, she felt it was unacceptable to observe his two inhalers sitting unattended on his dining room table. 6. Review of the provider's January 2026 Medication Storage Policy revealed medications were to be stored properly to maintain their integrity and support safe drug administration. Medication carts, rooms, cabinets, and medication supplies were to remain locked when not in use or when not attended by authorized personnel. 7. Review of the provider's January 2026 Medication Administration Policy revealed residents were allowed to self-administer medications only when specifically authorized by the prescriber, the nursing home's interdisciplinary team (IDT), and in accordance with facility procedures for self-administration.

Based on record review, interview, and policy review, the provider failed to ensure one of one discharged resident (67) received her physician-prescribed antibiotic intravenously (IV) (within a vein) as ordered for her right knee infection.Findings include: 1. Review of resident 67's closed electronic medical record (EMR) revealed she admitted to the facility on [DATE]. She went to a clinic appointment on 6/22/26 and was admitted to the hospital from that appointment, as she refused to return to the provider's facility. Resident 67's diagnoses included right artificial knee joint, right knee infection, anxiety disorder, depression, history of methicillin resistant staphylococcus aureus infection, right knee streptococcus, group A; cellulitis of right lower limb, type 2 diabetes, sepsis due to anaerobes.Her 6/18/26 Brief Interview of Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.Resident 67's 6/17/26 physician orders included an order for ceftriaxone sodium-dextrose (an antibiotic) intravenous solution to be administered every 24 hours for infection of prosthetic knee joint until 6/23/26. She had a peripherally inserted central line catheter (PICC) (a long, thin, flexible tube used as a long-term IV, that is inserted in a vein in the upper arm and guided through blood vessels until the tip rests in a large central vein near the heart).Resident 67's medication administration record (MAR) included documentation that on the 6/19/26 and 6/20/26 the antibiotic was administered through the PICC line. The MAR included that administration of Ceftriaxone 2000 IM (intramuscular) was also administered on 6/21/26.Resident 67's nurse progress notes indicated that on 6/17/26 resident 67 was admitted to the facility. At 11:37 p.m. her medications had not been delivered, and she did not want to be woken up to take them. She had a wound vac (a device that uses negative pressure remove excess fluid and debris from a wound to promote wound healing) on her right knee. There was a PICC line placed in her left arm. It was noted on 6/18/26 that her medications arrived from the pharmacy at 12:03 a.m.On 6/18/26 a nurse documented unable to flush PICC line after infusion of IV antibiotic. Antibiotic infused without difficulty. Call placed to [redacted name] Infectious disease for further direction.On 6/19/26, a nurse's progress note included Resident on IV antibiotic. PICC line unable to be flushed due to being plugged. No return call back from [redacted name] ID [infectious disease]. States she [resident 67] does not want to be here. Resident 67 complained of a burning sensation when her mouth was dry. An appointment was made for 6/22/26 for resident 67 to be evaluated for the burning sensation by a medical professional.On 6/19/26, there was a wound note for resident 67's right knee in the nurses' progress notes that indicated her right knee was pink, there was swelling present, and her skin was warm and dry. On 6/20/26, a wound note for her right knee indicated there was swelling present, the surrounding tissue of the wound was swollen, and her skin was warm and dry.On 6/21/26, a nurses' progress note indicated, Resident wants to go to [redacted name] hosp [hospital] for PICC line changed. Writer did call ER [emergency room] dept [department] requesting if resident can go in for PICC changed. Stated they don't. change PICC lines.On 6/21/26, a nurse's progress note indicated, Per AM treatment nurse. Stated PICC line flushed [flush] not working. IV antibiotics not administer [administered]. The nurse called the emergency room at a different hospital and reported the PICC line was not working. A physician's order for ceftriaxone 2,000 mg [milligram] intramuscular [IM] was obtained via facsimile. The physician's order included a notation of Reach out to PCP [primary care provider] for ER referral prn [as needed] for malfunctioning [not working] PICC Line.On 6/21/26, a wound note for resident 67's right knee indicated there was swelling and drainage present. Her IM ceftriaxone was administered at 4:30 p.m.On 6/21/26, a facsimile was sent to the clinic indicating resident 67's PICC [line] not flushing. The certified nurse practitioner responded on 6/22/26 with orders for resident 67 to be discharged to a rehabilitation hospital.On 6/22/26, resident 67 was seen at a clinic related to her evaluation for the burning sensation in her mouth. She was discharged to the rehabilitation hospital while she was at that appointment.Resident 67's Discharge Summary Plan of Care Recap of Stay evaluation indicated that she had an IV antibiotic in place.2. Interview and review of resident 67's EMR review on 8/27/26 at 2:21 p.m. with registered nurse (RN) KK, RN/regional director C, and administrator A regarding resident 67's antibiotic medication revealed that Resident 67 received her last hospital dose of antibiotic on 6/16/26. When resident 67 admitted to the facility on [DATE], her medications, including her physician-prescribed antibiotic, were not available to be administered until midnight on 6/17/26. Resident 67 had asked not to be woken up to take her medications.RN KK stated that when the lumen (a hollow space inside a tube-like structure or medical device) of the PICC line did not flush, she called an infectious disease doctor and left a message. That doctor did not return her phone call. She reported to the evening shift nurse that the lumen would not flush. RN KK indicated that she should have called the previous DON CC or a nurse case manager regarding care of the obstructed lumen. She stated she did not know if the provider's PICC line policy would explain how to care for the lumen, as she was not familiar with the policy.RN KK confirmed that resident 67's MAR included documentation that on the 6/19/26, 6/20/26, and 6/21/26, a different nurse administered the antibiotic through the PICC line. The MAR included that Ceftriaxone 2000 IM was also administered. RN KK indicated that the provider seldom admitted a resident who had a PICC line. She was unable to remember if she had annual education regarding IV access or PICC lines.3. Interview with previous contracted travel RN MM on 8/27/26 at 6:14 p.m. verified that she administered the IV antibiotic intravenously via the PICC line, as there were two lumens and one was occluded. She stated that she was able to flush one side of the lumen attached to the PICC line after she put new caps on the PICC line and was able to flush that same lumen after administering the antibiotic.4. Interview on 8/28/26 at 11:30 a.m. with administrator A revealed there were no documented PICC line or IV care competencies for RN KK.5. Interview and review of resident 67's EMR on 8/28/26 at 11:41 a.m. with RN X regarding resident 67's antibiotic administration revealed that on 6/21/26 she attempted to administer the antibiotic through her PICC line. She stated she tried both lumens in the PICC line, and both were occluded.RN X contacted a physician for an IM order of antibiotic. After receiving the order for ceftriaxone 2,000 mg IM, she administered it and called the emergency room at the hospital as resident 67 wanted to be transferred to the hospital. RN X stated she remembers resident 67 stating she wanted to go home as she did not feel the provider was doing their job. RN X stated she did not want to remove a PICC line as in her training and education, the line went into the heart and should not be removed by someone who does not have a lot of experience in PICC line care, and she felt she did not have that experience. Resident 67 was transferred to the hospital on 6/22/26.6. Review of the provider's Maintaining Patency of Peripheral and Central Vascular Access Devices IV Flush policy revealed: Vascular access devices are aspirated for blood return and flushed prior to each infusion to assess catheter function and prevent complications. Vascular access devices are flushed after each infusion to clear the infused medication from the catheter lumen. Each lumen of a multi-lumen catheter must be flushed individually. To succeed with saline flushing, a needleless connector with an anti-reflux design must be placed on the hub of EVERY lumen of EVERY vascular access device/catheter. Never inject against resistance. A pulsatile flushing technique of short boluses interrupted by brief pauses may be effective in better catheter clearance. Repeat for each individual lumen as needed.There was no indication in the provider's policy of the process for removing the obstruction of the PICC line.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure that insulin and nutritional supplements were stored at proper temperatures when the staff failed to document daily temperature readings for three of three sampled medication refrigerators (A, B, and C). One of three sampled medication refrigerators (C) did not maintain an acceptable temperature between 35 and 40 degrees Fahrenheit. Findings include:1. Observation and interview with licensed practical nurse (LPN)/infection preventionist (IP) H on 8/27/26 at 4:20 p.m. revealed that the medication storage room had three small refrigerators that were used to store medications. Refrigerator A had a temperature of 39 degrees Fahrenheit (F) and contained unopened cans of beer with residents' names on them and two stock bottles of Med Pass 2.0 Vanilla (a high-calorie, high-protein nutritional shake designed to be used with medications instead of water or juice for patients at risk for malnutrition). The daily temperature monitoring log sheet taped to the front of the refrigerator revealed temperatures were checked once daily. It indicated the refrigerator was 44 degrees F on 8/9/26; 42 degrees F on 8/11/26; and 42 degrees F on 8/23/26. All other August dates revealed temperatures documented between 35 and 40 degrees F, except 8/13/26 and 8/17/26, which were blank. LPN/IP H said the night shift staff were responsible for documenting the refrigerator temperatures. She stated that appropriate temperature range was between 35 and 40 degrees F and agreed that no temperature was documented for 8/13/26 and 8/17/26 for refrigerator A. She said if the temperature of a medication refrigerator was outside of the acceptable range, the staff were to notify maintenance director DD or director of nursing (DON) B. She did not know whether the staff had notified anyone when temperatures were documented as 42 and 44 degrees. Refrigerator B revealed it was locked and had a temperature of 40 degrees F. It contained unopened vaccine vials and an emergency insulin kit. The daily temperature monitoring log sheet taped to the front of the refrigerator revealed temperatures were checked once daily and were documented between 35 and 40 degrees F for each August date except 8/11/26, 8/13/26, 8/17/26, and 8/26/26, which were blank. LPN/IP H agreed that no temperature was documented on these four dates. Refrigerator C had a temperature of 50 degrees F and contained unopened vials of insulin and insulin pens with residents' names on them. The daily temperature monitoring log sheet taped to the top of the refrigerator revealed temperatures were checked once daily and were documented as 42 degrees F on 8/14/26, 8/18/26, and 8/20/26. No temperature was documented on 8/13/26, 8/17/26, and 8/26/26. All other August dates had a documented temperature of 40 degrees F. When LPN/IP H opened the refrigerator door, several of the insulin pens fell out and spilled onto the floor. She stated, It's way too full, that might be why the temperature is so high. She did not know if the staff had notified maintenance director DD or DON B when the temperature was documented as 42 degrees F, and she did not know how long the refrigerator had been at 50 degrees F. At 4:33 p.m., LPN/IP H transferred the insulin to refrigerator B and notified maintenance director DD that medication refrigerator C was reading at 50 degrees F. At 5:15 p.m. director of maintenance DD stated he had fixed refrigerator C and the temperature was coming down. At 6:01 p.m., medication refrigerator C had a temperature of 44 degrees F. 2. Observation and interview with LPN/IP H on 8/28/26 at 8:33 a.m. revealed refrigerator C was restocked with insulin and had a temperature of 40 degrees F. LPN/IP H said she reminded the staff not to fill the medication refrigerator so full that it would compromise its temperature. 3. Interview on 8/28/26 at 10:00 a.m. with DON B revealed she expected the night shift staff to verify the refrigerator temperatures every night and immediately notify maintenance director DD if the temperature was below 35 degrees F or above 40 degrees F. She said that if refrigerator C had a temperature of 50 degrees F for one day, she would have to verify with a pharmacist but believed opened insulin could remain at room temperature for up to 28 days. She was not concerned about the integrity of the insulin in refrigerator C. 4. Copies of the daily temperature monitoring logs for medication refrigerators A, B, and C were requested on 8/27/26 but were not provided. 5. Review of the provider's January 2026 Medication Storage Policy revealed that, Medications requiring refrigeration are kept in a refrigerator with a thermometer to allow temperature monitoring, and a temperature log or tracking mechanism is maintained to verify that temperatures remain within acceptable limits. Temperatures of refrigerators containing medication should be monitored and recorded at least once daily, the policy read, and twice daily for refrigerators containing vaccines. Insulin should be stored in the refrigerator until opened, and opened insulin should be stored at room temperature. B. Based on observation, interview, and policy review, the provider failed to ensure safe and secure storage of resident medications when contracted travel licensed practical nurse (LPN) II and registered nurse (RN) X left their medication carts unlocked, unattended, and accessible to anyone passing by, and when RN S left a bottle of Acetaminophen (an over-the-counter medicine that relieves mild-to-moderate pain and reduces fever) on top of an unattended medication cart. Findings include: 1. Observation on 8/25/26 at 9:12 a.m. revealed an unlocked medication cart sitting next to the nurse's station outside of the dining room. Contracted travel LPN II was sitting at the nurse's desk writing on a piece of paper. She then stood and walked away from the nurse's station and went into the dining room. At 9:13 a.m. she returned and spoke to certified medication aide (CMA) V at a different medication cart. 2. Interview at 9:15 a.m. with contracted travel LPN II revealed that she was responsible for the unlocked medication cart. She did not know the cart was unlocked. She locked the cart and said she did not normally leave it unlocked and that she had just stepped away to help a resident. 3. Observation on 8/26/26 at 3:03 p.m. revealed an unlocked medication cart sitting next to the nurse's station outside of the dining room. RN X was sitting at the nurse's desk working on a computer. Two staff members and one resident passed by the medication cart, and one resident stood near the nurse's office across the hall from the medication cart. 4. Interview on 8/26/26 at 3:08 p.m. with RN X revealed that she was responsible for the unlocked medication cart. She did not know the cart was unlocked. She walked around the nurse's station and locked the medication cart, apologized, and said she had gotten busy charting and had forgotten to lock it. 5. Observation and medication administration record (MAR) review on 8/26/26 at 3:30 p.m. revealed that RN S pulled a stock bottle of Acetaminophen out of the medication cart located in the east hallway. RN S placed two tablets in a medicine cup for resident 59, replaced the lid on the bottle of Acetaminophen and set the bottle on top of the cart. She then locked the medication cart and took the cup of two tablets to resident 59 in her room. RN S stepped into resident 59's room, gave the medication to resident 59, washed her hands at the sink in the resident's room, then walked back to the medication cart. RN S said, Oh, I forgot to get her pain rating, then locked the computer screen and walked back to resident 59's room, leaving the bottle of Acetaminophen on the unattended cart. RN S walked to the nurse's station, passing by the bottle of Acetaminophen on the unattended cart, and talked to RN X. At 3:37 p.m., RN S returned to the medication cart, unlocked the computer screen, documented resident 59's pain rating, unlocked the medication cart, and put the bottle of Acetaminophen away. 6. Interview on 8/26/26 at 4:42 p.m. with RN S revealed that she normally would not leave a bottle of Acetaminophen sitting on top of an unattended medication cart, but I just forgot today. She said she should have locked the Acetaminophen in the cart before taking medication to resident 59. 7. Interview on 8/26/26 at 10:00 a.m. with director of nursing (DON) B revealed that she felt it was unacceptable to leave Acetaminophen or any medication on top of an unattended medication cart. 8. Review of the provider's 1/2026 Medication Administration policy revealed that during administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse. No medications are kept on top of the cart. The cart must be clearly visible to the personnel administering medications when unlocked.

Based on observation, interview, and policy review, the provider failed to ensure a safe, sanitary and comfortable environment to prevent the development and transmission of communicable diseases and infections when registered nurse (RN) S neglected to clean shared medical equipment between uses with four of four observed residents (6, 25, 32, and 36) and failed to maintain appropriate hand hygiene during the administration of medications to two of two observed residents (11 and 53). Findings include:1. Observation on 8/26/26 at 3:27 p.m. revealed registered nurse (RN) S standing in the hallway at the east medication cart. She pulled a bottle of eye drops from the medication cart and, without performing hand hygiene or putting on gloves, she administered two eyedrops in resident 11's left eye. RN S then placed the bottle of eye drops in her scrubs pocket, walked into resident 11's room, washed her hands at the sink, and returned to the medication cart where she put the bottle of eye drops away. 2. Observation on 8/26/26 at 4:31 p.m. revealed RN S with the blood pressure machine in the dining room. She took resident 6's blood pressure, placed the blood pressure cuff into the basket on the stand that held the blood pressure machine, and then walked to resident 25 at another dining table. She removed the cuff from the basket and took resident 25's blood pressure, without cleaning the blood pressure cuff or performing hand hygiene. She placed the cuff back into the basket and pushed the blood pressure machine through the building while searching for resident 32, passing through the activities area, dining room, and east hallway. She located resident 32 in the east hallway and took his blood pressure, without cleaning the blood pressure cuff or performing hand hygiene. She then returned the blood pressure machine to the east hall medication cart and documented the blood pressure readings for residents 6, 25, and 32. She did not clean the blood pressure cuff or perform hand hygiene. 3. Interview on 8/26/26 at 4:41 p.m. with RN S revealed that she had forgotten to clean the blood pressure cuff and perform hand hygiene after each resident. She stated she should have cleaned the blood pressure cuff after taking each resident's blood pressure. RN S then pulled a disposable wipe from a container of Personal Wipe StayDry Disposable Washcloths, wiped down the blood pressure cuff, and placed the cuff back in the basket on the stand, without wearing gloves or performing hand hygiene after cleaning the cuff. 4. Observation on 8/26/26 at 4:46 p.m. revealed RN S in resident 36's room, taking her blood pressure. RN S then placed the blood pressure cuff in the basket and took the blood pressure stand to the nurse's station. She pulled a pair of disposable gloves from the medication cart next to the nurse's station, put them on, and pushed the blood pressure stand back to the east hall medication cart. Without cleaning the blood pressure cuff, she removed the gloves and discarded them in the trash bin. She did not perform hand hygiene. She then opened the computer screen and documented resident 53's blood pressure reading. 5. Observation on 8/26/26 at 4:58 p.m. revealed RN S at the dining room medication cart. She took a bottle of eye drops from the cart and, without performing hand hygiene or putting on gloves, she administered one eye drop in each of resident 53's eyes. RN S then prepared a cup containing seven medications and administered them to resident 53. Afterward, she discarded the medicine cup and unlocked the computer screen. She did not perform hand hygiene before preparing medications for another resident. 6. Interview on 8/28/26 at 10:00 a.m. with director of nursing (DON) B revealed she expected the staff to clean blood pressure cuffs between each resident using Super Sani-Cloth Germicide Disposable Wipes and to perform hand hygiene between each medication pass. She stated staff should wear gloves when administering eye drops. 7. Review of the provider's January 2026 Medication Administration Policy revealed the staff were required to wash their hands and apply gloves before administering ophthalmic (relating to the eye) medications, again after administration, and with any resident contact. 8. Review of the provider's June 2017 Medication Administration Quick Reference Guide revealed the staff were required to wash their hands prior to the start of medication pass and between residents. The guide specified that privacy must be maintained during medication administration and read, No medication is given in the dining room during a meal or activity. Eye drops . are completed in the resident's room or private area. Medications of this designation are not administered in front of other residents. 9. Review of the provider's March 2025 Standard Precautions Policy revealed staff were required to wash their hands after removing gloves and to clean or reprocess reusable equipment before using it for another resident.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation, and policy review, the provider failed to ensure two of two registered nurses (RNs) (D and J) had access to the emergency medication kit (e-kit) for one of one sampled resident (1) who subsequently did not receive his antipsychotic medication (a drug that alters specific brain activities to reduce symptoms of mental health conditions) and hallucinated and started a fire in his bedroom. Certified nursing assistant (CNA) K and RN J extinguished the fire, and no residents were injured as a result of the fire.Findings include:1. Review of the provider's 5/27/26 SD DOH FRI revealed that at approximately 5:00 a.m. on 5/27/26, staff found resident 1 in his room with a lighter after a small fire ignited and damaged a plastic water mug, part of his mattress, and his bed linens. Resident 2, resident 1's roommate, had alerted the staff, who quickly extinguished the fire with water and evacuated nearby residents until the fire department cleared the area. Emergency medical services (EMS) assessed both residents. Resident 1 was evaluated at the clinic and admitted to the hospital for observation, while his roommate declined further evaluation. Resident 1's family was notified, the lighter was removed, and his care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) was reevaluated upon his return to the facility.2. Review of resident 1's electronic medical record (EMR) revealed that he admitted to the facility from the hospital on 5/26/26. His 5/26/26 hospital referral packet indicated resident 1 was treated for delirium (sudden, severe confusion with trouble focusing and awareness). His doctor prescribed 2.5 milligrams (mg) of olanzapine, an antipsychotic medication, in the morning, and 7.5 mg of olanzapine at bedtime to treat his delirium. On 5/26/26, he received his morning dose of olanzapine at 7:35 a.m. at the hospital before he discharged from the hospital to the nursing facility. His 5/26/26 hospital discharge orders indicated he was to continue taking the morning and bedtime doses of olanzapine.A note categorized as Orders - Administration Note was entered on 5/26/26 at 9:34 p.m. that read, New admit awaiting meds.Throughout the night on 5/26/26 and into the early morning of 5/27/26, resident 1 was attempting to get out of bed by himself. He was given 2 mg of lorazepam (a medication used to treat anxiety), at around 12:10 a.m. on 5/27/26.A nursing progress note from 5/27/26 at 2:06 a.m. read, [resident 1] was found with bed pushed away from the wall and was attempting to climb out of bed. CNA's [Certified nursing assistants] assisted resident back into bed. The lorazepam medication was marked as effective on 5/27/26 at 4:40 a.m.A note categorized as Communication with Family. was entered on 5/27/26 at 6:41 a.m. that read, Resident's son [was] made aware of fire started this [morning] by resident. Let him know EMS [emergency medical service] checked him over and that there were reports of hallucinations at the time. [Resident 1's son] stated that he was having those [hallucinations] in the hospital as well.A nursing progress note written by contracted travel RN J on 5/27/26 at 7:09 a.m. read, At [5:00 a.m.], This nurse heard CNA yelling down [the] hallway. This nurse went down [the] hallway and walked into [the] resident's room to find soaker pad [an incontinence product, relating to involuntary urine or bowel leakage] and [bed] sheet on the floor on fire. As well as [the] mattress on fire with [resident 1] sitting near it. CNA grabbed [roommate's] water jug and dumped it on the bed. This nurse put out sheets on the floor. Room was filled with smoke. Got resident in his] wheelchair and out of [the] room. RN J assessed resident 1 and did not find any skin injuries or burns.A nursing progress note written by contracted travel RN J on 5/27/26 at 7:36 a.m. read, Called [telehealth, an electronic remote health service] to get a [one-time] dose for olanzapine [7.5 mg] instead of the [2.5 mg] due to [the] resident missing [a] dose last night due to pharmacy not bringing [the olanzapine].3. Interview on 6/1/26 at 11:42 a.m. with resident 2 revealed that he was resident 1's roommate and witnessed the fire on the morning of 5/27/26. He explained that resident 1 admitted to the facility on the evening of 5/26/26. Resident 2 stated that throughout the night on 5/26/26, resident 1 appeared anxious and verbalized that he wanted to go out to smoke. Resident 2 awoke early in the morning to a noise and saw resident 1 playing in the fire. He yelled for the staff, who came to their room right away and extinguished the fire.4. Interview on 6/1/26 at 2:34 p.m. with resident 1 revealed that he did not remember starting the fire or much from that night. He said, Apparently, I was hostile, but I don't remember. I was pretty mad, mad at the world. I don't know if I was dreaming.5. Review of the police department's report regarding the early morning fire on 5/27/26 revealed, when asked who else was in the room, [resident 1] stated that [four] adult males were also in his room, along with his roommate [resident 2]. [The officer] spoke to [resident 2], who stated that [resident 1] had used the lighter to start a fire. [Resident 2] stated that only [resident 1] and [resident 2] were in the room at the time.At this time, [the officer] cannot determine if the fire was intentional. [Resident 1] appeared to not understand how the fire started, and indicated in his statements about who else was in the room, that he was possibly hallucinating.6. A phone interview with resident 1's family member and responsible party was attempted throughout the survey, but the calls were not answered. There was no ability to leave a voicemail message for a return call, as the family member's phone voicemail box was full.7. Phone interview on 6/2/26 at 7:38 a.m. with contracted travel RN J revealed that resident 1 admitted to the facility late in the evening on 5/26/26 and the pharmacy did not deliver a supply of his bedtime dose of olanzapine to the facility. Olanzapine, both 2.5 mg and 7.5 mg, was available in the emergency medication kit (e-kit), but neither she nor RN D had access to unlock the e-kit. She called the telehealth provider early in the morning on 5/27/26 for an increased dose of resident 1's olanzapine because he hallucinated during the night and started a fire in his bedroom. Another nurse with access to the e-kit was present at that time and obtained the olanzapine from the e-kit and administered it to resident 1. She started working at the facility at the end of March 2026, and director of nursing (DON) B gave her a login username and password to access medications in the e-kit on Friday 5/29/26.8. Interview on 6/2/26 at 3:14 p.m. with contracted travel licensed practical nurse (LPN) I revealed that he started his contract at the facility on 5/25/26. He did not have access to the e-kit until Friday 5/29/26.9. Observation and interview on 6/2/26 at 3:23 p.m. with RN E in the medication room revealed there was a tall gray cart with multiple locked drawers. There was a computer on top of the cart and a fingerprint scanner. She explained that the cart was their e-kit. She believed the contracted travel nurses were not supposed to have access to the e-kit. She confirmed that olanzapine was available in the e-kit in 2.5 mg and 5 mg tablets.10. Interview on 6/2/26 at 3:45 p.m. with administrator A and director of nursing (DON) B revealed that resident 1 was a late admit. He arrived at the nursing home between 4:00 and 5:00 p.m. on 5/26/26. When residents admitted to the nursing home from the hospital, their medication orders were to be faxed to the pharmacy. Social services assistant (SSA) C was responsible for faxing the residents' medication orders to the pharmacy. If a resident was scheduled to receive a medication that was not delivered to the facility yet, DON B expected the nurses to obtain that medication from the e-kit to administer to the resident. She expected the nurses to call a nurse manager if they did not have access to the e-kit. DON B said that LPN G would have been available to go to the facility to unlock the e-kit for RNs D and J.Administrator A and DON B identified that not all licensed nurses had access to the e-kit after resident 1's fire-starting incident on the morning of 5/27/26. At that time, DON B did not have the capability to grant other nurses access to the e-kit. Once administrator A and DON B contacted the corporate office and DON B gained that capability, DON B started granting access to the e-kit to all licensed nurses on staff on 5/29/26.11. Review of the provider's e-kit instruction manual revealed that a person with an administrator's account had to log into their profile to add new employees to the system to grant access to the e-kit.12. Review of the provider's January 2025 Emergency Pharmacy and Emergency Kits (E-Kits) policy revealed that emergency needs for medication are met by using the nursing care center's approved emergency medication supply or by special order from the provider pharmacy. When an emergency or stat [immediate] medication is needed, the nurse first verifies and reviews the prescriber's orders for appropriateness, checks the resident's allergies, and removes the required non-controlled medication from the emergency kit. Emergency medications are only administered with a valid prescriber's order.13. Review of the provider's November 2016 admission policy revealed the policy did not contain instructions or guidance related to the process of receiving new resident physicians' orders or obtaining a resident's medications before admitting to the facility.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, interview, observation, record review, and policy review, the provider failed to ensure residents were protected from risk of injury or harm by certified nursing assistants (CNAs) who failed to safely use total body lift devices (a mechanical lift and sling used to lift a person's full body) for two of two sampled residents (1 and 3), who needed the assistance of two staff members to transfer between surfaces. Contracted travel CNAs I and H failed to safely transfer resident 1 from her wheelchair to her bed using the total body lift. CNAs K and L failed to use a compatible sling type to transfer resident 3 using the total body lift. That failure put all residents, who needed staff assistance with the use of a lift for safe transfers, at risk for falling, injury and/or serious harm. Immediate Jeopardy (IJ) at F689, scope and severity J, began on [DATE] at 5:40 p.m. when resident 3 was lowered to the floor during a transfer from her wheelchair using a full body lift by CNAs K and L. Resident 3 had a full body lift sling in her room that was brought with her from the hospital when she admitted to the facility earlier that same day. Resident 3's family members handed the sling to CNAs K and L, who placed it under resident 3. As one of the CNAs began placing the sling straps of the lower body portion of the sling to the corresponding hooks on the full body lift, resident 3 started to move around and slid forward in the sling. The CNAs readjusted the resident in the sling and attached the rest of the sling onto the full body lift hooks. Resident 3 continued to move around in the sling and slid forward towards the edge of the wheelchair seat, causing the sling to tilt in a downward position. CNAs K and L could not complete the transfer, and instead lowered resident 3 to the floor. Resident 3's buttocks made first contact with the floor, and then she was assisted to a lying position. Resident 3 did not hit her head but did express pain to her ribs. She received a chest X-ray on the morning of [DATE]. The X-ray did not show any breaks or fractures. The provider indicated in the FRI that staff [were] educated regarding resident transfers, staff competency regarding transfers initiated and ongoing, audit of resident appropriate total body lift sling size initiated and ongoing. Interviews with staff throughout the survey from [DATE] to [DATE] revealed they did not recall any recent education or competencies related to safe transfers with total body lift and sit-to stand lift (a mechanical lift used to assist from a seated to a standing position) - If not mechanical, then (a manual lift used to assist from a seated to a standing position)use and they were unaware of which sling to use for specific residents. Record review revealed that CNAs K and L, and other direct care staff, did not complete the total body lift or sit-to-stand lift competencies after the incident on [DATE] and both worked shifts since then. Further review of staff education and competencies revealed that not all direct care staff had competencies completed related to using mechanical lifts as described in the provider's FRI. Observation on [DATE] at 3:40 p.m. of contracted travel CNAs H and I while transferring resident 1 using the full body lift revealed they used the burgundy-colored sling (size large). CNA I was on resident 1's left side, while CNA H was on her right side. CNA I was facing resident 1 and looped her left arm under the resident's left arm. CNA I used her right arm to lean resident 1 forward in the wheelchair. CNA H then placed the burgundy sling behind the resident and resident 1 leaned back in the wheelchair. The CNAs pulled the lower straps of the sling towards and under the resident's thighs and interlaced the straps to secure the resident in the sling. CNA H told resident 1 to give herself a hug. Resident 1 crossed her arms, while both CNAs discussed what color loops to use. The black loops (the innermost loop) on the upper shoulder straps were used and attached to the full body lift, and the green loops (the middle loops) on the thigh straps were used and attached to the full body lift. CNA H added the burgundy loop (outer-most loop) on the right thigh strap to the full body lift. Resident 1 reached up to grab the crossbar of the full body lift and CNA H told resident 1 to hug herself again. CNA I was operating the lift controls to lift the resident while CNA H was holding on to the back handle of the sling to stabilize resident 1. Resident 1's wheelchair pad and the left handle of the wheelchair were caught on the lift sling, and it lifted the wheelchair off the floor with the resident in it. While the resident and her wheelchair were still in the air, CNA H pulled on the wheelchair pad, which was between the resident and the sling, to release the pad from the sling. The CNAs then noticed that the wheelchair was also caught in the sling. CNAs H and I switched tasks while the resident and the left side of her wheelchair were suspended in the air. CNA H lowered the resident and her wheelchair using the lift control until her wheelchair was back on the floor, while CNA I wrapped her arms around the back of the wheelchair and pulled resident 1 in her sling to guide her back into the wheelchair. Once resident 1 was seated in the wheelchair, CNA I released the left handle of the wheelchair from the sling strap. CNAs H and I did not reposition resident 1's sling before lifting her up again. The bottom of the sling (that was to be placed under the resident's bottom) was positioned at her mid-back. Once resident 1 was lifted in the air, CNA I stated, Let's hurry and get her in there [the bed], this is all wrong. CNA H then moved the full body lift and resident 1 suspended in the lift sling over to the bed and lowered her onto the bed. Record review revealed CNA I had a mechanical lift competency performed on [DATE], but there was no documentation that CNA H had a competency completed since resident 3's FRI accident on [DATE]. Record review revealed the mechanical lift sling size was not identified on the resident's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) or the Kardex (a report of the resident's care needs and interventions) for at least five sampled residents who utilized mechanical lifts (residents 1, 2, 6, 7, and 8). Administrator A, special projects administrator Q, and registered nurse (RN) clinical liaison P were notified of the IJ on [DATE] at 6:30 p.m., and an IJ removal plan was requested. The initial removal plan was received on [DATE] a.m. at 10:39 p.m. by email. The edited removal plan was received on [DATE] at 11:36 a.m. An additional edit was received on [DATE] at 2:27 p.m. The final edit was made on [DATE] at 2:47 p.m. The removal plan was accepted on [DATE] at 2:49 p.m. by email and phone call. The IJ was removed on [DATE] at 5:15 p.m. as confirmed by onsite verification by the survey team. After the IJ removal, the scope and severity of the non-compliance remained at a D. The census was 57. Findings include:1. Review of the provider's [DATE] SD DOH FRI involving resident 3 revealed that CNAs K and L were using a full body lift to transfer the resident from her wheelchair to her bed using a lift sling that the resident's family had brought to the facility. Due to the resident repositioning herself in the sling, the CNAs could not safely complete the transfer, and the CNAs lowered resident 3 to the floor using the upper portion of the sling while the lower portion of the sling was attached to the lift, as described above. 2. Review of resident 3's electronic medical record (EMR) revealed her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact. Resident 3's diagnoses included cellulitis of bilateral lower limbs (a painful red bacterial skin infection on both lower legs), chronic kidney disease stage 3 (when kidneys are damaged, filter blood poorly, causing waste buildup), lymphedema (swelling caused by a buildup of lymph fluid in the body between the skin and muscle), atrial fibrillation (when the heart's upper chambers beat too fast and irregularly), polyneuropathy (damaged peripheral nerves, causing numbness, weakness, tingling), and hypertension (high blood pressure). Resident 3's diagnoses included cellulitis of bilateral lower limbs (a painful red bacterial skin infection on both lower legs) and polyneuropathy (damaged peripheral nerves, causing numbness, weakness, and tingling). Resident 3's [DATE] Morse fall scale (a tool for assessing a patient's risk of falling) assessment score was 60, which indicated that she was had a high risk for falling. Resident 3's care plan indicated that she was to be transferred by two staff members with the use of a mechanical lift [a mechanical lift used to assist from a seated to a standing position or a mechanical lift and sling used to lift a person's full body]. Neither her care plan nor the Kardex included the type of lift (full body lift or sit-to-stand lift) or what sling size the staff was to use when assisting her to transfer. 3. Interview on [DATE] at 8:59 a.m. with CNA C revealed that she would choose the size of the mechanical lift slings based on the size of the resident's body. The smaller-bodied residents would get a medium or a smaller sized sling, and the larger-bodied residents would get a larger sling size. She said that new staff members needed to ask other staff members to know which sling size to use for which resident, or by referring to the Kardex information. 4. Interview on [DATE] at 9:12 a.m. with RN D and licensed practical nurse (LPN) J revealed that the information on the mechanical lifts and the lift slings was stored in two binders at the nurse's station. However, RN D could not find those binders. She asked LPN J where those binders were, but LPN J did not find them at the nurse's station either. LPN J found information on total body lifts in director of nursing (DON) B's office, and she said that the information was usually available for staff at the nurse's station. 5. Interview on [DATE] at 9:18 a.m. with CNA E revealed that she had worked at the facility for the past month. She did not receive any training on the safe use of the mechanical lifts at the facility. She previously worked at other nursing homes and relied on the training she received at those facilities. She stated that she chose the resident's lift sling size based on the resident's body type. She stated there was no resource she referred to help her determine the resident's correct sling size to use. She stated, I just go based on what the resident looks like by their body type and guess. 6. Review of the EMRs for residents 1, 2, 6, 7, and 8 revealed that neither their care plans nor their Kardex contained information on what sling sizes the staff needed to use for their transfers. Resident 1's care plan and Kardex revealed she required two people to assist her with transfers, but there was no indication about what type of equipment to use when transferring her. 7. Interview on [DATE] at 9:45 a.m. with CNA M revealed she completed a training refresher course four years ago on how to work a mechanical lift at the facility but did not receive recent lift use training. She stated she chose the mechanical lift sling size based on the body size of the resident. She was unable to locate documentation that indicated what size sling to use for each resident who utilized the mechanical lifts. 8. Interview on [DATE] at 10:45 a.m. with RN O revealed that she chose the size of the lift sling based on the body size of the resident. At that time, RN D, CNA E, and CNA C all began looking in the red communication binder at the nurse's station. They then found a paper dated [DATE] with resident sling size information on it. RN O stated, Well, this isn't updated at all. 9. Interview on [DATE] at 11:10 a.m. with RN F revealed that she did not know what the residents' mechanical lift sling sizes were. She would ask a CNA to help her and to tell her which sling size to use. 10. Interview on [DATE] at 3:58 p.m. with CNA I regarding the transfer with resident 1 observed on [DATE] at 3:40 p.m. above revealed that she stated the transfer was not good. She explained that it was hard to get the sling positioned under the resident. The resident was moving, and the CNAs had to pull up hard to get the sling in the correct position under her legs. She thought that the sling was too big for resident 1, and it was mispositioned. She stated, I know the sling size based on the resident's body, but this sling was too big for her. She needs a different size and a different type of sling. One that cradles her more. She needs a medium sling. 11. Interview on [DATE] at 4:35 p.m. with CNA H regarding the above observed transfer with resident 1 revealed that the sling should have been tucked under the resident more. She was worried when the wheelchair was caught in the sling because the resident was confused, moving, and grabbing at everything. She indicated that she just knew the resident's sling size based on whatever sling is in the room. If a sling in a resident's room did not look right, she would look for another sling to use based on the resident's body size. 12. On [DATE] at 6:30 p.m. administrator A, special project administrator Q, and RN clinical liaison P were notified of the IJ. On [DATE] at 10:39 a.m., the initial removal plan was received by email. An edited removal plan was received on [DATE] at 11:36 a.m., 2:27 p.m., and 2:47 p.m. The removal plan was accepted on [DATE] at 2:49 p.m. by email and phone call. REMOVAL PLAN: Resident [1] was assessed by [DON B] after surveyors witnessed two [CNAs] improper use of mechanical lift on [DATE]. [Resident 1] was noted to have a 2.5cm x 4cm erythema [reddened skin] area to right forearm during this assessment. [Resident 1] had no complaints of pain at this time. Nursing will monitor area until resolved. Physician, [resident 1's] son and Hospice notified of incident. [Administrator A] will review all education and competencies to ensure nursing staff current and new employees/agencies know appropriate mechanical lift and sling size for each resident. Residents that require mechanical lift were audited and reviewed by [interdisciplinary team] on [DATE] to ensure proper mechanical lift, proper sling size on [care plan] and adequate number of slings in place that are needed for. [Care plans] were updated to reflect any changes identified. All mechanical lifts were inspected by maintenance for proper function on [DATE]. [DON B] and Senior Director of Nursing inspected slings to ensure adequate number of slings and back up slings on hand in case sling becomes soiled on [DATE]. [Administrator A] and Senior DON verified each resident that has appropriate assigned sling with name on sling, stored in their room with back up slings available if needed on [DATE]. All resident labeled slings are stored in resident room. All extra slings are stored in beauty shop, 2nd floor. Education, return demonstration and competency were completed by [DON B] on [DATE] initiated at [10:00 p.m.] for all nursing staff on duty this evening regarding proper use of mechanical, proper sling size, where sling can be found and location of extra slings in case slings become soiled. [CNA I] that was involved in the incident was educated during last night's evening shift on [DATE]. [CNA H] will be educated and competence completed prior to her next scheduled shift, which as this time is Thursday [DATE]. [CNA H and I's staffing agencies] were notified of the IJ citation on [DATE] involving their staff. [DON B] and [administrator A] will collaborate to schedule a manager at the beginning of each shift for education, return demonstration and competency of Nursing staff including current nursing staff, clipboard, prn nursing staff, any travel staff prior to next shift. Request made to Clipboard for customized education to be completed in onboarding process through their platform. DON was at facility on [DATE] prior to 6:00am shift for education and competency for nursing staff. [Administrator A] will perform observational audit every new admission to ensure proper mechanical lift and sling is appropriate on care plan based on height and weight. Additional observational audits will be completed Randomly for proper use of mechanical lifts and appropriate sling size and type. Both audits will be completed 3 times a week for 4 weeks and weekly for one month thereafter to ensure ongoing compliance. Results of these audits will be reviewed in monthly [Quality Assurance and Performance Improvement] for review and recommendation. This removal plan asserts that the likelihood for serious harm to any recipient no longer exists by [DATE]. 13. Review of the provider's updated list of transfer equipment to be used for each resident and observations of slings in residents' rooms on [DATE] beginning at 3:30 p.m. revealed that two of the thirteen slings that were in the residents' rooms did not match the updated list or the Kardex information. Resident 5's sling in his room was an extra-large size, and the updated list reflected the same. However, resident 5's Kardex listed that his sling was supposed to have been a size large. Resident 6's sling in his room was size large, and his Kardex reflected the same. However, the updated list indicated that his sling was supposed to have been a size extra-large. 14. Interview on [DATE] at 4:35 p.m. with DON B revealed that she was going to review the inconsistencies of the sling information on residents 5 and 6 and update them with the correct sling size. 15. Observation and record review on [DATE] at 5:15 p.m. of resident 5 and 6's slings in their rooms, the resident's Kardex, and the updated list of transfer equipment to be used for each resident revealed the discrepancies were fixed and the immediacy was removed. 16. Review of the operator's instructions for the EZ Way Smart Lift (total body lift) 500, 600 & 1,000 lb. (pound) capacities revealed that when transferring a patient from a chair, wheelchair, or toilet, the first step is to position the sling under the resident, the second step is to position the EZ Way Smart Lift near the resident, the third step is to attach the sling to the lift, and the fourth step is to lift the resident upwards. Before fully lifting the resident, the instructions indicated to push the UP button on the hand control to initiate the upward motion of the lift. Continue the upward motion until there is tension on the legs of the sling, making sure all the loops on the sling are securely hooked on the hanger bars. Smooth the sling legs under the [resident's] thighs with a slight pull on the outside seam of the sling legs, if necessary. 17. Review of the EZ Way Sling Sizing Chart revealed that the gray slings were a size small, would hold a person of 70 to 100 pounds, and the maximum distance from a person's tailbone to the base of their neck was 21 inches. The beige slings were a size medium, would hold a person of 90 to 220 pounds, and the maximum distance from a person's tailbone to the base of their neck was 24 inches. The burgundy slings were a size large, would hold a person of 190 to 320 pounds, and the maximum distance from a person's tailbone to the base of their neck was 26 inches. The green slings were a size XL [extra-large], would hold a person of 280 to 450 pounds, and the maximum distance from a person's tailbone to the base of their neck was 29 inches. The black slings were a size XXL, would hold a person of 400 to 600 pounds, and the maximum distance from a person's tailbone to the base of their neck was 36 inches. The brown slings were a size XXXL, would hold a person of 600 or more pounds, and the maximum distance from a person's tailbone to the base of their neck was 37 inches. The sizing chart indicated, The size/weight designations are merely estimates and basic guidelines. A proper fit will depend on factors other than weight measurements, including the height and girth of a patient [person]. A proper fit will involve the judgment of the caregiver. There was a diagram on how to measure the sling relative to the person that had the following description, Height of sling – Two inches below Tailbone to top of Shoulder Line.It is important that the base of the sling be positioned two inches below the tailbone and the top of the sling is parallel with the top of the shoulder line (base of neck).

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and observation, the provider failed to protect a resident's right to be free from potential neglect by one of one certified medication aide (CMA) (N) who left one of one sampled resident (2) unattended on the toilet for about two hours. Resident 2 was identified at risk for falling and developing pressure ulcers (skin and/or underlying tissue injury from prolonged pressure), and needed staff assistance with the use of a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) to transfer on and off the toilet. That failure resulted in the resident having reddened skin on his buttocks with risk for that area developing into a pressure ulcer. Findings include:1. Review of the provider's 2/9/26 final SD DOH FRI revealed that resident 2 was found sitting on the toilet in the beauty shop bathroom at around 4:20 p.m. on 2/7/26. He required the use of the sit-to-stand lift for transfers, and that lift was left attached to the resident. The door was closed, and the call light was not activated. Before that, a certified nurse aide (CNA) on the evening shift saw that resident 2's room call light was on, but resident 2 was not in his room. That CNA turned off resident 2's room call light and proceeded to answer other resident's call lights down that same hallway. The charge nurse found resident 2 sitting on the toilet in the beauty shop bathroom at around 4:20 p.m. on 2/7/26. She assisted him off the toilet, helped with personal hygiene, and assessed him for pain and skin injuries. Resident 2 denied experiencing any pain. His buttocks had slight redness consistent with the seat of the toilet, that was due to prolonged sitting for an unknown time on the toilet. The redness subsided [resolved] before the end of the shift. The provider's investigation concluded that CMA N assisted resident 2 to the beauty shop bathroom sometime between 2:15 p.m. and 2:30 p.m. on 2/7/26 as that was when resident 2's wife witnessed CMA N and her husband head towards the beauty shop bathroom before she left for the day. CMA N denied that he assisted resident 2 to the beauty shop bathroom, although there were witnesses who confirmed seeing him take resident 2 to that bathroom. CMA N did not inform any other staff member that he had taken resident 2 to the beauty shop bathroom before the end of his shift. The provider suspended CMA N's employment on 2/9/26 pending further investigation when CMA N was identified as the staff member who left resident 2 on the toilet by resident 2's wife. The provider initiated staff education related to abuse/neglect policy and resident cares. Education was continued regarding Assisting Residents with Toileting needs, to include remaining with residents that require close supervision. Additional staff education to the CNA's and nurses was initiated regarding Shift Hand off/Report [the shift leaving gives a verbal report to the oncoming shift while walking and seeing each resident and his/her location] during change of shift to include head count of residents of assigned units. A sign reading vacant and occupied was added to the outside of the beauty shop door to indicate to staff when the beauty shop bathroom was in use. Lastly, the provider terminated CMA N's employment with the facility. 2. Review of resident 2's electronic medical record (EMR) revealed his 1/7/26 Brief Interview for Mental Status (BIMS) assessment score was 8, which indicated his cognition was moderately impaired. Resident 2's care plan included that he required the use of a sit-to-stand lift for transfers, maximal/substantial transfer assistance while using the toilet, and he was dependent on the staff for toileting hygiene. There was a focus area that read, I have the potential for pressure ulcer development related to immobility, incontinence. The associated goal read, I will have intact skin, free of redness, blisters, or discoloration by/through [the] review date. Resident 2's 1/6/26 Braden scale (a tool used to assess the risk of developing pressure ulcers) assessment score was 13, which indicated he had a moderate risk for developing pressure ulcers. Resident 2 had diagnoses of Parkinson's disease (a brain disorder that damages movement-control cells, causing shaking, stiffness, slow movements, balance and mood problems), unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities), hallucinations (to see, hear, smell, taste or touch something that is not there), and unspecified sensorineural hearing loss (a hearing loss caused by damage to the inner ear or auditory nerve, with no known specific cause). Resident 2's 9/3/25 Morse fall scale (a tool for assessing a patient's risk for falling) assessment score was a 75, which indicated he had a high risk for falling. There was no documented pain assessment or skin assessment after resident 2 was left on the toilet for an extended period on 2/7/26. 3. The surveyor team was not able to interview resident 2 during the survey from 3/23/26 to 3/25/26 due to the resident sleeping or being unavailable during attempted interview times. 4. Interview on 3/24/26 at 8:59 a.m. with CNA C revealed she checked on her assigned residents every two hours. These checks included assisting residents to reposition if they were not able to reposition themselves. If she assisted a resident to the bathroom, she would give them five to ten minutes of privacy and then go back to check on them if the resident had not used their call light to ask for assistance. She said she checked on them at this time frame because if a resident sat on the toilet any longer, they would get redness from the pressure of sitting on the toilet seat too long. 5. Interview on 3/24/26 at 9:18 a.m. with CNA E revealed that some resident's bathrooms were not big enough to maneuver for the sit-to-stand or the full-body lift (a mechanical lift and sling used to lift a person's full body). If a resident needed to use the bathroom and their bathroom was too small for the transfer equipment, the staff were to take those residents to the beauty shop bathroom. CNA E stated that there was no specific process or policy about when the CNAs were expected to go back to assist the resident after they were transferred onto the toilet. She would assist them on the toilet, and then she just remembers to go back for them and assist them off of the toilet. 6. Observation on 3/24/26 at 2:27 p.m. revealed a staff member transferred a resident into the beauty shop, then closed the door behind them. That staff member did not change the sign on the door from Vacant to Occupied before shutting the door. 7. Review of the provider's investigation documentation for the 2/7/26 incident revealed education on the abuse and neglect policy had previously been initiated on 2/1/26 related to a previous complaint survey citation. That education was ongoing through 3/2/26 to ensure that all staff received the education. There was no documentation to support that ongoing audits were completed to ensure the staff understood resident safety interventions and the education that they were provided, or documentation that the provider ensured no other residents were left on the toilet at the time of the incident. 8. Interview on 3/24/26 at 5:45 p.m. with administrator A revealed that she confirmed there were no audits completed after the incident involving resident 2 on 2/7/26. 9. Review of the provider's March 2025 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation policy revealed that Neglect was defined as Failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Neglect occurs when the facility is aware of, or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s), resulting in physical harm, pain, mental anguish, or emotional distress. The policy included procedures for conducting a thorough investigation, protecting other residents from potential abuse or neglect, and coordinating how the staff were to report potential abuse or neglect situations with the provider's Quality Assurance and Performance Improvement (QAPI) program.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), SD DOH complaint records, interview, and policy review, the provider failed to report a FRI and results of their final investigation to the SD DOH within the required time frame regarding nine of nine residents (1, 6, 7, 8, 9, 10, 11, and 12) who had a reportable incident. Findings include:1. Interview and review of the SD DOH FRI (a required reporting of unexpected or adverse events) reports and 1/22/26 SD DOH complaints records with administrator A and director of nursing (DON) B on 1/28/26 at 6:51 p.m. revealed: *Resident 1 reported an allegation of abuse on 1/3/26 at 6:00 p.m. -The initial report was submitted on 1/14/26 at 9:45 a.m. -The final investigation report was submitted on 1/16/25. -The complaints record stated, The facility failed to ensure timely reporting for Resident [1]. Review of reporting records showed the initial report was not submitted until 1/14/26, approximately 11 days after the event occurred. Additionally, while a final report was submitted on 1/16/26, the initial reporting delay failed to ensure immediate protection and oversight. -Administrator A and DON B verified that the initial and final FRI reports regarding resident 1's incident on 1/3/26 were not reported or submitted to the SD DOH within the required time frame. -Administrator A submitted those FRI reports and indicated the initial report was denied and resubmitted on 1/14/26. She could not identify a specific reason why it was not completed within the required time frame. She indicated that she was aware of the SD DOH required reporting time frames and was responsible for doing so. *Resident 6 had a fall that required further medical evaluation for a head laceration needing staples on 12/28/25 at 9:45 p.m. -The initial report was made 12/28/26 at 9:45 p.m. -The final report was submitted 1/20/26 at 3:25 p.m. -The SD DOH complaints record stated, The facility failed to ensure timely reporting of an alleged violation involving Resident [6]. Review of the incident report showed the event occurred on 12/28/25 at 2145 [9:45 p.m.]; however, the initial report was not submitted until 12/29/25 at 2037 [8:37 p.m.], exceeding the required 2-hour reporting timeframe. Additionally, review of reporting records showed the final investigation report was not received until 1/20/26 at 1525 [3:25 p.m.], which exceeded the required 5 working-day timeframe. This failure placed the resident at risk for unaddressed abuse or neglect. -Administrator A and DON B verified that the initial and final FRI reports regarding resident 6's event on 12/28/25 at 9:45 p.m. were not reported or submitted to the SD DOH within the required time frame. -Administrator A submitted those reports and was unsure why it was not completed in the required time frame. *Resident 6 had a fall that required further medical evaluation for a head laceration on 1/4/26 at 2:28 p.m. -The initial report was submitted on 1/4/26 at 3:29 p.m. -There was no final investigation report submitted. -The SD DOH complaints record stated, The facility submitted the initial report for Resident [6] on 1/4/26 at 1529 [3:29 p.m.], meeting the required 2-hour timeframe. However, review of records confirmed no final investigation report was ever submitted. The facility failed to comply with 483.12(c)(4) requirements for reporting investigation results. -Administrator A and DON B verified the FRI regarding resident 6 on 1/4/26 did not have a final investigation report submitted to the SD DOH. -DON B submitted the initial report and was not sure why the final report was not submitted to the SD DOH. *Resident 7 had a fall that required further medical evaluation for head and pelvic pain on 10/13/25 at 4:18 p.m. -The initial report was submitted 10/13/25 at 6:20 p.m. -There was no final investigation report submitted. -The SD DOH complaints record stated, The facility failed to submit the results of an investigation for Resident [7]. While the initial report was submitted timely, the [SD DOH] State Survey Agency rejected the initial report on 11/19/25 and again on 1/20/26, requesting submission of a final investigation report. Review of records confirmed no final report was ever submitted. The facility failed to report investigation results within 5 working days as required. -Administrator A and DON B verified the FRI regarding resident 7 on 10/13/25 did not have a final investigation report submitted to the SD DOH. -DON B submitted the initial report and stated the final investigation report did not get submitted because it got stuck in the cracks. * Resident 8 had a fall that required further medical evaluation for a head laceration and received a steri-strip (laceration closing dressing) to close the laceration on 11/5/25 at 8:55 p.m. -The initial report was submitted 11/6/25 at 1:41 p.m. -There was no final investigation report submitted. -The SD DOH complaints record stated, The facility failed to ensure timely reporting for Resident [8]. Review of reporting records showed the initial report was not submitted until 11/6/25 at 1341 [1:41 p.m.], exceeding the required 2-hour timeframe. Additionally, the report was rejected on 11/19/25 and again on 1/20/26 with requests for submission of a final investigation report. No final report was received. The facility failed to comply with both initial reporting and investigation reporting requirements. -Administrator A and DON B verified the FRI regarding resident 8 on 11/5/25 was not reported in the required time frame, and the final investigation report was not submitted to the SD DOH. -DON B submitted the initial report. She said she was not aware of the incident until after the required time frame to report it and stated the final investigation report did not get submitted because it got stuck in the cracks. *Resident 9 had a fall that required further medical evaluation due to having a seizure (a sudden, temporary abnormal brain activity) on 11/16/25 at 7:30 p.m. -The initial report was submitted on 11/17/25 at 7:11 p.m. -There was no final report submitted. -The SD DOH complaints record stated, The facility failed to report an alleged violation involving Resident [9] in a timely manner. Review of records showed the initial report was not received until 11/17/25 at 1911 [7:11 p.m.].exceeding required reporting timeframes. Additionally, no final investigation report was ever submitted. The facility failed to ensure timely reporting and completion of the investigation process. -Administrator A and DON B verified the FRI regarding resident 9 on 11/16/25 was not reported in the required amount of time, and no final investigation report was submitted to the SD DOH. -DON B submitted the initial report and did not recall why it was not submitted in the required time frame or why the final investigation report was not done. *Resident 10 had a fall that required further medical evaluation due to hitting her head and having a seizure on 12/5/26 at 9:05 p.m. -The initial report was submitted on 12/6/25 at 12:12 p.m. -The final investigation report was submitted on 12/15/25. -The SD DOH complaints record stated, The facility failed to ensure timely reporting for Resident [10]. Review of reporting records showed the initial report was submitted on 12/6/25 at 1212 [12:12 p.m.], exceeding the required 2-hour reporting timeframe. Additionally, the final investigation report was submitted on 12/15/25, exceeding the required 5 working-day timeframe. The facility failed to comply with both reporting requirements. -Administrator A and DON B verified that the initial and final FRI reports regarding resident 10 on 12/5/25 were not submitted within the required time frame to the SD DOH. -Administrator A submitted those reports and was unsure why they were not completed within the required time frame. *Resident 11 had a fall that required further medical evaluation due to a left arm fracture on 12/17/25 at 5:30 a.m. -The initial report was submitted on 12/17/25 at 9:30 p.m., per the FRI report. -There was no final report submitted. -The SD DOH complaints record stated, The facility failed to ensure timely reporting for Resident [11]. Review of the incident report showed inconsistent event dates listed as 12/17/25 and 12/24/25. The initial report was not received until 12/29/25 at 2129 [9:29 p.m.], which exceeded the required reporting timeframe regardless of the event date. Additionally, no final investigation report was submitted. The facility failed to ensure accurate documentation and timely reporting. -Administrator A and DON B verified the FRI regarding resident 11 was on 12/17/25 and that it was not submitted in the required time frame, and no final investigation report was submitted to the SD DOH. -Administrator A submitted the initial report and was not sure why the initial report was not submitted in the required time frame and was not sure why the final investigation was not completed. *Resident 12 had an alleged potential resident-to-resident physical abuse on 11/21/26 at 7:00 a.m. -The initial report was submitted on 11/22/25 at 3:00 a.m. -There was no final investigation report submitted. -The SD DOH complaints record stated, The facility submitted the initial report for Resident [12] on 11/22/25 at 0300 [3:00 a.m.], which met the required 24-hour reporting timeframe. However, review of records confirmed the facility never submitted a final investigation report. The facility failed to report investigation results within 5 working days as required. -Administrator A and DON B verified the FRI regarding resident 12 on 11/21/25 did not have a final investigation report submitted to the SD DOH. -Administrator A submitted the initial report, and she recalled doing the investigation, but was unsure why the final investigation report was not submitted to the SD DOH. 2. Interview on 1/27/26 4:44 p.m. and on 1/28/26 at 4:37 p.m. with administrator A revealed: *She started working at the facility on 11/10/26. *She acknowledged the facility had issues with reporting FRIs to the SD DOH. *Incidents that required reporting to the SD DOH were abuse/neglect, falls with injury, medication errors, falls with unknown origin, allegations, and missing medications. -Allegations, falls of unknown origin, and falls with major injury were to be reported to the SD DOH within two hours. -All other incidents needed to be reported to the SD DOH within 24 hours. -The final investigation report needed to be submitted to the SD DOH within five days. *All managers had completed their education regarding incidents that needed to be reported to the SD DOH. *She and DON B were responsible for completing reports to the SD DOH. Staff were to call her or DON B, even in the middle of the night, to be informed of any resident's incidents so they could determine if they needed to be submitted to the SD DOH. *Administrator A and DON B put a reminder on a shared calendar to remind them when a final investigation report needed to be submitted to the SD DOH. *Around 50% (percent) of the staff had completed the all-staff education regarding resident reportable events, and they still had a few days to complete it by the deadline they had given. *She completed her education regarding reporting to the SD DOH. 3. Interview on 1/27/26 at 5:44 p.m. with social services director C revealed that administrator A or DON B were responsible for completing the initial and final FRI reports to the SD DOH. 4. Review of the provider's October 202[?] Abuse Reporting and Response policy revealed: * The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and federal law. *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 survey agency and other officials in accordance with state law.as follows: -immediately but not later than 2 hours-All allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, if the events that cause the allegation involve abuse or result in serious bodily injury. -**Note-reporting requirements are based on real clock time, not business hours. *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. *The Center identifies staff responsible for implementation of corrective actions, expected date of implementation, and those responsible for monitoring. *Additional training is conducted with staff, and staff competency is evaluated as necessary. *Failure to report suspicion or allegations of abuse timely by staff will result in disciplinary action up to and including termination.

Based on interview, record review, and policy review, the provider failed to ensure care services were provided for:*One of one resident (4) who had pain with urination, a temperature, and physician's orders to collect a urine sample on 1/12/26, which was not collected by the provider, and may have delayed treatment.*One of one resident (5) who had black stools, strong-smelling urine, and physician's orders to collect lab work on 1/9/26, which was not collected until 1/14/26, and may have delayed treatment. Findings include:1. Interview on 1/28/26 at 2:20 p.m. with resident 4 in his room revealed:*He had his urine tested in Sioux Falls, he was unsure when, but it had been negative, but he continued to have burning with urination. 2. Review resident 4's paper and electronic medical record (EMR) revealed:*He was admitted to the facility on [DATE].*He had diagnoses of alcoholic cirrhosis of the liver with ascites (extensive scarring and fluid buildup caused by long-term alcohol use) and acute kidney failure (sudden decline in kidney function).*His 12/10/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated his cognition was intact.*A 1/12/26 at 2:57 p.m. physician's order stated, Please collect a UA [urine analysis] sample and bring to clinic today.*A nursing progress note on 1/12/26 at 4:56 p.m. written by licensed practical nurse (LPN) L stated, Resident c/o [complained of] painful urination and increased frequency and urgency. Resident [4] describes pain as being sharp and only when he attempts to urinate. No pain over bladder upon palpation. Resident [4] states he drank about half of his water mug which equals to be approximately 450 cc of water.-Vital signs obtained [were] BP [blood pressure]-118/72, P [pulse]-103, R [respirations]-18, T [temperature]-101.1 O2 [oxygen]-95%, P [pain]-10/10.-Resident [was] informed that [the] provider [doctor] will see him tomorrow 1/13/26 during Doctor rounds. Family informed of this as well.* A nursing progress note on 1/13/26 at 12:28 p.m. written by registered nurse (RN) M stated, Staff reporting temp of 102 and Dr. [resident 4's primary care provider (PCP)] requests he be seen at [the] clinic today for further evlauaution [evaluation] and to postpone upcoming GI [gastrointestinal] testing scheduled for 1-14-26.Clinic app't [appointment] made for 3:15pm and resident informed.*A late entry nursing progress note created on 1/15/26 at 5:20 p.m. for 1/13/26 written by LPN/care coordinator (CC) E stated, [Resident 4's PCP] here for in-house rounds and recommended resident be seen in the clinic d/t [due to] fever and nausea.*A 1/13/26 at 3:19 p.m. family medicine visit report indicated the resident had urinary retention (unable or difficulty urinating). They completed a bladder scan and which revealed 906 cc (cubic centimeters) of urine was in his bladder. They inserted a Foley catheter, obtained a urine sample, administered IV antibiotics, and would start oral antibiotics the next day for a suspected UTI.*A 1/13/26 physician's order that stated, RSV [respiratory syncytial virus]/COVID/Influenza swabs collected; Also strep swab. All swabs negative. UA ordered. Foley catheter [flexible tubing placed in the bladder to drain urine]. Catheter cares BID [twice a day]. Can attempt to discontinue foley 1/15. IV [intravenous] Rocephin [antibiotic] administered for suspected UTI [urinary tract infection]. Cipro 250 mg [oral antibiotic] BID ordered to started [start on] 1/14/26. Diagnosis: UTI *A nursing progress note on 1/13/26 at 5:46 p.m. by RN D stated, Sister was informed [that] resident [4] remain [remained] @ [at] ER [emergency room] all test [tests] are negative . COVID RSV etc [etcetera]. On IV antibiotics now, back @ the manor [facility] in an hour.*A nursing progress note on 1/13/26 at 6:21 p.m. written by RN D stated, Resident returned per RHCC [facility] van. With orders. RSV/COVID /Influenza swabs collected. Also strep swabs All negative. UA ordered. Foley placed . catheter cares BID. Can attempt to discontinue Foley 1/15. IV Rocephin administered- for suspected UTI. Cipro 250 mg BID ordered start 1/14/26 [period] 3. Interview on 1/28/26 at 5:15 p.m. with director of nursing (DON) B revealed:*There was no documentation of what information was sent to resident 4's physician before the UA order was received on 1/12/26 at 2:57 p.m. *She indicated that resident 4's UA should have been collected on 1/12/26 as ordered by the physician, and verified that not doing so may have caused a delay in treatment. 4. Interview on 1/28/26 at 5:53 p.m. with LPN/CC F revealed:*She was not sure what notification the physician received that prompted the order for the UA on 1/12/26.*The UA should have been collected on 1/12/26 as ordered by his physician.*On 1/13/26, the physician requested that resident 4 to be seen in the clinic that same day, and a UA was collected at the clinic on 1/13/26 at 4:36 p.m.*The UA was not cultured because that was not indicated per the test results.*The physician treated him with antibiotics due to his elevated temperature and symptoms. 5. Interview on 1/28/26 at 2:25 p.m. with resident 5 in her room revealed:*She felt like she was able to see a doctor if she needed to and felt the staff completed physician order lab work in a timely manner. 6. Review of resident 5's paper and EMR revealed:*She was admitted to the facility on [DATE].*She had a diagnosis of intracerebral hemorrhage (bleeding in the brain).*Her 11/26/25 BIMS assessment score was 11, which indicated her cognition was moderately intact.*On 1/8/26 a fax was sent to the resident 5's physician that stated, Staff reports dark black stool x [for] 2 days. In addition, her urine has a strong odor. Please advise.*An undated physician's order stated, she [resident 5] is on iron supplements, which can cause dark stools versus GI bleed-she should have labs done check CBC [complete blood count] and CMP [complete metabolic panel] today as well as a UA.-The physician's order was acknowledged as received by staff on 1/13/26, but the time was not documented.*On 1/9/26 at 1:10 p.m. resident 5's physician sent an email with a document attached to it to LPN/CC F and requested a status update on resident 5. LPN/CC F responded by email on 1/9/26 at 1:16 p.m. that her vital signs were stable, resident 5 stated she felt fine, and staff had no further information to report.*A progress note on 1/13/26 at 9:03 a.m. written by RN N stated, Resident [5] had dark stools and strong urine odor, [provider name] CNP [certified nurse practitioner] , gave order to collect CBC and CMP and a UA today.*A progress note on 1/14/26 at 1:13 a.m. written by LPN O indicated the day and evening shift did not obtain a urine sample, and the resident was asleep. The urine sample was rescheduled to be collected when she was awake.*On 1/14/26 at 1:27 p.m. LPN/CC F sent an email to resident 5's physician which stated, When you get a chance would you look at the labs from this am [period] Resident 5's physician responded at 2:40 p.m. that her labs were okay. LPN/CC F informed the physician that they were waiting on a UA sample from resident 5 due to her being unable to urinate and did not want a catheter placed. The physician stated they did not need to collect a UA unless resident 5 had symptoms other than odor.*There was a CMP lab report collected on 1/14/26 at 8:15 a.m.*There was no CBC report to review.*There was a progress note on 1/14/26 at 2:37 p.m. written by LPN/CC F that indicated resident 5's CMC and CMP were collected, and the clinic obtained the CMP. 7. Interview on 1/28/26 at 5:15 p.m. with DON B revealed:*She was not sure when the order for the labs was received.*She expected the labs to be collected on the day the order was received from the physician, if it was during lab business hours. 8. Interview on 1/28/26 at 5:53 pm. with LPN/CC F revealed:*The document that was attached to the physician's email received on 1/9/26 at 1:10 p.m. was the order for resident 5's CBC, CMP, and UA labs.*She left the facility before then on 1/9/26 so she did not receive that email.*She stated that the physician's order was faxed to the facility on 1/9/26 and was not acknowledged by staff until 1/13/26.* She collected resident 5's CBC and CMP on 1/13/26 at 11:31 a.m. The CMP needed to be recollected by the lab the next morning because the sample was unable to be tested.*Resident 5's CMP, CBC, and UA lab specimens should have been collected on 1/9/26 when the physician's order was received.*The labs, including the UA should have been collected on 1/9/26 when the order was received. 9. Interview on 1/28/26 at 2:45 p.m. with LPN/CC F revealed:*She felt if a resident needed to be seen by a physician, the clinic typically scheduled them an appointment in a timely manner.*Physician rounds at the nursing home were done twice a month. Once by the doctor and once by the CNP.*Physicians orders were to be entered into the residents EMR during the same shift that they were received in.*Lab work could be done at the nursing home and taken to the lab at the clinic/hospital.-The lab was open Monday through Friday until 5:00 p.m. and on Saturdays until 12:00 p.m.-If emergent, lab work could be dropped off at any time because the clinic/hospital had a lab technician on call.*The physicians were notified of residents' health concerns, and orders were received by email or by fax. 10. Interview on 1/28/26 at 2:50 p.m. with RN D revealed physician's orders were to be processed immediately. 11. Review of the provider's April 2024 Physician Orders policy revealed:* Physician orders are reviewed and revised daily, via the Electronic Health Record [EHR].* The licensed nursing staff is responsible for inputting admission, telephone and verbal physician's orders into the EHR immediately upon receipt from the provider.* The Director of Nursing establishes the licensed clinician responsible for recap and reconciliation of New, Discontinued, or Completed orders in the EHR daily and initiates corrections daily.

Based on record review, interview, and policy review, the provider failed to implement wound treatment orders for one of one sampled resident (1) with blisters on her buttocks and identified at risk for developing pressure ulcers, which resulted in the blisters going untreated for several days and the development of a stage 2 pressure ulcer (skin wound caused by prolonged pressure where the first two layers of skin are damaged, and the area appears as a shallow, open wound or an intact or ruptured blister) on her sacrum (lower back).Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed that she was admitted on [DATE] with diagnoses of sepsis (a life-threatening condition caused by the body's extreme response to an infection), pneumonia (a lung infection), epilepsy (a neurological condition causing seizures), neuromuscular dysfunction of bladder (bladder control problems caused by nerve or muscle signal issues), restlessness and agitation, dysphagia (difficulty swallowing), major depressive disorder, gastrostomy status (having a surgical hole inserted into the stomach for artificial nutrition and hydration), encephalopathy (brain disorder causing confusion, memory loss, or behavior changes), Type 2 Diabetes Mellitus (T2DM) with diabetic neuropathy (a condition involving disruptions in how the body regulates blood sugar, with associated nerve damage), aphagia (brain condition that makes speaking and understanding language difficult), and acute respiratory failure with hypoxia (sudden onset of difficulty breathing with loss of blood oxygen saturation).The resident relied on staff for completion of all activities of daily living and required the use of a full body mechanical lift for transfers. She had a urinary catheter and was incontinent of bowel. She was unable to reposition herself in bed and required the assistance of two staff members to reposition. Resident 1 was nonverbal due to her aphasia. Staff were directed to communicate with her using yes/no questions, as she was able to shake her head for the yes/no questions. Staff were to assess for signs and symptoms of pain using nonverbal cues.The admission nursing assessment completed on 10/8/25 indicated that her skin appearance was warm, dry and intact. No skin wounds were noted on that assessment. She did not have another skin assessment until she returned to the facility on [DATE] following a hospitalization that began on 10/19/25.Her 10/8/25 admission Braden Scale for Predicting Pressure Score Risk score was 11, which indicated she had a high risk for developing pressure ulcers.Her 10/15/25 Braden score was 12, which indicated she had a high risk for developing pressure ulcers.Her care plan included interventions initiated on 10/9/25 related to impairment of skin integrity such as Follow facility protocols for treatment of injury, Identify/document potential causative factors and eliminate/resolve where possible, Keep skin clean and dry. Use lotion on dry skin, Monitor/document location, size and treatment of skin injury. Report [skin] abnormalities, failure to heal, s/sx [signs and symptoms] of infection, maceration [skin softening and breakdown] etc. to MD [medical doctor]. Her care plan did not include preventative interventions for staff to follow to ensure no skin breakdown occurred, such as regular repositioning to offload pressure or the use of pillows for position support.Registered nurse (RN) L entered a nursing progress note on 10/16/25 that read, Resident sleeping most evening shift. Regular repositioning. Neb [nebulizer] administer[ed].Resident has 2 spots blister to [her] buttocks. E care [eCare, a telemedicine service] notified with orders. Plan The note did not include what the plan was. There was no documentation that indicated the eCare provider orders had been entered or followed.The 10/16/25 eCare provider note read, .During the assessment the nurse also noted 2 small blister like areas to the [resident's] bilateral [both] buttocks. The resident is being repositioned regularly due to permanent bed-riddance. Nurse is requesting orders for Opti Foam [a wound dressing product] to apply to the areas, [to] change every 3 days and PRN [as needed]. Wound nurse to follow up.Plan: .5. For blisters to bilateral buttocks, continue with repositioning and may apply Opti foam to the areas, change every 3 days and as needed if loose or soiled. 6. Follow up with wound nurse on next rounds.There was no documented skin assessment of the resident's blisters. There was no documentation that the nursing management team or the wound nurse had been notified of the resident's blisters. There was no documentation that resident 1's primary care provider or her power of attorney were notified of the resident's blisters.The 10/16/25 orders for the Opti Foam were not entered into resident 1's EMR physician orders, so it is unknown if the orders were followed. There was no documentation to indicate if, or how often, the resident was repositioned to prevent pressure ulcers.The 10/16/25 eCare progress note was scanned into resident 1's EMR without having been noted by a nurse, meaning that there was no signature of who received the order, entered the order into the resident's EMR, and scanned that document into the resident's EMR.Resident 1 was experiencing a fever and low oxygen concentration levels on the morning of 10/18/25. The eCare provider was notified and an order was given for resident 1 to be sent to the local emergency department (ED) for evaluation and treatment. She was readmitted to the nursing home that same day with instructions to closely monitor her intakes and outputs, increase her fluid intake, monitor her blood sugar levels, and ensure her sliding scale insulin is applied as ordered. Resident 1's condition declined on the morning of 10/19/25. Her fever worsened, she was having difficulty breathing, and her oxygen concentration levels were not improving. The eCare provider was notified again, and ordered for resident 1 to be sent back to the local ED. From the local ED, resident 1 was transferred to a different hospital for further treatment.Resident 1's 10/19/25 hospital admission assessment included resident 1 had a stage II [stage 2, open wound or blistering of the first two layers of skin] sacral decubitus ulcer [pressure ulcer on the lower back].2. Interview on 11/18/25 at 10:40 a.m. with certified nurse aide (CNA) H revealed that she remembered that resident 1 had an air mattress on her bed at one point for pressure reduction. She was assigned to resident 1's hallway when resident 1 was a resident at that nursing home. She tried to reposition the resident every two hours, sometimes sooner.3. Interview on 11/18/25 at 10:57 a.m. with resident care manager (RCM)/licensed practical nurse (LPN) O revealed that she thought the redness on resident 1's bottom was noted when she first admitted . There were wound treatment orders when resident 1 readmitted to the nursing home from the hospital on [DATE]. Resident 1's mattress was switched from her initial spatial awareness mattress that had raised borders so the resident could tell where the edge of the bed was, to a pressure-reducing air mattress. She could not remember when they switched the style of mattress.4. Interview on 11/18/25 at 11:32 a.m. with CNA N revealed that she confirmed resident 1 required total staff assistance with all activities of daily living. She really depended on us. CNA N said resident 1 was nonverbal, and because of that, she felt the staff could not really tell if or when resident 1 was in pain. She confirmed that resident 1 had the start of a tiny red spot on her tailbone area before she went to the hospital on [DATE]. She was not assigned to resident 1's hallway, but she would help the other CNAs reposition resident 1 in bed and transfer her from one area to another.5. Further interview on 11/18/25 at 11:55 a.m. with RCM/LPN O revealed that she was not the nursing home's designated wound nurse. RCM/LPN K was the wound nurse and would know more about the resident's wound evaluations and treatments.RCM/LPN K was not available for interview during the survey from 11/17/25 to 11/18/25 as she was out of the country.6. Phone interview on 11/18/25 at 11:59 a.m. with RN L revealed that she remembered calling eCare on 10/16/25 regarding resident 1's respiratory distress and oxygen saturation problems, but she could not remember anything about the resident's blisters. When asked more specifically about the progress note that she entered which mentioned the blisters, she again said that she could not remember anything about those wounds.7. Interview on 11/18/25 at 12:07 p.m. with interim director of nursing (IDON) C revealed that when resident 1 first admitted to the nursing home, she provided education to staff about her repositioning schedule, to support her body with pillows as resident 1 had leg contractures, and how to effectively communicate with a nonverbal person.Resident 1's mattress was switched to the pressure-relieving air mattress when she readmitted to the nursing home from the hospital on [DATE], but all our beds are more or less pressure relieving.She expected that if a nurse on duty received provider's orders by fax machine, that nurse should have entered the order into the EMR, communicated with the pharmacy about any supply needs, notified the nursing management team about the new orders, and notified the dietitian to see if there were any nutrition recommendations for wound healing.8. Interview on 11/18/25 at around 12:20 p.m. with administrator A revealed that she was not aware of resident 1's wounds, as her first day as administrator at that facility was the previous week. She expected the nurse to assess a wound upon first discovering it, notify the director of nursing, notify the resident's primary care provider, notify the resident's family, and obtain wound treatment orders, if any, from the resident's physician.9. Further interview on 11/18/25 at 1:13 p.m. with IDON C revealed that she confirmed she could not find any documentation on resident 1's blisters that were first noted on 10/16/25 by RN L, other than the progress note that RN L entered in the resident 1's EMR, and the eCare progress note that was scanned into the resident's EMR.She explained that the eCare progress note was scanned into the EMR, but it was not noted by a nurse to indicate that the note was reviewed, and orders were entered in the resident's EMR.She expected whichever nurse found the wound to complete an initial skin assessment, contact the nurse management team, contact the resident's primary care provider, and contact the resident's family.She confirmed that RN L notified eCare about the blisters on 10/16/25, but did not assess the wounds, notify the resident's primary care provider, her family, the wound nurse, or the nursing management team, and did not enter the resident's wound treatment orders in the EMR. She confirmed there was no documentation to support that the wound treatment orders were initiated or followed.10. Review of the provider's July 2025 Skin Integrity policy revealed that in an effort to maintain the resident's optimal level of skin integrity and promote healing of skin ulcers/pressure ulcers/wounds, the facility has a systematic approach and monitoring process for evaluation and documenting skin integrity. In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. 1. The nurse completes the 'Braden Scale/Skin Integrity Evaluation at admission, weekly for three weeks, and then annually. 2. The nurse establishes a plan of care based on risk factors in an effort to limit their potential effects. 3. The resident's skin is inspected daily with completion of [activities of daily living]. Changes in the resident's skin are reported to the Licensed Nurse (LN). 4. Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the treatment administration record (TAR) with their initials. 5. For skin impairment identified with admission (abrasion, bruise, burn, excoriation, pressure sore, rash, skin tear, surgical wound, etc.), the LN completes the following: A. Documents skin impairment that includes measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment in the 'Weekly Wound Evaluation' for surgical, pressure, burns, and venous stasis ulcer.C. Notifies the medical provider and, if needed, obtains a treatment order and documents on the TAR [treatment administration record] after [the] order is implemented. D. Notifies resident/representative of skin condition and treatment plan. E. Evaluates environment, mobility equipment, functional and cognitive ability, medications, and labs to identify interventions to promote healing/resolution of skin impairment. 6. If skin impairment is noted after admission (in addition to the above steps), the LN: A. Initiates alert charting. B. Completes (and documents) notifications to the medical provider and resident or resident representative. C. Implements new interventions as needed. Documents on the resident's care plan. D. Notifies Food and Nutrition Services Manager (FANS) and/or Registered Dietitian of new pressure injury or worsening wound condition for nutritional needs evaluation. E. Notifies Director of Nursing Services (DNS) of skin impairments that indicate potential significant change in condition (Stage II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs, groin). F. The DNS and/or designee complete a comprehensive review of the resident's medical record to evaluate if the pressure injury was avoidable or unavoidable. This evaluation is documented in the nurse's notes.8. Wounds are evaluated weekly by facility clinicians. Arterial, pressure, stasis, and venous ulcers, significant surgical wounds, and burns are evaluated, measured, and findings [are] documented in the medical record. This evaluation includes pain associated with the wound during wound care. If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the medical provider and Resident's Representative are notified. If a new treatment order is obtained the LN: A. Re-evaluates plan of care and resident's condition (e.g. off-loading pressure from skin impairment area, nutritional intake, blood sugars, and lab values).

Based on South Dakota Department of Health (SD DOH) facility reported incidents (FRIs), interview, record review, and policy review, the provider failed to ensure medications were available and administered to:*One of one sampled resident (2) who did not receive physician-ordered anti-seizure medication for five doses and who had increased seizure episodes that resulted in the resident's transfer to the emergency department.*One of one sampled resident (4) who did not receive his physician-ordered blood clot preventing medication for 7 daysFindings include: 1. Review of the provider's SD DOH FRI received on 9/3/25 revealed:*Resident 2 did not receive five doses of his physician-ordered scheduled anti-seizure medication.*On 9/2/25, resident 2 had seizures that lasted longer than five minutes.*He was sent to the emergency department (ED) for evaluation due to his increased seizure activity. 2. Review of resident 2's electronic medical record (EMR) revealed.*He had orders to receive Zonisamide (a medication to treat seizures) 100 milligrams (mg)/5 milliliters (ml) scheduled twice daily at 8:00 a.m. and 8 p.m.*On 8/30/35 at 8:00 p.m., RN I administered resident 2's Zonisamide.*On 8/31/25 at 8:00 a.m., CMA P documented resident 2's Zonisamide was not administered and it was On Order From Pharmacy.*Resident 2's subsequent four scheduled doses of Zonisamide were documented as not administered and it was On Order From Pharmacy. 3. Interview on 9/23/25 at 4:20 p.m. with registered nurse (RN) G revealed:*Residents' medications were to be ordered when the supply of a medication was depleted.*She reported that if medications did not arrive on time, there were medications available in an emergency kit. 4. Interview on 9/24/25 at 10:45 with certified medication aide (CMA) R revealed:*She was working her first week as a CMA.*She was trained to re-order residents' medications after she administered the last dose of medication.*She demonstrated how to re-order medications in the facility's electronic documentation system, Point Click Care (PCC). 5. Interview on 9/24/25 at 11:00 a.m. with licensed practical nurse (LPN) X revealed:*She had worked at the facility for approximately three weeks and was trained to re-order a resident's medication when there were eight pills left.-She explained that the last column on a medication card was highlighted in blue to remind staff to re-order the medication.*She demonstrated how to re-order medications in PCC. 6. Interview on 9/24/25 at 2:32 p.m. with LPN O revealed:*She would re-order medications when a resident's supply of medication had three days of doses left.*She did not feel it was appropriate to wait until the last dose had been administered to re-order a resident's medications. 7. Interview on 9/25/25 at 9:35 a.m. with RN N revealed:*She was a contracted travel nurse who worked at the facility for approximately a month, but had worked at the facility previously.*She ordered the medication when she removed the last dose for administration from a resident's medication supply.*She did not recall any problems with pharmacy not delivering medications timely. 8. Follow-up interview on 9/25/25 at 9:52 a.m. with RN G revealed:*She re-ordered medications when there were eight doses left.*For a liquid medication not marked with a reminder to re-order, she stated I use my better judgement. I don't wait until the last dose.*She felt that resident 2's medication should have been re-ordered before it was depleted. 9. Interview on 9/25/25 with director of nursing (DON) B revealed se expected staff would re-order residents' medications before they were depleted to ensure doses were not missed. 10. Interview on 9/25/25 at 1:25 p.m. with pharmacy director S revealed:*The pharmacy recommended that medications be re-ordered when there was a three-day supply of the medication remaining.*She recalled that resident 2's medication was requested to be filled by fax on Sunday 8/31/25.-The pharmacy's fax machine was not checked on Sundays.*She explained that Monday 9/1/25 was a holiday and the pharmacy's fax machine would not have been checked that day.-There was a phone number for staff to call to re-order medications.*It was her opinion that resident 2 missing five doses of his anti-seizure medication was a significant medication error due to the type of medication and the outcome of resident 2's seizure episodes, followed by the resident's transfer to the ED. 11. Review of the facility's medication re-order sheet from 8/31/25 revealed:*A request for a refill of resident 2's Zonisamide.-with comments that included Total Quantity Remaining-0, Unable to give this morning. Next [dose] due [on] 8/31/25 [at] 2000 [8 p.m.].*The bottom of the medication reorder sheet included instructions to, *Please reorder medication in advance (3 day minimum) of need to assure an adequate supply is on hand.* 12. Review of the provider's SD DOH FRI received on 8/13/25 revealed:*Resident 4 did not receive his coumadin, a blood thinning medication used to prevent blood clots from 8/7/25 through 8/12/25.*The provider reported that the resident's coumadin medication was unavailable due to an updated lab schedule. 13. Review of resident 4's EMR revealed:*Resident 4 was to receive Coumadin every day to prevent blood clots.*There was no administration of Coumadin from 8/7/25 through 8/12/25. 13. Interview on 9/23/25 at 4:20 p.m. with registered RN G regarding resident 4's missed doses of coumadin revealed:*She reported that resident 4 had recently had a change in his lab schedule to determine is dose of Coumadin.-The order was changed from every week to every two weeks and pharmacy must not have been notified.-The pharmacy would adjust resident 4's Coumadin dose each week based on his lab values.-Because there were no new lab values, pharmacy did not re-order the resident's Coumadin.*She stated Something definitely should have been done. -She did not say exactly what should have been done. 14. Review of the provider's January 2022 medication ordering and receiving from pharmacy provider policy revealed:*Procedure, Section 1. C, All medications shall be reordered in advance by writing the medication and prescription number, or applying the peel-off bar coded label from the prescription label on the reorder sheet and faxing or otherwise transmitting the order to [the] pharmacy.

Based on observation, interview, record review, and policy review, the provider failed to provide effective pain management to one of one resident (7) who transferred to the emergency department with complaints of increased pain.Findings include: 1. Observation and interview on 9/24/25 at 8:50 a.m. with resident 7 revealed:* She had resided at the facility for about a month.*She had increased pain over the past several days.*She reported that her pain was not being adequately controlled and was getting worse.*Her left lower abdomen was visibly swollen.*She reported she was not able to turn to her side anymore due to the discomfort.*She stated, the nurses have looked at it, but she did not feel anything was being done.*She stated, I'd like to see my specialist. 2. Review of resident 7's electronic medical record (EMR) revealed:*She had medical diagnoses that included secondary malignant neoplasm (cancer) of other digestive organs, acute kidney failure (kidney's inability to filter blood properly), and anxiety disorder (a disorder characterized by feelings of worry, anxiety, or fear that are strong enough to interfere with one's daily activities).*She was sent to the emergency department to be evaluated for increased abdominal pain on 9/14/25.-While in the emergency department, she received Fentanyl a controlled (medications at risk for abuse and addiction) pain medication, and Lorazepam, a controlled medication for anxiety.*She was discharged from the emergency department and returned to the facility on 9/14/25 with orders to have a follow-up appointment with her primary care physician in two to four days.*No documentation indicated a follow-up appointment with her primary care provider was made. No follow-up care from the emergency department visit was obtained.*On 9/15/25 and 9/16/25, she received three doses of PRN oxycodone 2.5 mg.*A progress note entered on 9/16/25 at 11:12 p.m. by licensed practical nurse (LPN) Y stated, Resident [resident 7] c/o [complains of] her abdomen getting bigger with fluid. LLQ [left lower quadrant of her abdomen] does appear bigger than [the] right and [resident 7] stated she is having more pain and pressure.*On 9/17/25, 9/18/25, and 9/19/25, she received two doses of PRN oxycodone 2.5 mg.*A progress note entered on 9/18/25 at 3:58 p.m. by RN G stated, PRN [as needed] lorazepam was administered twice today for c/o anxiety. Resident [resident 7] noted to be restless at times. She was reminded to write down when she takes medication as she is forgetful and overfocuses on PRN acetaminophen [Tylenol] and lorazepam. PRN acetaminophen [was] administered today x2 [twice] for c/o of abdominal pain of 6/10 [six on a zero-to-ten scale]. She states the abdominal pain is the same pain she had when she was hospitalized .*A progress note entered on 9/19/25 at 3:16 p.m. by RN G stated, PRN oxycodone administered today x2 for c/o abdominal pain 6/10. She [resident 7] states the abdominal pain is the same pain she had when hospitalized .*A progress note entered on 9/20/25 at 3:59 p.m. by LPN O stated, Resident [resident 7] does verbalize pain and discomfort frequently and asks for prn pain medication.*On 9/20/25, she received two doses of PRN oxycodone 5 mg.*On 9/21/25, she received two doses of PRN oxycodone 2.5 mg.*On 9/22/25, she received three doses of her PRN oxycodone 2.5 mg and one dose of 5 mg oxycodone.*A progress note entered on 9/23/25 at 11:22 p.m. by RN Q stated, Resident [resident 7} concerned stated her lower abdomen is getting bigger. Stated she wants to be seen by [a] specialist.*On 9/23/25, she received three doses of her PRN oxycodone 2.5 mg and one dose of 5 mg oxycodone.*A progress note entered on 9/24/25 at 10:52 a.m. by LPN O stated, Resident [resident 7] utilizes prn oxycodone and prn acetaminophen for c/o pain; reminded [her] to reposition as she lays in bed most of the day. Resident satisfied with pain regime.*On 9/24/25, she received three doses of PRN oxycodone 5 mg.-At 3:30 a.m., LPN Z administered one of those 9/24/25 doses and documented resident 7's pain rating was 0/10.*A progress note entered on 9/24/25 at 3:33 p.m. by RN Q stated, Check resident [resident 7] for eve [evening] incoming nurse. She is sleeping but easily awaken. Asked her about her chronic lower abd [abdominal] pain stated she wants more pain med [medication]. Pain rated 10/10. Administer 5 mg [milligrams] oxycodone per tubing. Asked resident if she wants to be seen @ [at] clinic now since rounds visit today was cancelled. Stated she will wait until [NAME]. [tomorrow] a.m [morning]. if [a] Physician will be here.*A progress note entered on 9/24/25 at 5:43 p.m. by RN Q stated, [Resident 7's] Daughter is here. Spoke to her, resident concern. Lower abdomen is getting bigger having a lot of pain rated 10/10. Administer PRN oxycodone 5 mg. Offered resident to go to ER [emergency room] to be seen there. Agreed. Refuses to go with ambulance. Her daughter transported her to the [[NAME] Flandreau Hospital] hosp. [hospital] ER.*A progress note entered on 9/24/25 at 11:50 p.m. by RN Q stated, Resident was sent to SF [another town] per [[NAME] Flandreau Hospital] ER (emergency room).*A progress note entered on 9/25/25 at 8:18 a.m. by director of nursing (DON) B stated, Spoke with RN on Oncology unit, stated that resident [resident 7] has been admitted [to the facility]. 3. Interview and record review on 9/24/25 at 4:30 p.m with social services designee E revealed:*A progress note dated 9/23/25 at 11:22 p.m. had no writing in it.*Social service designee E reported that she had not finished the note, but it was because resident 7 had notified her of increased pain. 4. Interview on 9/24/25 at 4:35 p.m. with registered nurse (RN) Q regarding resident 7's pain revealed:*She was concerned about resident 7's pain because the resident frequently reported a pain level of six on a zero-to-ten scale and rated her pain that day at ten.*She stated Today is the first day she [resident 7] has been like this. 5. Interview on 7/25/25 at 9:52 a.m. with RN G regarding resident 7's pain revealed:*She felt resident 7 was tough to read, was anxious and always rated her pain at six on a zero-to-ten scale.*After resident 7 got Tylenol (medication for mild pain) or Oxycodone (a prescription for moderate to severe pain), she would say that her pain was better. 6. Review of the provider's 6/2025 pain management policy revealed:*Policy Statement: It is the policy of this center that resident's receive care to attain and maintain the highest quality of care and life.*4) An appropriate pain scale is selected for use based upon resident ability and needs. Examples may include but are not limited to: Numeric 1-10, Verbal Descriptor Scale, Wong-Baker Faces, and PAINAD (Pain Assessment in Advanced Dementia).*6) If it is determined that pain is not controlled to the resident satisfaction, the medical provider is consulted, and the resident remains on alert charting.

Based on review of South Dakota Department of Health Facility Reported Incident (SD DOH FRI), interview, record review, and policy review, the provider failed to protect the resident's right to be free of abuse by:*One of one certified nursing assistant (CNA) T who slapped a resident's door and told that resident that she would get her pain medication when her name came up on the nurse's list, when one of one resident (7) requested pain medication. The resident reported that interaction caused her increased anxiety.*One of one certified medication aide (CMA) U who refused refused to assist a resident with taking medication for one of one sampled resident (6) who cried and expressed feelings of emotional distress.*One of one CNA V who told a resident he would fight him, grabbed the resident's arm, and took a breakfast bar from one of one sampled resident (5) with diet restrictions who took a breakfast bar from a snack cart.Findings include: 1. Review of the provider's 8/19/25 SD DOH FRI revealed: *On 9/19/25, resident 7 reported to social services designee (SSD) E that she used her call light to request pain medication, Certified Nursing Assistant (CNA) T answered the call light and told resident 7 “You will get your pain medication when your name comes up on the list.”, then left the resident's room. -Resident 7 put on her call light again, CNA T responded to her call light “in an unpleasant tone and manner.” and said to resident 7, “I told you you will get your medicine when the medication nurse gets to you, and slammed her fist on the door.” *Resident 7 told SSD E that the interaction with CNA T that day “made her feel distressed.” *Resident 7 told SSD E that if she were to see CNA T again, “it would cause her a great deal of anxiety.” *CNA T was suspended pending further investigation by the provider. Interview on 9/24/25 at 8:50 a.m. with resident 7 regarding the 8/19/25 incident revealed: *She recalled she had increased pain that day and put her call light on to ask for pain medication. *She did not recall receiving care from CNA T before that day. *She stated that the first time she put on the call light, CNA T was rude and said “You will get your pain medication when your name comes up on the list.” *She reported putting on her call light again a few minutes later, CNA T answered the call light again, and said “I told you, you will get your medications when the nurse gets to you, and then slapped the door with her hand.” -Since then, she did not want to put on her call light and she felt increased anxiety when she would see CNA T walking by her room. Interview on 9/24/24 at 10:40 a.m. with CNA AA revealed: he worked with CNA T on the day of the above incident and did not witness that incident or CNA T exhibiting negative interactions with residents that day. Interview on 9/25/25 at 9:52 a.m. with RN G revealed resident 7 often rated her pain at a six (on a zero to ten pain scale) and stated resident 7 was very anxious. Interview on 9/25/25 at 11:13 a.m. with director of nursing (DON) B revealed: *When CNA T was interviewed about the incident by DON B, Her manner was very rude. Her language was not professional. *The DON reported that CNA T referred to the resident 7 as the lady with all of the tubes. CNA T did not deny her actions or apologize for them during the interview. *DON B reported that CNA T would no longer be employed due to her treatment of resident 7. 2. Review of the provider's 4/29/25 submitted SD DOH FRI regarding resident 6 revealed: *Resident 6's Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. *On 4/27/25 at 8:00 a.m.an argument had occurred between resident 6 and CNA/CMA U when the resident was administered her medications. -Resident 6 had asked for CNA/CMA U to assist her with her cup of water when taking her medications. *Medication pills and water were found lying on the floor of resident 6's room after CNA/CMA U had left the room. *Resident 6 indicated CNA/CMA U was rude and did not want to help her with small things. *The incident was reported by CNA H on 4/28/25 to the former director of nursing (CC). *The resident's emergency contact, primary care provider, and local law enforcement were notified of the incident. *The provider reviewed resident 6's care plan which showed: -Schizoaffective disorder (a mental health condition that combines symptoms of schizophrenia and a mood disorder, such as depression or bipolar), trauma, bipolar, and acute and chronic anxiety. -Nutritional assistance needed by one staff if hands are not working properly. *Her care plan did not include that she self-administered of any medications. *Interventions included: -Offer reassurance and support as needed. -Provide safe and welcoming environment interactions. -One staff member for assistance with nutritional needs. -Interviews with 3 random residents were conducted to ensure the residents were receiving appropriate care. *Based on the provider's investigation, findings the provider verified the incident due to resident 6's statement. Interview on 9/23/25 at 12:40 p.m. with registered nurse (RN) G revealed she: *Heard something had happened between resident 6 and CNA/CMA U but was not aware of what happened. *Indicated that resident 6 did not mention to her that an incident had occurred between her and CNA/CMA U. *Did not feel resident 6 exhibited behaviors that indicated she was upset after the incident had occurred. *Thought CNA/CMA U presented as a “hot head” and did not always get along with other staff members. Interview on 9/23/25 at 12:49 p.m. with resident 6 revealed she: *Did not recall an incident where she had been upset with staff member CNA/CMA U. *Denied knowing CNA/CMA U or if she had worked at the facility. *Had received appropriate care at the facility and stated, “staff are doing the best that they can do.” *During the investigation, resident 6 stated to former DON CC “She made me feel like a dummy and that I didn't know anything about my medications” Interview on 9/23/25 at 2:40 p.m. with CNA H revealed: *On 4/27/25 she had heard a confrontational argument between resident 6 and CNA/CMA U in the resident's room. *When she entered the resident's room, the resident had been crying and stated, “I don't want her in here” and pointed at CNA/CMA U. *Resident 6 indicated to CNA H, she had asked for CNA/CMA U to remain by her side when she took her medications and CNA/CMA U refused to assist the resident with her cup of water or to remain by her side when she took her medications. Interview and record review on 9/23/25 at 4:05 p.m. with RN I revealed: *There was no active order on resident 6's medication administration record (MAR) that indicated staff were to remain with the resident when administering medications. *Resident 6's care plan did not include staff were to remain with the resident when medications were administered or to assist her with her cup of water. *She indicated resident 6 requested staff to remain with her and assist her when taking her medications. Record review of resident 6's electronic medical record (EMR) revealed: *Care plan, MAR, TAR (treatment assessment record), and active and discontinued physician orders did not reveal that staff must remain with the resident when her medications were administered. *Resident 6 ‘s self-administration of medication evaluation had been completed on 4/24/25 and indicated the resident was unable to self-administer medications. On 9/24/25 at 1:05 p.m. the provider provided documentation that revealed: *CNA/CMA U had received education on abuse, reporting, and neglect of residents. -Unable to interview former administrator BB and former DON CC that were employed at the facility, at the time the incident had occurred on 4/27/25, as they no longer are employed at the facility. 3. Review of the provider's 8/28/25 submitted SD DOH FRI regarding resident 5 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was 00, which indicated his cognition was severely impaired. *On 8/28/25 at 9:35 p.m. resident 5 was observed taking a breakfast bar from the snack cart. *The resident's diet was regular with pureed food and thickened liquids. *He was educated on his diet restrictions by licensed practical nurse (LPN) O, but the breakfast bar was not taken away from the resident. *LPN O witnessed CNA V approach the resident and in a joking manner, and indicated he would fight the resident for the breakfast bar. *Actions by CNA V escalated and became aggressive towards the resident. *He had approached the resident in a boxing-type movement (closed fists in the air) and circulated his body around resident 5, who was seated in a wheelchair. *CNA V grabbed the resident's arm and took the bar from the resident's hand. *The resident and CNA V were separated by LPN O and CNA J. *The resident was assessed by LPN O and no injuries were found at that time. *CNA V had no further contact with the residents after the incident. His shift ended that day at 10:30 p.m. *The resident's emergency contact and primary care provider were notified. *Review of the resident's care plan showed: -He had a diagnosis of bipolar (manic depression), behavior syndromes associated with physiological disturbances and physical factors, intellectual disabilities, adjustment disorder with depressed mood, and cerebral palsy (CP) (a disorder that affects a person's ability to move, maintain balance, and control posture caused by abnormal brain development most often occurring before birth). -He had a communication problem related to a hearing deficit, neurological symptoms, and weak or absent voice due to CP. -The resident shook his head back and forth to indicate “No” and shrugged his shoulders to indicate “Yes.” *Interventions included: -When communicating with the resident, allow adequate time to respond, repeat as necessary, do not rush, request clarification to ensure he understands and face him when speaking. -Ensure and provide safe environment. *Based on the provider's investigation, the provider verified the incident. -CNA V had violated policy and his employment at the facility was terminated on 9/5/25. Resident 5 was not interviewed because the resident was nonverbal. Interview on 9/24/25 at 9:55 a.m. with LPN O revealed she confirmed the incident as described in the facility reported incident (FRI): *Had witnessed resident 5 take a breakfast bar from the snack cart on 8/28/25 at 9:35 p.m. -Did not take the breakfast bar from the resident but provided education on his special diet. *Witnessed CNA V when he had approached the resident, in what she believed was in a joking manner. *Indicated CNA V had told the resident; he would fight him for the breakfast bar and his actions became aggressive and escalated towards resident. *Indicated CNA V had approached the resident in a boxing type movement (closed fists in the air) and had circulated his body around the resident who was seated in the wheelchair. -Witnessed CNA V grab the resident's arm and retrieved the bar from the resident's hand. *Separated CNA V and the resident with assistance from CNA J. *Assessed the resident and no injuries were found at that time. On 9/24/25 at 1:05 p.m. documentation was provided and revealed: *CNA V had received education on abuse, reporting, and neglect of residents. Interview on 9/25/25 at 8:36 a.m. with CNA J revealed: *She indicated on 8/28/25 at 9:35 p.m. resident 5 was having an “off night” and was being confrontational. *CNA V was passing out bedtime snacks to the residents. *Resident 5 took a breakfast bar from the snack cart. *CNA V grabbed the resident's arm and took the bar from the resident's hand. *She confirmed she and LPN O separated CNA V and the resident. Interview on 9/25/25 at 1:28 p.m. with CNA H revealed she: *Referred to the resident's Kardex (quick reference medical record system) and the resident information on the assignment sheets to know how to care for residents. *Indicated resident 5 had exhibited aggressive behaviors in the past. *Would accommodate resident 5 such as when he wants to get out of bed, to alleviate any negative behaviors. Interview on 9/24/25 at 3:05 p.m. with administrator A revealed: *She expected that staff would report to the director of nursing DON or herself, any resident abuse or neglect concerns. *A staff member reported in a suspected abuse incident would be suspended until the investigation was completed. *No documentation was provided that indicated all staff members had received abuse and neglect training after the 8/28/25 incident. *Former assistant director of nursing (ADON) DD and the former DON CC were notified of the incident directly after it had occurred. -They were not interviewed as they no longer work at the facility. Review of the provider's 3/2025 CNA job description revealed: *”Reporting Relationships, 1. Reports to the Licensed Nurse directing and overseeing resident care on assigned unit.” Review of the provider's 10/2022 Abuse Reporting and Response policy revealed: *“Policy Statement: The center immediately reports all suspected and or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source in accordance with state and feral law.” -“Staff immediately reports all alleged or suspected violations to the supervisor and Executive Director.” -“Reports of alleged violations by others such as staff, residents, visitors, other health care providers, or others do not need to be explicitly characterized as “abuse”, “neglect”, “mistreatment”, or “exploitation” to require reporting, investigation, and further necessary steps.” *”The Executive Director or designee reports alleged violations to the state survey agency and other officials in accordance with state law (such as Adult Protective Services and local law enforcement) as follows:” *”c. Serious bodily injury means an injury involves extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ, or mental faculty; requiring medical intervention such as surgery, hospitalization, or physical rehabilitation.” Review of the provider's 10/2022 Abuse Investigation policy revealed: *”Policy Statement: The center conducts a thorough investigation of potential, suspected and or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown origin, in accordance with state and federal regulations.” -“The center identifies and interviews, involved person, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations.” -“ The center protects the alleged victim during and after the course of the investigation.”

Based on observation, interview record review and policy review provider failed to recognize and adequately manage pain for one of two hospice sampled resident (49). Findings include: 1. Observation on 2/25/25 at 2:11 p.m. revealed: *Resident 49 was being repositioned by certified nursing assistant (CNA) F and hospice registered nurse (RN) G. *Resident 49 could be heard in the hall moaning. *Resident grimaced and moaned in pain with any repositioning. 2. Observation and interview on 2/26/25 at 8:31 a.m. with CNA D revealed: *CNA was repositioning and checking resident 49 for incontinence every two hours. *Resident 49 grimaced and moaned in pain with even small movement. *Resident 49 would shout help, help with repositioning. *CNA made effort to be very gentle with the resident, but the resident was still in pain. *He reported resident 49 has had increased pain with repositioning for the past several days. *CNA reported his increased pain to RN E. 3. Interview on 2/26/25 at 8:40 a.m. with RN E revealed: *She tried to assess resident 49's pain as often as possible. *She also relied on the CNAs to let her know if he was having increased pain. *She was aware he was having increased pain with repositioning. *She did not feel his pain was adequately controlled with pills; she would prefer liquid morphine for pain control for a hospice resident. 4. Interview on 2/26/25 at 1:30 p.m. with director of nursing (DON) A and RN C revealed: *It was DON A's expectation resident 49 would be repositioned every two hours. *RNC C stated pain should be assessed every shift. *There were changes to resident 49's medication that day and DON A would like to see if the new medication was effective in relieving the resident's pain. 5. Phone interview on 2/26/25 at 2:15 p.m. with hospice RN G revealed: *She had no concerns with the quality of care resident 49 was receiving from the provider's staff. *She recognized the resident's increased pain during her previous visit and requested a change of pain medication to scheduled morphine. *She reported observing past hospice residents not having their pain controlled. She reported she thought resident pain was perceived as behavior issues. 6. Observation and interview on 2/26/25 at 4:30 p.m. with CNA K revealed: *CNA K was repositioning and checking the resident's brief for incontinence. *She reported the resident appeared to be more comfortable than usual. *She reported the resident seemed to have a lot of pain with movement and repositioning. 7. Review of resident 49's electronic medical record (EMR) revealed: *He was admitted to hospice care on 2/18/25. *His brief interview for mental status (BIMS) score was was 3, which indicated he was severely cognitively impaired. *He had medical diagnoses including right humerus fracture, congestive heart failure, and depression. *Nursing progress note on 2/25/25 at 1:11 a.m. documented by licensed practical nurse (LPN) S noted Repositioned q [every] 2 hrs [hours]. He is lethargic, but yells every time he is touched. Refuses to eat, drink, and take medication. 8. Review of resident 49's 12/30/24 care plan revealed: -A Focus of I am on pain medication therapy r/t [related to] injury to R [right] Humerus fx [fracture]. -Goals of The resident will be free of any discomfort or adverse side effects from pain medication through the review date. -Interventions/tasks of Administer ANALGESIC medications as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT [every shift]. -A Focus of I have an alteration in musculoskeletal status r/t fracture of the R Humerus. -Goals of The resident will remain free from pain or at a level of discomfort acceptable to the resident through the review date. -Interventions/tasks of Anticipate and meet needs. Be sure call light is within reach and respond promptly to all requests for assistance. Give analgesics as ordered by the physician. Monitor and document for side effects and effectiveness. -A Focus of I have identified PAIN that interferes with sleep, rehabilitation activities, day to day activities Depression, Fracture of R Humerus. -Goals of The resident will not have an interruption in normal day to day activities due to pain through the review date. The resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the review date. The resident will display a decrease in behaviors of inadequate pain control such as irritability, agitation, restlessness, grimacing, perspiring, hyperventilation, groaning, crying through the review date. -Interventions/tasks of Administer analgesia as per orders. Give 1/2 hour before treatments or care. Anticipate the resident's need for pain relief and respond immediately to any complaint of pain. 9. Review of resident 49's treatment administration record (TAR) revealed: *His pain was to be monitored each shift, at 7:00 a.m, 3:00 p.m., and 11:00 p.m. *On 2/25/25 at 7 a.m., RN CC documented the resident's pain was 0 out of 10 during repositioning, indicating the resident had no pain. *On 2/25/25 at 3 p.m., RN R documented resident's pain 0 out of 10. *On 2/25/25 at 11 p.m., LPN DD documented resident's pain 0 out 10 *Resident 49 had a physician's order to receive 2.5 milligrams (mg) of Oxycodone (narcotic pain medication) every hour as needed for pain. *On 2/25/25, resident 49 did not receive Oxycodone for pain. 10. Review of the provider's 1/2025 pain management policy revealed: *Policy Statement: It is the policy of the center that residents receive care to attain and maintain the highest quality of care and life. *Residents are evaluated for pain upon admission, routinely, and prn [as needed] with the RAI [resident assessment instrument] process. *Procedure: 2. The resident is evaluated every shift for signs and symptoms of pain, receiving pain management according to the Preliminary Plan of Care and/or physician order. This data is collected on the medication administration record (MAR), in the interdisciplinary progress notes and through the Daily Clinical meeting process. *An appropriate pain scale is selected for use based upon resident ability and needs. Examples may include but are not limited to: Numeric 1-10, Verbal Descriptor Scale, Wong-Baker Faces, and the Pain AD (Pain Assessment in Advanced Dementia). *11. If the resident is a hospice client or receiving palliative/comfort care the nurse and the hospice manager collaborate to develop and evaluate the pain management plan of care.

Based on observation, interview, record review, policy review, and job description review, the provider failed to develop and implement pressure relieving measures to ensure facility acquired pressure ulcers had not developed for three of five sampled residents (10, 12, and 49) who were identified at high risk for skin breakdown and dependent upon the staff assistance with their activities of daily living (ADL). Findings include: 1. Observation on 2/25/25 at 10:08 a.m. of resident 10 revealed: *He was in his room and lying on the bed with a nursing home gown on. *He was laying mostly on his back with a pillow placed underneath of his right arm. -His body was positioned and was facing towards the wall with the upper portion of his body towards the left of the bed. -From his waist down his body was laying on the right side of the bed. -His buttocks and thighs laid directly on the mattress. *There was a heel lift device underneath the lower part of his legs to help decrease pressure from the mattress on his heels. -He had been positioned low in the bed and his left foot was flat up against the footboard. *His left ankle was laying directly on the edge of the mattress and his right heel was laying directly on the mattress. -There was no pressure relief for his left ankle from the edge of the mattress or his foot from the footboard. *He had been awake and watching television. 2. Random observations on 2/25/25 from 11:10 a.m. through 2:20 p.m. and interview with resident 10 revealed: *He had been lying in the same position as observed above. *He was either sleeping or watching television during those observations. *He had a towel placed underneath his chin that had a brown stain on it from some type of liquid. *He was not observed getting out of bed for breakfast or lunch. *When asked if he was getting out of bed today, he asked what day it was and then stated, Yes. 3. Interview on 2/26/25 at 7:27 a.m. with registered nurse (RN) B revealed: *Resident 10 had a stage two pressure ulcer (wound with partial thickness skin tissue loss from prolonged pressure) on each heel. *She had already completed his pressure ulcer wound care that day. 4. Observation on 2/26/25 at 8:00 a.m. of resident 10 revealed: *He had been lying in bed with his body propped onto his left side by a pillow. *His feet, ankles, and heels were in the same position as observed the day before (2/25/25). 5. Interview on 2/26/25 at 8:05 a.m. with certified nursing assistants (CNAs) V and W regarding resident 10 revealed: *He did not like to get out of bed and often refused. *He could reposition himself but they would have to verbally cue him to turn over. *The surveyor had requested to watch them provide personal cares for him. *CNA V stated: Not sure when today but will at some point. 6. Random observations on 2/26/25 from 8:45 a.m. through 12:10 p.m. of resident 10 revealed he had been in the same position as observed above for the entire morning. At 12:10 p.m. CNA W came and got the surveyor to observe them providing his personal care. 7. Observation on 2/26/25 at 2:49 p.m. of resident 10 revealed he was in his wheelchair at bingo. 8. Observation and interview on 2/27/25 at 7:18 a.m. with RN B while she provided wound care treatment to resident 10 revealed: *He had given the surveyor permission to observe his wound care. *He had a stage two pressure ulcer on his right and left heels. *He had an abrasion on his coccyx (tail bone). *RN B stated the wounds were facility acquired. *Staff were to complete wound assessments once a week. *Skin assessments were to be completed weekly on the residents' bath days, and they label a yes or no if there was a new skin condition or not. *If there was a new skin condition, then staff would complete a weekly skin evaluation form. 9. Interview on 2/27/25 at 12:27 p.m. with director of nursing (DON) A revealed: *She thought all facility acquired pressure ulcers were preventable including resident 10's. *She did not think the staff were providing the residents' pressure ulcer prevention measures or completing skin assessments on residents who had risks of acquiring pressure ulcers. *She wanted to start plan of care (POC) charting task that would include including repositioning residents every two hours and toileting. *She planned to start staff competencies including what to look for during skin assessments and how to document them. 10. Review of resident 10's electronic medical record (EMR) revealed: *An admitted [DATE]. *He had a Brief Interview for Mental Status (BIMS) assessment score of 15 which indicated he was cognitively intact. *His diagnoses included venous insufficiency, hypertension, chronic kidney disease, and diabetes. *He was dependent on staff for bathing, bed mobility of moving right and left, transferring out of bed, toileting, and implementing any preventative interventions to ensure skin breakdown would not have occurred. *A stage two pressure ulcer was acquired on his right heel on 8/26/2024. *A stage two pressure ulcer was acquired on his left heel on 1/3/2025. *A superficial abrasion to his coccyx was acquired on 2/25/25. 11. Review of resident 10's care plan last updated on 5/30/2024 related to his skin integrity included: *Focus: I have the potential for pressure ulcer development r/t [related to] Hx [history] of ulcers, immobility. *Goal: I will have intact skin, free of redness, blisters or discoloration by/through review date. *Interventions: -Elevate/float heels when in bed to offload pressure as I allow. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -Frequent repositioning while resting. -Inspect skin while providing cares, notify nurse of any new skin conditions. -Instruct/assist/encourage me to shift weight in W/C [wheelchair] routinely. -Pressure reducing air mattress to bed. -Pressure reducing cushion to wheelchair. *There was no indication on his care plan that he had any pressure ulcers or abrasions on his skin. 12. Review of resident 10's Braden Scale for Predicting Pressure Sore Risk assessments revealed: *On 2/23/24 and 5/17/24 his score was a fourteen which indicated he had moderate risk for the development of a pressure ulcer. *On 8/13/24 and 9/16/24 his score was a fifteen which indicated he had mild risk for the development of a pressure ulcer. *On 12/13/24 his score was a sixteen which indicated he had a mild risk for the development of a pressure ulcer. 13. Review of a 2/24/25 weekly skin evaluation for resident 10 signed by RN B revealed: *The left heel had a stage two pressure ulcer acquired on 1/3/25. It: -Had minimal drainage and measured 1 centimeter (cm) in length, 1 cm in width, and 0 cm in depth. -Required pressure-reducing interventions including a mattress and boots. -Had a dressing order to cleanse, pat dry, apply silicone cream, cover with Optifoam (a type of wound dressing), and change daily. *The right heel had a stage two pressure ulcer acquired on 8/26/24. It: -Had no drainage and measured 1 cm in length, 2 cm in width, and 0 cm in depth. -Worsened from a stage one on 2/17/25 to a stage two on 2/24/25. -Had the same dressing order as the left heel. 46453 14. Random observations on 2/25/25 from 9:45 a.m. through 2:20 p.m. of resident 12 revealed: *She had been in her room sitting in a recliner. *Her feet were elevated by the footrest, and she appeared to have been sleeping. *Staff were not observed assisting her to offload or reposition/transfer to another location such as her bed. 15. Observation on 2/25/25 at 3:18 p.m. of resident 12 in her room revealed: *She had been moved to her wheelchair. *She was sitting on an inflatable cushion. 16. Random observations on 2/26/25 from 7:45 a.m. through 11:20 a.m. of resident 12 revealed: *There was a heel lift device (a device that helped decrease the pressure from the mattress on a person's heels) that was not in use. It was sitting on the other bed in her room. *She had been lying in her bed sleeping. *She had an air mattress overlay on her bed to help with relieving pressure to any areas that would have been at risk for skin breakdown. *She had been laying on her back, both of her heels were positioned directly on the air mattress, and the bottoms of her feet were positioned against the footboard of the bed. *She remained in that position for over three hours. *At 8:00 a.m. the surveyor asked CNA D to observe them assisting the resident. He stated that he would come and get that surveyor when that happened. 17. Review of resident 12's EMR revealed: *A nursing progress note from 2/23/25 at 11:30 a.m. that read, Called [hospice provider] to update on Res [resident] refusing pain medication and new skin issues. Hospice nurse will come to assess resident today. *A scanned Coordination Notes Report hospice note that was signed as noted by DON A on 2/25/25. -It included six pages of notes and assessment details. DON A signed the first page. -On 2/23/25, RN E called the hospice triage phone number to discuss concerns with resident 12 refusing pills and [RN E] states that she believes [resident 12] may be developing a Kennedy ulcer [an ulcer that can develop rapidly as a person is in the dying process] on her coccyx, as she has discoloration that is purple in color and described as a stage 1. -[Resident 12] also has an injury to the back of her left thigh caused by catheter tubing pressing against her skin. -No current wound care orders for either area are present at [the] facility at this time. -[RN E] does not think skin issues have been assessed by hospice yet. -Later in the day on 2/23/25, a hospice RN was present at the facility and noted that RN E was present to assist with assessments. -Wound measures 2.5cm [centimeters] [by] 7.5cm dark purple area with a 1.5cm [by] 1.5cm open area in the center. Wound picture taken and care plan updated. Orders placed along with calendar updated. *A weekly skin audit had been completed on 2/20/25 after her bath with no new skin impairment identified. *There were no physician's orders or wound assessments found regarding the skin impairments on her coccyx and thigh. 18. On 2/26/25, a list of all residents with current skin and wound concerns was requested and interview on 2/26/25 at 8:27 a.m. with DON A regarding that list revealed: *Resident 12 was not on that list. *She was not aware that resident 12 had any skin issues relating to her coccyx or thigh. *She was aware that the hospice provider wanted to look at her skin, but she was not aware of any current skin issues. *Additional documentation relating to wound assessments and treatment orders was requested relating to resident 12's wounds. Continued interview on 2/26/25 at 8:35 a.m. and 9:27 a.m. with DON A revealed: *She could not find any orders from hospice regarding wound care. -She had to call the hospice provider to obtain their wound assessments and treatment orders. *She did not know if resident 12's primary care physician was notified of the wounds. *She confirmed she missed the wound assessment note from hospice on 2/23/25. *She confirmed she had signed her initials on that hospice note on 2/25/25. *They had recently changed their process on how they were to complete residents' weekly skin assessments. -Previously, the nurse would complete a weekly skin audit evaluation on each resident. -Now, they have a yes or no question that was triggered weekly. The nurse would check yes if there was a skin issue and that would trigger a full skin assessment. If no was checked, that meant no new skin impairments. *They implemented the following measures to prevent pressure ulcers for resident 12: -An air mattress. -The cushion for her wheelchair. -[NAME] brand skin barrier cream. 19. Observation and interview on 2/26/25 at 10:20 a.m. with RN X regarding resident 12 revealed: *She was massaging resident 12's hands and washing her face. *She was the hospice care case manager and had come in that day to see the resident. *She was not there to complete personal care for the resident but to offer comfort and support in other measures. *She would have expected the residents on hospice care to have been repositioned at a minimum of every two hours. *The resident had recently acquired a Kennedy ulcer to her coccyx area. -That ulcer had the potential to worsen when proper repositioning had not occurred. *They would have completed a wound assessment for their own purposes and records. -That skin assessment would not have been provided for the facility's records. -The facility was responsible for completing their own skin assessments. -The residents were still the primary responsibility of the facility. -She explained that hospice services were an additional support for the resident. 20. On 2/26/25 at 11:20 a.m., CNA U came and got the surveyor to observe them assisting the resident. That had been the first time in the morning that the staff had assisted her with repositioning and personal care. 21. Interview on 2/26/25 at 12:58 p.m. with RN E about resident 12's wound revealed: *She noticed the bruise on resident 12's coccyx on Sunday 2/23/25. The area was purple. *She did not assess it at that time because I didn't want to be pressing on it. I didn't know if it was a deep tissue injury. *She called the hospice provider because Hospice takes care of the wound care orders and the assessments. -The hospice provider indicated that they would send someone that day to assess the wound. *She did not notify the resident's primary care physician, saying, I didn't even think to do that. -She also did not notify the DON because she did not want to disturb her on a Sunday. *She passed the information along to RN R who was the oncoming nurse for the next shift. *For pressure ulcer preventative measures, she expected staff to reposition resident 12 on a regular basis, such as moving from the bed to a chair, shifting to different positions in the chair, and moving her to the wheelchair. *Resident 12 had an air mattress on her bed and a cushion in her chair for pressure redistribution. 22. Observation on 2/26/25 at 1:08 p.m. of resident 12 revealed that she was dressed for the day and had been moved to her recliner. 23. Observation on 2/26/25 at 4:07 p.m. of resident 12 revealed that she was still sitting in her recliner. The recliner was in a slight reclined position. 24. Interview on 2/26/25 at 4:53 p.m. with RN R revealed: *She confirmed she was present at the facility on 2/23/25 when the hospice nurse came to assess resident 12's wounds. *She did not perform a wound assessment because hospice did the assessment. -The hospice nurse measured the wound. -She asked me to apply Optifoam and that's it. -At the time of the assessment, resident 12's coccyx was red and there was a little bit of scraping and bleeding. *She did not notify the resident's primary care physician because they have their own hospice physician and hospice staff notify the physician. *She did not notify the DON. *She indicated that if the hospice nurse had a new order, she would have entered it into the EMR system, and the DON would have been notified that way. -There were no new orders that she entered from hospice regarding that wound. *Wound treatments were usually completed during the day shift. 25. Interview on 2/27/25 at 8:05 a.m. with DON A revealed: *She expected staff to complete assessments on wounds when they were noticed right away, complete the skin evaluation, and notify the family and physician. *They used telehealth services to obtain treatment orders. *That process should not change due to a resident receiving hospice services. *She explained that hospice was an additional service, and staff should not be passing along the responsibility of caring or a resident onto the hospice service. 26. Review of resident 12's current care plan revealed: *She was completely dependent on staff and required substantial to maximum assistance for ambulation, transferring, and repositioning. *One intervention read, Skin at risk: Barrier cream, Lotion to dry skin, Pressure reducing mattress, Specialty mattress: Air Mattress, Turn/reposition routinely, Wheelchair cushion. Initiated on 10/4/23. Revised on 1/31/24. *There were several interventions that mentioned she experienced frequent loose stools and was incontinent of her bowels. Her care plan indicated for Staff to cleanse and keep skin dry. Apply barrier cream BID [twice per day] and with each incontinent episode. *She preferred to lay on her back and would only reposition to her side for short periods of time. *Pressure-reducing measures included the specialty air mattress and a pressure reducing cushion in her wheelchair. *She had a history of a venous ulcer to the bottom of her right foot. *Another intervention that read, Utilize pillows/foam wedges for placement between bony prominences. Initiated on 3/16/25. Revised on 2/13/24. 27. Review of resident 12's EMR revealed: *Her diagnoses included endometrial cancer, multiple sclerosis, type 2 diabetes, peripheral vascular disease, and congestive heart failure, among others. *A significant change Minimum Data Set assessment was completed on 1/6/25 that included: -Her BIMS assessment score was 10, which indicated she was moderately cognitively impaired. -She was dependent on staff to transfer from surface to surface. -She required substantial to maximum assistance for repositioning. -She had a catheter due to a neurogenic bladder, and she was always incontinent of bowel. -She was at risk for developing pressure ulcers. -She did not have any pressure ulcers at the time of the assessment. 50915 28. Observations on 2/25/25 from 9:45 a.m. through 3:00 p.m. of resident 49 revealed: *At 9:45 a.m., the resident was laying on his back with a pillow under his back on the right side, but mostly flat. *At 1:10 p.m., the resident was laying in the same position, mostly flat, with a pillow under his back on his left side. *At 2:15 p.m., the hospice nurse was at his bedside, the pillow was moved to right side, and the resident laying mostly flat. *At 3:00 p.m., his position was unchanged. 29. Interview on 2/26/25 at 7:50 a.m. with RN E revealed resident 49 was to be repositioned every two hours to help prevent pressure ulcers. 30. Observation and interview on 2/26/25 at 8:10 a.m. with certified medication aide (CMA) D revealed: *He was repositioning resident 49 every two hours. *He reported the resident's condition had significantly declined over the past few days. *During observation of repositioning, resident 49 was unable to follow commands and moaned in pain when moved. 31. Observations on 2/26/25 of resident 49 revealed: *At 9:00 a.m. he had been in bed and was laying on his back. -The extra pillow had been placed above his head. -Both of his feet and heels had been laying directly on the mattress with no pressure relieving device in place. -He had been positioned down low on the mattress to where his feet rested directly up against the footboard. 32. Interview on 2/26/25 at 12:30 p.m. with CNA U revealed: *Residents should have been repositioned every two hours. *He agreed: -Residents 12 and 49 were dependent upon the staff to reposition them. -Those residents were vulnerable and were at risk for skin breakdown and should have been repositioned every two hours. *His partner had left early that day, and he was left by himself to reposition them. -He confirmed those residents had gone longer than two hours without being repositioned. *He agreed: -Repositioning residents with their feet directly against the footboard created the potential for skin breakdown to have occurred. -The residents' heels should not have been left directly on the mattress. A heal lift should have been used to relieve the pressure. 33. Observation on 2/26/25 at 4:30 p.m. of CNA K revealed: *She was changing resident 49's brief because he had been incontinent. *There was a bandage on resident's buttock. *CNA was not sure what the bandage was covering but would let the charge nurse know it was starting to peel away from his skin. 34. Interview on 2/26/25 at 5:20 p.m. with hospice nurse RN G revealed: *She reported doing resident 49's skin assessments. *She reported there was some redness to the resident's coccyx, but did not believe there were any pressure ulcers. 35. Observation and interview on 2/27/25 at 10:47 a.m. with RN B revealed: *She was performing skin cares on resident 49's coccyx and buttocks. *After removing cream from resident's coccyx, two open area were revealed, each measuring approximately one centimeter (cm) around. *She reported these to be stage two pressure ulcers. *She reported this was the first time she had seen these ulcers. *She reported when performing resident cares on 2/24/25, the ulcers were not present. *She did not feel the ulcers could have been prevented because resident was repositioned appropriately. 36. Interview on 2/27/25 at 12:33 p.m. with DON A revealed: *She found out about resident 49's pressure ulcers earlier in the morning. *Regarding resident 49's pressure ulcers, she felt they were absolutely preventable. *Regarding facility acquired pressure ulcers, she felt they are all preventable. *She did not think CNAs received appropriate training. *She felt sometimes staff did not listen to her guidance in regard to the education she provided them. *She wanted to implement POC [point of care] documenting. (The care is documented at the time it occurs, not when it is scheduled). This would increase accountability of completing resident tasks. *It was her expectation for staff to follow her instructions. *She planned to implement a competencies program with a skills checklist. -She was hopeful with the hiring of a new assistant DON education of staff and competencies could soon become a priority. 37. Review of resident 49's EMR revealed: *He was admitted to hospice care on 2/18/25. *His BIMS assessment score was three, which indicated he was severely cognitively impaired. *He had medical diagnoses including Alzheimer's/dementia with behaviors, fall with major injury, right humerus fracture, congestive heart failure, and depression. *He was dependent upon the staff to: -Assist him with all of his mobility needs (repositioning in bed) and ADL. -Implement any preventative interventions to ensure skin breakdown would not have occurred. -Anticipate his needs as he was unable to make them known. *His Braden Scale score on 2/20/25 was sixteen. -That score had indicated he was at mild risk for skin breakdown. *On 2/27/25 his Braden Scale score was reassessed and was an eight. -Within seven days his skin breakdown risk had increased to a very high risk. *The first documentation of his pressure ulcers was in nursing progress note on 2/26/25 at 11:59 p.m. by RN R, after his skin bandage was witnessed earlier in the day. -Resident in bed PM cares. Reposition to sides. No intake. Took his comfort meds. Hospice nurse here after supper. Both writer & hospice nurse [name], we did measure open sores. Coccyx one cm [centimeter] x 3/4 cm. Right cheek [buttock] 1 cm x 3/4 cm. 38. Review of resident 49's care plan revealed: *A focus of I have the potential for impairment to skin integrity r/t [related to] edema, fragile skin. *Goals of The resident will maintain or develop clean and intact skin by the review date. The resident will be free from injury through the review date. *Interventions/tasks of Avoid scratching and keep hands, and body parts from excessive moisture. Follow facility protocols for treatment of injury. Keep skin clean and dry. Use lotion on dry skin. The resident needs pressure reducing cushion to protect the skin while up in chair. The resident needs pressure reducing mattress to protect the skin while IN BED. Use draw sheet or lifting device to move resident. 39. Review of the provider's January 2025 Skin Integrity policy revealed: *In the event that a resident is admitted with or develops a skin ulcer/pressure ulcer/wound, care is provided to treat, heal, and prevent, if possible, further development of skin ulcers/pressure ulcers/wounds. *1. The nurse completes the Braden Scale/Skin Integrity Evaluation at admission, weekly for three weeks, and then annually. The Braden Scale is s guide to determine risk stratification for skin impairment. -a. Residents are at a level of risk per the Braden scale and the completion merely guides the practitioner to determine if future intervention is required. -2. The nurse establishes a plan of care based on risk factors in an effort to limit their potential effects. -3. The resident's skin is inspected daily with completion of ADL's [activities of daily living] (unless resident is independent in ADL completion). Changes in the resident's skin are reported to the Licensed Nurse (LN). -Ongoing evaluation continues weekly with the LN completing a full body skin audit. Completion of the skin audit is documented on the Treatment Administration Record (TAR) with their initials, and either a 'No' or 'Yes.' *If skin impairment is noted after admission, the LN: -a. Initiates alert charting. -b. Completes (and documents) notifications to the physician and Resident or Resident Representative. -c. Implements new interventions as needed. Documents on the resident's care plan and ISP. -d. Notifies Food and Nutrition Services Manager (FANS) and/or Registered Dietician of new pressure injury or worsening wound condition for nutritional needs evaluation. -e. Notifies Director of Nursing Services (DNS) of skin Impairments that indicate a potential significant change in condition (State II or greater Pressure Ulcer, surgical wound dehiscence, hematoma, or bruise on an area of the body not usually vulnerable to trauma (e.g. head, breasts, inner thighs, groin). -f. The DNS and/or designee complete a comprehensive review of the resident's medical record to evaluate if the pressure injury was avoidable or unavoidable. This evaluation is documented in the Nurse's Notes. *If a wound condition fails to improve after 2 weeks of treatment or the condition of the wound deteriorates, the Physician and Resident's Representative are notified. 40. Review of the provider's March 2012 CNA job description revealed: *Essential Functions: .5. Turns and repositions bedfast residents, alone or with assistance, and utilizing proper body mechanics, to prevent pressure ulcers.

Based on observation, interview, record review, and policy review, the provider failed to ensure quality of care was provided related to one of one sampled resident's (20) wound care improperly delegated by registered nurse (RN) R to certified nurse assistant (CNA) J, hospice coordination of care for two of two sampled residents (12 and 49), and pain management for one of one sampled resident (49). Findings include: 1. Interview on 2/25/25 at 10:11 a.m. with resident 20 and his wife in their room revealed: *He had a sore on his bottom. *He was supposed to have his wound dressing changed every other day in the evenings. *Both resident 20 and his wife indicated that CNA J had performed the wound dressing change that previous evening. *They indicated that RN R was supposed to have completed the wound dressing change, not CNA J. *They described a specific type of ointment that was placed on the wound. They mentioned the word collagen. Review of resident 20's electronic medical record (EMR) revealed: *His 1/7/25 annual Minimum Data Set assessment indicated a Brief Interview for Mental Status assessment score of 14, which indicated he was cognitively intact. *A 12/18/24 physician's order for Posterior L &R [left and right] Thighs &L buttock Abrasions: Cleanse with wound cleanser, pat dry, apply Moistened Collagen [wound healing product] to wound beds, cover with Optifoam [wound dressing]. As needed for when falls off/after bath. -The treatment administration record (TAR) indicated that order had been last completed on 2/20/25 by RN E. *A 12/18/24 physician's order for Posterior L &R Thighs &L buttock Abrasions: Cleanse with wound cleanser, pat dry, apply Moistened Collagen to wound beds, cover with Optifoam. Every day shift every 2 day(s) for Abrasions until healed. -The TAR indicated that order had last been completed on 2/23/25 by RN B. Interview on 2/26/25 at 4:08 p.m. with RN R revealed: *Wound treatments were usually completed during the day shift. *Resident 20 sometimes requested a new Optifoam dressing after he used the bathroom. -If he requested a new dressing at night when she was very busy, she would ask the CNA to apply the Optifoam dressing. *The only treatment that she had completed for resident 20 on the evening shift was applying an ointment on his left hip for pain. Interview on 2/26/25 at 4:26 p.m. and 4:35 p.m. with CNA J revealed: *She confirmed that she had applied resident 20's ointment and dressing bandage when the nurse was busy. *She could not remember what type of ointment she applied for resident 20, but she said it was yellow. -She thought the yellow ointment might have been a barrier cream, but she was not sure. -The nurse would give her the ointment in a medicine cup. *She said that resident 20 had a bath the other day, and the nurse asked her to apply the yellow ointment and the bandage on his bottom. Interview on 2/27/25 at 7:47 a.m. with DON A revealed: *Resident 20 had Optifoam dressings on the back of his thighs directly underneath his buttocks, and on his coccyx region. *The wounds on the back of his thighs were from an abrasion due to his briefs. He would slide back and forth in his recliner, which she thought caused friction abrasions. *He was independent with ambulation and toileting. *She confirmed it was not normal practice for a licensed nurse to delegate a treatment of applying a resident's ointment and dressing to a CNA. Review of the provider's March 2012 CNA job description revealed: *Job Summary: Under general supervision performs a combination of following duties in caring for residents in the Center, consistent with the plan of care and established long-term care standards and Center policies and processes. The CNA is expected to perform duties in compliance with state and federal regulations. *Reporting Relationships: 1. Reports to the Licensed Nurse directing and overseeing resident care on assigned unit. Review of the Administrative Rules of South Dakota (ARSD), Chapter 20:48:04.01 for Delegation of Nursing Tasks revealed: *20:48:04.01:01. General criteria for delegation. A licensed registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction. A licensed nurse may delegate selected nursing tasks to a nursing assistant. A nursing assistant may not substitute for the licensed nurse in the performance of nursing functions. A nursing assistant may not redelegate a delegated task. *A licensed nurse shall assess a situation and determine whether delegating nursing tasks to a nursing assistant is appropriate. The delegation of nursing tasks to a nursing assistant must comply with the following criteria: -(1) The nursing task is one that a reasonable and prudent licensed nurse would find within the scope of sound nursing judgment to delegate; -(2) The nursing task is one that, in the opinion of the delegating nurse, can be properly and safely performed by a nursing assistant without jeopardizing the client's welfare; -(3) The nursing task does not require a nursing assistant to exercise nursing judgment; -(4) The licensed nurse evaluates the client's nursing care needs before delegating the nursing task; -(5) The licensed nurse verifies that the nursing assistant is competent to perform the nursing task; and -(6) The licensed nurse supervises the performance of the delegated nursing task in accordance with the requirements of ARSD Chapter 20:48:04.01:02. *20:48:04.01:02. Supervision. The licensed nurse shall supervise all nursing tasks delegated to a nursing assistant in accordance with the following conditions: -(1) The licensed nurse determines the degree of supervision required after considering: --(a) The stability of the client's condition; --(b) The competency of the nursing assistant to whom the nursing task is delegated; --(c) The nature of the nursing task being delegated; and --(d) The proximity and availability of the licensed nurse to the nursing assistant when the nursing task is performed; -(2) The delegating nurse or another licensed nurse is readily available either in person or by electronic communication . 50915 2. Observations and interviews made throughout the survey revealed residents 12 and 49 had not been repositioned or transferred on a routine basis, which potentially contributed to the development of pressure ulcers on resident 12's coccyx first noted on 2/23/25, and on resident 49's coccyx first noted on 2/27/25. Interviews with RN E and RN R indicated they had not assessed resident 12's wound and had not obtained orders from a physician for treatment. Interviews with RN E and RN R indicated resident 12's hospice service was managing the wound, so they did not assess or treat the wound. Interviews with DON A throughout the survey revealed that she was not aware of resident 12's pressure ulcer, and she expected staff to conduct their own assessments and obtain treatment orders whether a resident was on hospice or not. Refer to F686, findings 14 through 27 regarding resident 12. 3. Observations and interviews throughout the survey revealed that resident 49 was experiencing consistent pain with repositioning. There were several instances where he was heard moaning and shouting out in pain. He was seen grimacing in pain. Record review revealed that he had orders for as needed pain management, but that had not been administered due to pain assessment documentation showing as a 0 out of 10 on three separate occasions on 2/25/25. Interviews with hospice staff revealed that they had concerns about previous residents and their pain, which was to be managed by the provider. By not recognizing that the resident was experiencing increased pain and not administering the prescribed pain medication, resident 49 experienced pain with personal cares and repositioning. Refer to F697.

Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to notify the required entities of allegations of physical, mental, and verbal abuse by certified nursing assistant (CNA) J towards two of seven sampled residents (7 and 9). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy at F609 was given verbally and in writing via email on 1/8/25 at 3:57 p.m. to director of nursing (DON) B and division director of clinical operations (DDCO) C relating to failure to report allegations of abuse. A plan for removal of the immediacy was requested. On 1/8/25 at 4:30 p.m., DDCO C emailed a written plan for the removal of the immediate jeopardy. The removal plan was approved soon after 4:30 p.m. on 1/8/25. It was determined that the removal plan for F600 sent on 1/7/25 at 12:56 p.m. included action items to report the allegations of abuse to the required entities. F609. The provider learned about concerns regarding the care and services a CNA was providing to residents on 1/1/25 at around 1:30 p.m. The provider failed to protect the residents from potential further abuse during the investigation by allowing the CNA to keep working an overnight shift from 10:30 p.m. on 1/1/25 to around 7:30 a.m. on 1/2/25. The provider failed to get more information from the reporting party to understand the extent of the situation. The provider failed to report the incidents to the necessary entities. The provider conducted an investigation into the allegations including assessing the residents involved for injuries but nothing was documented. The CNA has been suspended as of 1/6/2025 pending investigation. The initial report to DOH was submitted on 1/6/2025. All residents had a skin assessment completed and any residents with a BIMS [Brief Interview for Mental Status] above an eight have been interviewed regarding any potential for abuse by 11 am. A total of 49 residents were interviewed with no concerns, 1 resident with a concern that was reported to DOH this morning, residents with a BIMS below eight, the responsible party was contacted, seven with no concerns and five were left a voicemail. The reporting party has had a thorough investigation/interview with re-enactment completed by 10 am on 1/7/2025 by [ED A]. Abuse education provided by [DDCO C] to [ED A and DON B] as well as validating documentation in place to monitor skin or affected body parts for injury. Several staff from nursing, day shift 4, evening shift 2, night shift 1; dietary, one from days and one from evening; maintenance, activities, therapy and HR across all shifts have been interviewed regarding if they have ever seen another staff member abuse or neglect a resident in any way on 1/7/2025, no concerns noted. Primary witness statements from other CNAs who witnessed the alleged perpetrator kick a resident in the shin twice, and a separate incident with a different resident where the alleged perpetrator put a washcloth over a resident's mouth to quiet the resident. Both those residents have dementia. Statements from staff indicate that this has been an ongoing issue and the alleged perpetrator improves their actions for a short while after being talked to by administration, but then slips back into their old ways. There is serious concern that the alleged perpetrator will potentially re-offend. The CNA's making the allegation have been interviewed and a re-enactment of events has been conducted by [ED A]. The perpetrator was suspended 1/6/2025 pending investigation. The two residents in [question] were assessed for physical harm, unable to assess for psychosocial harm due to cognition status. Both were placed on alert charting for 72 hours. The [perpetrator] had a background check completed on 10/11/2023 with negative results for abuse. The provider needs to take immediate action to prevent further potential abuse from occurring. The provider failed to report the incidents to the required entities, allowed the alleged perpetrator to work a shift following the report of alleged abuse, failed to conduct a thorough investigation, and failed to follow their abuse/neglect policy. The event was reported 1/6/2025. [DDCO C], educated [ED A and DON B] on abuse policy, abuse reporting, suspension pending investigation and investigation by 1/6/2025 via phone. All staff were re-educated on the facility abuse policy on 1/7/2025 and prior next working shift. Grievances for [the last] 30 days were reviewed for possible abuse allegations on 1/7/2025. [Nurse's] notes for residents were reviewed for the last 30 days for possible abuse allegations on 1/7/2025. An Ad hoc [meaning when necessary or needed] QAPI [quality assurance and performance improvement] is being completed 1/07/25 and the Medical Director was informed of the alleged deficient practice and current plan. Called at 10 AM by [DON B]. The immediacy at F609 was determined to have been removed on 1/7/25 at 4:30 p.m. after onsite review. After removal of the immediacy, the severity and scope was a level G. The census was 62. 2. Review of the SD DOH complaint intake form dated 12/31/24 revealed: *The SD DOH received an email on 12/27/24 detailing allegations of abuse by CNA J. They wanted to remain anonymous. *The complainant claimed to have reported their concerns to management previously. They did not include any dates about when the concerns were reported. -I reported [CNA J's] rudeness and 'roughness' prior, she would get talked [to] and [had her work] hours cut but within a week [she's] back to being rude and rough with the residents. *See F600 finding 2 for details pertaining to the alleged abuse. 3. Review of an additional SD DOH complaint intake form dated 1/6/25 revealed: *The SD DOH received an email on 1/3/25 from a different anonymous complainant. *The complainant claimed to have reported their concerns to management previously. They did not include any dates about when the concerns were reported. -I have reported this to the administration to no avail. *See F600 finding 3 for details pertaining to the alleged abuse. 4. Interview on 1/6/25 at 5:28 p.m. with DON B revealed: *She denied that any staff had reported allegations of abuse or neglect against any other staff. *When questioned specifically about any knowledge of incidents involving a staff member kicking residents or holding a cloth over a resident's mouth, she denied any knowledge of such incidents. 5. Confidential interview on 1/6/25 with anonymous staff member M revealed: *Anonymous staff member M was initially afraid to come forward with the allegations against CNA J, due to CNA J's retaliatory nature. *Anonymous staff member M was aware incidents of abuse were required to be reported immediately. *Anonymous staff member M explained the reason why they did not report those incidents immediately was because previously when incidents were reported, CNA J's actions would improve for a short while, but then would return to the abusive behaviors. *Anonymous staff member M confirmed that they and another staff member reported the above incidents to executive director (ED) A. -Anonymous staff member M could not remember when they reported those incidents to ED A. 6. Interview on 1/6/25 at 6:30 p.m. with ED A revealed: *He denied that any staff had reported allegations of abuse or neglect against any other staff. *However, when asked specific questions about CNA J allegedly having kicked a resident and having held a cloth over another resident's mouth, he confirmed he had been aware of those allegations. -He explained that the staff member who brought forward those allegations was nondescript and could not describe specifically what CNA J had done. *He confirmed the allegations were not reported to the required entities. 7. Continued interview on 1/6/25 at 6:35 p.m. with ED A and DON B about the allegations revealed: *They confirmed they did not report those allegations to the required entities. *They confirmed they were aware that allegations of abuse should have been reported to the SD DOH, law enforcement, and the Department of Human Services. 8. Interview on 1/6/25 at 7:04 p.m. with DON B revealed: *She confirmed she learned about the allegations on 1/1/25 around 1:30 p.m. when registered nurse (RN) F contacted her. -RN F told her that staff had come forward with concerns. -RN F did not provide any details about the concerns, and DON B did not ask further questions about the concerns. *She did not contact ED A about the allegations until the morning of 1/2/25. *DON B confirmed that CNA J worked from 10:30 p.m. on 1/1/25 to 7:30 a.m. on 1/2/25 after she learned of the allegations against the CNA. -CNA J did not clock back in until 12:08 p.m. on 1/3/25 and worked until around 2:00 p.m. *DON B explained that she had been the DON since July 2024. She was the Minimum Data Set (MDS) Assessment coordinator prior. -She was not aware that the above allegations were the type that required reporting. *She was not aware of the Administrative Rules of South Dakota detailing what type of incidents were required to have been reported. *She was not aware of the provider's abuse and neglect prohibition policy on reporting and investigating allegations of abuse and neglect. *She again confirmed the allegations of abuse were not reported to the required entities when they should have been. 9. Interview on 1/7/25 at 2:21 p.m. with DDCO C revealed: *ED A was placed on suspension related to his failure to follow the provider's policy regarding abuse and neglect prevention and prohibition. -He was supposed to have been acting as the abuse/neglect coordinator. *She expected all allegations of abuse to have been taken seriously and reported to the required entities within the required timeframe. 10. Interview on 1/8/25 at 9:53 a.m. with DON B and DDCO C revealed: *DDCO C explained that, to her understanding, the above incidents happened several weeks ago, and the witnesses came to ED A recently to report the incidents. -It was her expectation that staff should have immediately reported the abuse. -It was her expectation that all allegations should have been taken seriously, and the allegations should have been investigated thoroughly. 11. Refer to F600 finding 12 for additional details regarding when the anonymous staff members brought their concerns to ED A. It was confirmed that ED A learned about the allegations of abuse on 12/30/24 and had not reported or investigated the incidents. 12. Review of six employee training records, including CNA J, revealed each employee had received initial and/or annual training on the topics of abuse and neglect, resident rights, and mandatory reporting. 13. Review of the provider's March 2012 Director of Nursing Services (DNS) job description revealed: *Essential Functions - .6. Demonstrates an understanding and knowledge of certification laws and requirements, survey requirements, and Medicare program. - .8. Validates that reporting departments consistently meet state and federal requirements for long-term care facilities for licensure. - .10. Maintains open communication with ED regarding resident care activities, personnel or staffing problems, and other related topics. - .13. Understands the relationships with state and federal regulatory agencies, and works to maintain positive relationships. 14. Review of the provider's November 2019 Executive Director job description revealed: *Essential Functions - .4. Compliance Management -- .b. Grievance Official: Responsible for overseeing the grievance process. Responsibilities include: receiving and tracking grievances through to their conclusion, leading any necessary investigations, and complying with federal and state regulations and company policies as they apply to the grievance process. -c. Abuse Coordinator: Oversee the implementation of policies and procedures necessary to prohibit and prevent abuse and neglect, including but not limited to: screening, training, prevention, identification, protection, and reporting/response. Coordinate abuse and neglect investigations. --d. Compliance Liaison: Oversee the facility Compliance and Ethics Program. Coordinate employee, contractor, and volunteer compliance training to include the Code of Conduct, HIPAA [Health Insurance Portability and Accountability Act] policy, and other mandatory compliance policies. *Knowledge, Skills, and Abilities -1. Familiarity with State Nursing Center rules and regulations, and applicable Federal and State laws. 15. Review of the provider's November 2019 Abuse, Neglect, or Exploitation policy revealed: *1. Complaints of abuse, neglect, or exploitation are viewed as very serious and are reported to your Regional [NAME] President and/or Regional Nurse Consultant immediately. * .4. If abuse, neglect, or exploitation of a resident is suspected, act immediately to protect the resident from additional harm. * .8.contact the appropriate State agency as soon as possible during the required reporting timeframe. *9. Notify the resident's family/significant other(s) of the suspected or alleged abuse. *10. Depending on the type of incident, it may also be appropriate to call the Long-Term Care Ombudsman, Adult Protective Services Offices, and/or the local police. * .13. A staff member may notify the appropriate state agency of suspected/alleged abuse, neglect, or exploitation without fear of retribution. It is the responsibility of each employee to assure compliance with state abuse or suspected abuse reporting regulations. 16. Review of the provider's October 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation policy revealed: *Definitions: -Mandatory Reporter: Anyone who is an employee, manager, agent, operator, owner, or contractor of a Medicare or Medicaid certified nursing facility . -Immediately: Means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. (Based on real clock time) *Procedure: - .7. Reporting and Response: The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, .mistreatment, and injuries of unknown source in accordance with state and federal law. 17. Review of the provider's November 2016 Abuse Prohibition Notification policy revealed: *Policy Statement: The Center complies with Federal and State requirements to screen, train, prevent, identify, investigate, protect, and report abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. * .4. Alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of resident property, are reported immediately to the Executive Director (ED) and to other officials in accordance with Federal and State law. - .The results of investigations are reported to the ED or his/her designated representative and to other officials in accordance with Federal and State law, not to exceed five working days of the incident.

Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to protect two of seven sampled residents' (7 and 9) right to be free from physical, mental, and verbal abuse by certified nursing assistant (CNA) J. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing via email on 1/6/25 at 8:32 p.m. to executive director (ED) A, director of nursing (DON) B, and over the phone to division director of clinical operations (DDCO) C for F600 related to allegations of physical, mental, and verbal abuse that several staff had reported with no actions taken to protect the residents from further potential abuse. A plan for removal of the immediacy was requested. On 1/7/25 at 10:20 a.m., DDCO C provided a written plan for removal of the immediate jeopardy via email. The removal plan, after agreed-upon revisions, with guidance from the long-term care advisor for the SD DOH, was approved on 1/7/25 at 12:56 p.m.: F600. The provider learned about concerns regarding the care and services a CNA was providing to residents on 1/1/25 at around 1:30 p.m. The provider failed to protect the residents from potential further abuse during the investigation by allowing the CNA to keep working an overnight shift from 10:30 p.m. on 1/1/25 to around 7:30 a.m. on 1/2/25. The provider failed to get more information from the reporting party to understand the extent of the situation. The provider failed to report the incidents to the necessary entities. The provider conducted an investigation into the allegations including assessing the residents involved for injuries but nothing was documented. The CNA has been suspended as of 1/6/2025 pending investigation. The initial report to DOH was submitted on 1/6/2025. All residents had a skin assessment completed and any residents with a BIMS [Brief Interview for Mental Status] above an eight have been interviewed regarding any potential for abuse by 11 am. A total of 49 residents were interviewed with no concerns, 1 resident with a concern that was reported to DOH this morning, residents with a BIMS below eight, the responsible party was contacted, seven with no concerns and five were left a voicemail. The reporting party has had a thorough investigation/interview with re-enactment completed by 10 am on 1/7/2025 by [ED A]. Abuse education provided by [DDCO C] to [ED A and DON B] as well as validating documentation in place to monitor skin or affected body parts for injury. Several staff from nursing, day shift 4, evening shift 2, night shift 1; dietary, one from days and one from evening; maintenance, activities, therapy and HR across all shifts have been interviewed regarding if they have ever seen another staff member abuse or neglect a resident in any way on 1/7/2025, no concerns noted. Primary witness statements from other CNAs who witnessed the alleged perpetrator kick a resident in the shin twice, and a separate incident with a different resident where the alleged perpetrator put a washcloth over a resident's mouth to quiet the resident. Both those residents have dementia. Statements from staff indicate that this has been an ongoing issue and the alleged perpetrator improves their actions for a short while after being talked to by administration, but then slips back into their old ways. There is serious concern that the alleged perpetrator will potentially re-offend. The CNA's making the allegation have been interviewed and a re-enactment of events has been conducted by [ED A]. The perpetrator was suspended 1/6/2025 pending investigation. The two residents in [question] were assessed for physical harm, unable to assess for psychosocial harm due to cognition status. Both were placed on alert charting for 72 hours. The [perpetrator] had a background check completed on 10/11/2023 with negative results for abuse. The provider needs to take immediate action to prevent further potential abuse from occurring. The provider failed to report the incidents to the required entities, allowed the alleged perpetrator to work a shift following the report of alleged abuse, failed to conduct a thorough investigation, and failed to follow their abuse/neglect policy. The event was reported 1/6/2025. [DDCO C], educated [ED A and DON B] on abuse policy, abuse reporting, suspension pending investigation and investigation by 1/6/2025 via phone. All staff were re-educated on the facility abuse policy on 1/7/2025 and prior next working shift. Grievances for [the last] 30 days were reviewed for possible abuse allegations on 1/7/2025. [Nurse's] notes for residents were reviewed for the last 30 days for possible abuse allegations on 1/7/2025. An Ad hoc [meaning when necessary or needed] QAPI [quality assurance and performance improvement] is being completed 1/07/25 and the Medical Director was informed of the alleged deficient practice and current plan. Called at 10 AM by [DON B]. On 1/7/25 at 4:30 p.m., the survey team determined the immediacy was removed. After removal of the immediacy, the severity and scope was a level G. The census was 62. 2. Review of the SD DOH complaint intake form dated 12/31/24 revealed: *The SD DOH received an email on 12/27/24 detailing allegations of abuse by CNA J. They wanted to remain anonymous. *The complainant claimed to have reported CNA J to management previously. - .she [CNA J] got talked to and [had her work] hours cut, after getting talked to before, she would be good only for a week if that before she continued her verbal and physical abuse. *The complainant described a witnessed incident involving resident 7 and CNA J. The complainant did not mention a date. -Resident 7 was non-verbal. -The complainant and CNA J were transferring resident 7 using a full-body mechanical lift. -CNA J slammed a cloth over [resident 7's] mouth and held it there with her fingertips. -The complainant felt as if CNA J did that as a means to quiet the resident. *The complainant described another witnessed incident involving resident 9 and CNA J. The complainant did not mention a date. -Resident 9 had dementia and tended to reach out to people walking by to hold their hand. -Resident 9 was sitting in her wheelchair in the hallway next to anonymous staff member N. -Resident 9 reached out towards CNA J as she was walking past and said, Hey come here quick. -CNA J was witnessed to have kicked resident 9 twice in the shin. 3. Review of an additional SD DOH complaint intake form dated 1/6/25 revealed: *The SD DOH received an email on 1/3/25 from a different anonymous complainant. *There is a CNA that works here named [CNA J] and she is abusing residents. *I have witnessed her kicking, yelling and calling [them] names, which is mental abuse. *I have reported this to the administration to no avail. *The complainant did not include any dates. They wished to remain anonymous. 4. The survey team entered the facility on 1/6/25 at 4:15 p.m. and requested several items, including staff schedules. Review of the staff schedules revealed that CNA J was scheduled to work an overnight shift that night. 5. Interview on 1/6/25 at 5:28 p.m. with DON B revealed: *She denied that any staff had reported allegations of abuse or neglect against any other staff. *When questioned specifically about any knowledge of incidents involving a staff member kicking residents or holding a cloth over a resident's mouth, she denied any knowledge of such incidents. *Refer to F600 findings 8 and 9 where DON B confirmed she was aware of the incidents. 6. Confidential interview on 1/6/25 with anonymous staff member M revealed: *They were initially afraid to come forward with the allegations against CNA J, due to CNA J's retaliatory nature. *During one incident, anonymous staff member M was assisting CNA J with transferring resident 7 using the full body mechanical lift. -[CNA J] put a cloth over [resident 7's] mouth. -She held the cloth over the resident's mouth for about a minute. -Anonymous staff member M perceived it to be forceful, as a way to quiet resident 7. *During another incident, anonymous staff member M and another staff member witnessed CNA J kick resident 9 in the shin. -I brought [resident 9] into the hallway . [Resident 9] reached her hand out to [CNA J] and [CNA J] kicked [resident 9] twice in the shin. -They confirmed they witnessed this incident happen. -Anonymous staff member M could not recall when the kicking incident occurred, but guessed it was within the last three to four weeks. *They explained the reason why they did not report those incidents immediately was because previously when incidents were reported, CNA J's actions would improve for a short while, but then would return to the abusive behaviors. *Anonymous staff member M confirmed that they and another staff member reported the above incidents to ED A. -Anonymous staff member M could not remember when they reported those incidents to ED A. 7. Interview on 1/6/25 at 6:30 p.m. with ED A revealed: *He denied that any staff had reported allegations of abuse or neglect against any other staff. *However, when asked specific questions about CNA J allegedly having kicked a resident and having held a cloth over another resident's mouth, he confirmed he had been aware of those allegations. -He explained that the staff member who brought forward those allegations was nondescript and could not describe specifically what CNA J had done. *He explained that DON B would have completed an investigation regarding the alleged abuse, including performing resident assessments and educating staff. 8. Continued interview on 1/6/25 at 6:35 p.m. with ED A and DON B about the above incidents revealed: *On 1/2/25, DON B had given CNA J a written warning like your actions and how you hold yourself can be perceived different [differently] by others. -CNA J had denied harming any residents. *DON B indicated she interviewed other residents (residents 2, 8, and 10) to see if they had any concerns regarding abuse or neglect. None of the residents she talked to expressed concerns. -She did not document any of those interviews as part of the investigation. *They confirmed there had been no other documented disciplinary actions against CNA J during her employment with the provider. 9. Interview on 1/6/25 at 7:04 p.m. with DON B revealed: *She conducted a visual inspection of residents 7 and 9 on 1/2/25 prior to speaking with CNA J about the allegations. *Resident 9 was not able to verbalize if she remembered the incident or not. *Resident 9 was still in her nightgown, so DON B looked at her legs and did not see any bruising. -The resident did not act any differently. *DON B confirmed she did not follow-up with resident 7 as much. -I laid eyes on her. [Resident 7] does not like to be talked to. I did not engage with [resident 7]. I did an up-close assessment and checked on her. -She confirmed the assessment of resident 7 was face-to-face. Resident 7 was under her bed covers, but the room light was on, so she was able to visualize resident 7's mouth and nose area. -She did not notice any redness or other signs of trauma around the resident's mouth and nose. *DON B confirmed she did not document those visual inspections. -She was confused about what should have gone into a resident's medical chart versus something more private like risk management (the provider's system of electronically tracking incidents). *She confirmed she learned about the allegations on 1/1/25 around 1:30 p.m. when registered nurse (RN) F contacted her about the allegations. -RN F told her that staff had come forward with concerns. -RN F did not provide any details about the concerns, and DON B did not ask further questions about the concerns. *She did not contact ED A about the allegations until the morning of 1/2/25. *DON B confirmed that CNA J worked from 10:30 p.m. on 1/1/25 to 7:30 a.m. on 1/2/25 after she learned of the allegations against the CNA. -CNA J clocked back in at 12:08 p.m. on 1/3/25 and worked until around 2:00 p.m. *DON B had never suspended any staff pending an investigation before. -I knew that I had to have a conversation with her [CNA J] and I felt that was the steps I needed to take. -She had not considered suspending CNA J pending the investigation. *DON B explained that she had been the DON since July 2024. She was the Minimum Data Set (MDS) Assessment coordinator prior to that. -She indicated she had not received a lot of training when she took over the DON position. -She was not aware that the above allegations required reporting. *She was not aware of the Administrative Rules of South Dakota detailing what type of incidents were required to have been reported. *She was not aware of the provider's abuse and neglect prohibition policy when it came to reporting and investigating allegations of abuse and neglect. *She again confirmed the following: -CNA J was not suspended pending investigation and was allowed to work an overnight shift prior to the investigation. -The allegations of abuse were not reported to the required entities. -The investigation was not documented. 10. Interview on 1/7/25 at 2:21 p.m. with DDCO C revealed: *ED A was placed on suspension related to his failure to follow the provider's policy regarding abuse and neglect prevention and prohibition. -He was supposed to have been acting as the abuse/neglect coordinator. 11. Interview on 1/8/25 at 9:53 a.m. with DON B and DDCO C revealed: *At the time RN F called her on 1/1/25, DON B did not know the extent of the details of the alleged abuse, like the allegations that CNA J held a washcloth onto resident 7's mouth and kicked resident 9 in the shin. -She was aware, however, of the allegations of CNA J having been potentially rough when providing care to residents. *DDCO C explained that, to her understanding, the above incidents happened several weeks ago, and the witnesses came to ED A recently to report the incidents. -It was her expectation that staff should have immediately reported the abuse. -It was her expectation that all allegations should have been taken seriously, and the allegations should have been investigated thoroughly. -She explained the investigation should have consisted of a root-cause analysis, the 5 Why's should have been explored, and a scene reenactment should have been completed. 12. Confidential interview on 1/8/25 with anonymous staff member N revealed: *The incident involving CNA J and resident 9 happened two to three weeks ago, but they could not remember exactly when that occurred. *Resident 9 was sitting in her wheelchair in the hallway outside her room. *Resident 9 tended to reach her hand out to people to grab them. *Anonymous staff member N observed resident 9 reaching towards CNA J. -CNA J kicked resident 9 twice on the right shin hard enough that [resident 9] made a face about it .but not hard enough to leave a bruise. *Resident 9 looked sad and shocked. She was not very verbal, so resident 9 did not say anything about that incident. *Anonymous staff member N also overheard CNA J say to resident 9, You're an ugly gremlin. I can tell you've had a hard life. I can tell you probably smoked all your life. *Anonymous staff member N wheeled resident 9 away from the situation afterward to see if she was okay. *That event potentially happened at the beginning of December 2024, but anonymous staff member N was not sure. *Anonymous staff member N did not report that incident to the nurse or to management at that time. -Anonymous staff member N was aware they were required to report incidents like abuse immediately. -Anonymous staff member N feared retaliation from CNA J. *Anonymous staff members M and N finally reported their concerns to ED A on 12/30/24 around lunchtime. -Both anonymous staff members M and N were specific when detailing the alleged abuse to ED A and provided the specific incidents. *On 1/1/25, they again reported the alleged abuse to RN F after no improvements were observed in CNA J's behavior towards residents. -Anonymous staff member N confirmed they were very specific with details of the alleged abuse when reporting their concerns to RN F. 13. Interview on 1/8/25 at 12:09 p.m. with RN F revealed: *She confirmed that two staff members reported CNA J's alleged abuse on 1/1/25. *She denied that they were specific about the abuse allegations. -They did not specify exactly what happened that was rough. *She confirmed that she called DON B immediately to report the concerns. 14. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had diagnoses including senile degeneration of brain, unspecified dementia, age-related cognitive decline, adult failure to thrive, anxiety disorder, and other recurrent depressive disorders. *There was nothing in her EMR that indicated she had been assessed after the alleged abuse was reported. *Her Brief Interview for Mental Status (BIMS) assessment score was 2 on the 12/11/24 quarterly MDS assessment, which indicated she was severely cognitively impaired. *Her care plan indicated she was dependent on staff for ambulation, bathing, dressing, bed mobility, and eating. -She required the use of a stand-lift for transfers. 15. Review of resident 9's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included repeated falls, unspecified muscular degeneration, unspecified depression, dementia in other diseases classified elsewhere, and senile degeneration of brain. *Her care plan indicated she used a wheelchair for locomotion, required maximal/substantial assistance with bathing, dressing, bed mobility, and grooming. *There was nothing in her EMR that indicated she had been assessed after the alleged abuse was reported. *Her BIMS assessment score was 3 on the 10/16/24 significant change MDS assessment, which indicated she was severely cognitively impaired. 16. Review of CNA J's employee file revealed: *Her hire date was 10/1/23. *She was trained on all the required training topics on 10/2/23, including resident rights and abuse prohibition. *The background check completed on 10/11/23 did not reveal any criminal charges of abuse of another individual. *A Disciplinary Action Form completed by DON B on 1/2/25 included the following: -[DON B] had conversation with [CNA J] about complaints of aggressive cares [and] comments with residents. [DON B] explained that even though we have bad days, we need to keep [redacted] that attitude at home [and] not to project on others. [DON B] explained to [CNA J] that she needs to be thoughtful on how others perceive her actions [and] words. If behavior doesn't improve, written warning, probation, suspension procedure will be followed. 17. Review of the provider's March 2012 CNA job description revealed the CNA is expected to perform duties in compliance with state and federal regulations. 18. Review of the provider's March 2012 Director of Nursing Services (DNS) job description revealed: *Job summary: Is directly accountable to the Executive Director (ED) for the day-to-day operations, activities, and success of the resident care staff, as governed by the Center policies, and state and federal regulations. Validates that the nursing department continues to develop and maintain high standards of excellence by being knowledgeable of industry changes and trends, and by implementing up-to-date nursing practices. *Essential Functions -1. Develops and maintains a nursing service philosophy, objectives, standards of practice, policy and process manuals. -2. Manages, supervises, and develops plans of action for assigned units, providing consistent monitoring and follow-through. -3. Establishes systems for care planning, including assessments, plan of treatment, objectives and goals, evaluations, and discharge planning period maintains accurate and timely documentation reflecting same. - .6. Demonstrates an understanding and knowledge of certification laws and requirements, survey requirements, and Medicare program. - .8. Validates that reporting departments consistently meet state and federal requirements for long-term care facilities for licensure. - .10. Maintains open communication with ED regarding resident care activities, personnel or staffing problems, and other related topics. - .13. Understands the relationships with state and federal regulatory agencies, and works to maintain positive relationships. 19. Review of the provider's November 2019 Executive Director job description revealed: *Job summary: The Executive Director (ED) is directly accountable .to provide strong overall leadership and management of a long-term care center. Manages delivery of the highest level of health services and quality of care that is responsive to customers' needs. *Essential Functions - .2. Quality Management --a. Lead the process to develop and implement programs to maintain quality of care to meet established goals. --b. Responsible to maintain a safe, healthy, clean, and well-organized building that reflects a high standard of care and service. -- .d. Verify the Center meets state and federal requirements for long-term care Centers for licensure. -3. Human Resource Management -- .e. Ultimately accountable for the adequate staffing of the Center. --f. Hire and manage within Federal and State laws, and Center policies and processes. --g. Facilitate communications from administrative level to staff and vice versa to promote optimum performance and understanding of goals. -- .j. Implement a management style that embodies the company's core mission, values, and culture, and holds department managers to the same standards. -4. Compliance Management -- .b. Grievance Official: Responsible for overseeing the grievance process. Responsibilities include: receiving and tracking grievances through to their conclusion, leading any necessary investigations, and complying with federal and state regulations and company policies as they apply to the grievance process. -c. Abuse Coordinator: Oversee the implementation of policies and procedures necessary to prohibit and prevent abuse and neglect, including but not limited to: screening, training, prevention, identification, protection, and reporting/response. Coordinate abuse and neglect investigations. --d. Compliance Liaison: Oversee the facility Compliance and Ethics Program. Coordinate employee, contractor, and volunteer compliance training to include the Code of Conduct, HIPAA [Health Insurance Portability and Accountability Act] policy, and other mandatory compliance policies. *Knowledge, Skills, and Abilities -1. Familiarity with State Nursing Center rules and regulations, and applicable Federal and State laws. 20. Review of the provider's November 2019 Abuse, Neglect, or Exploitation policy revealed: *1. Complaints of abuse, neglect, or exploitation are viewed as very serious and are reported to your Regional [NAME] President and/or Regional Nurse Consultant immediately. *2.Abuse may be defined as an act by an individual which injures, exploits, or jeopardizes an individual's health, welfare, or safety, including, but not limited to: -Physically damaging or potentially damaging non-accidental acts (e.g. staff striking a resident). -Emotionally damaging verbal behavior and harassment. *3. Abuse, neglect, or exploitation can involve: .One or more resident(s) and staff. *4. If abuse, neglect, or exploitation of a resident is suspected, act immediately to protect the resident from additional harm. *5. Act quickly to gather pertinent information. If an employee is suspected of the abuse, the employee is suspended pending the outcome of an investigation, for the employee's protection as well as the protection of the resident. -A staff person suspected or accused of abuse, neglect, or exploitation does not have access to any resident until the Community investigates and takes action to assure resident safety. *6. Complete an Incident Report and make appropriate documentation in the resident's Service Notes. *7. Initiate an investigation. Staff on duty at the time the alleged abuse occurred are interviewed prior to leaving their respective shift. This applies to staff as well as other residents in the area. *8.contact the appropriate State agency as soon as possible during the required reporting timeframe. *9. Notify the resident's family/significant other(s) of the suspected or alleged abuse. *10. Depending on the type of incident, it may also be appropriate to call the Long-Term Care Ombudsman, Adult Protective Services Offices, and/or the local police. * .13. A staff member may notify the appropriate state agency of suspected/alleged abuse, neglect, or exploitation without fear of retribution. It is the responsibility of each employee to assure compliance with state abuse or suspected abuse reporting regulations. *14. If a staff member reports a suspected or alleged case of abuse, he/she is not retaliated against for making a good faith report. However, protection from retaliation does not prevent the Community from taking appropriate personnel action related to false reporting, policy violations, or performance deficiencies. 21. Review of the provider's October 2022 Freedom from Abuse, Neglect, Corporal Punishment, Involuntary Seclusion, Mistreatment, Misappropriation of Resident Property, and Exploitation policy revealed: *Policy Statement: each resident has the right to be free from abuse, including verbal, mental, .or physical abuse . -The Center implements policies and processes so that residents are not subjected to abuse by staff . *Definitions: -Abuse: The willful infliction of injury .with resulting physical harm, pain, or mental anguish. 'Willful,' as used in this definition of abuse, means the individual acted deliberately, not that the individual must have intended to inflict injury or harm. -Mental Abuse: The use of verbal or nonverbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. It includes but is not limited to .harassment, .and verbal assault that includes ridiculing, yelling, or swearing. -Verbal Abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. --Examples of mental and verbal abuse include, but are not limited to: Harassing a resident; mocking, insulting, ridiculing . -Physical Abuse: Includes, but is not limited to, hitting, slapping, punching, choking, pinching, biting, kicking throwing objects, grabbing, and shoving. Physical abuse also includes controlling or correcting behavior through corporal punishment. -Corporal Punishment: Inflicting physical pain or injury upon a resident. Physical punishment that is used as a means to correct or control behavior. Includes but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object. -Mistreatment: Inappropriate treatment or exploitation of a resident. -Mandatory Reporter: Anyone who is an employee, manager, agent, operator, owner, or contractor of a Medicare or Medicaid certified nursing facility . -Staff: Staff includes employees, medical director, consultants, contractors and volunteers. Staff also includes caregivers who provide care and services on behalf of the Center . -Immediately: Means as soon as possible, in the absence of a shorter State time frame requirement, but not later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury. (Based on real clock time) -Serious Bodily Injury: Means an injury involving extreme physical pain . -Staff to Resident Abuse: Any form of abuse directed by staff to a resident. *Procedure: - .3. Prevention: The Center implements written policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation. -4. Identification: The Center implements written procedures to assist staff in identifying abuse, neglect, and exploitation of residents . -5. Investigation: The Center conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown source, in accordance with state and federal regulations. -6. Protection: The Center protects residents from physical and psychosocial harm during and after an investigation. -7. Reporting and Response: The Center immediately reports all suspected and/or allegations of abuse, neglect, and exploitation of residents, .mistreatment, and injuries of unknown source in accordance with state and federal law. 22. Review of the provider's November 2016 Abuse Prohibition Notification policy revealed: *Policy Statement: The Center complies with Federal and State requirements to screen, train, prevent, identify, investigate, protect, and report abuse, neglect, mistreatment, exploitation, and misappropriation of resident property. * .4. Alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source, exploitation, and misappropriation of resident property, are reported immediately to the Executive Director (ED) and to other officials in accordance with Federal and State law. -At the time of an alleged violation, an investigation is initiated. -The alleged victim is protected to prevent harm during the investigation. -The results of investigations are reported to the ED or his/her designated representative and to other officials in accordance with Federal and State law, not to exceed five working days of the incident. *5. Instances of disregard for the Center's policies and processes is cause for corrective action up to and including suspension, termination, and reporting to licensing agencies. 23. Review of the provider's October 2022 Abuse Investigation policy revealed: *Policy Statement: The Center conducts a thorough investigation of potential, suspected and/or allegations of abuse, neglect, and exploitation of residents, misappropriation of resident property, mistreatment, and injuries of unknown origin, in accordance with state and federal regulations. *1. The Executive Director is the designated abuse coordinator and is responsible for assigning and overseeing staff that are to assist with investigations. *2. The Center identifies and interviews involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations. *3. The Center protects the alleged victim during and after the course of the investigation. *4. Through investigation, the Center works to determine if the abuse, neglect, exploitation, misappropriation of property, and/or mistreatment has occurred and to determine the extent and cause. *5. The Center maintains complete and thorough documentation of the investigation. * .7. The Center investigates patterns, trends, or events that suggest the possible presence of abuse, neglect, misappropriation of resident property, exploitation, mistreatment, and injuries of unknown source, identified through analysis conducted by the QAA [Quality Assessment and Assurance] Committee, with intervention, reporting, or policy/process modification conducted as appropriate.

Based on South Dakota Department of Health (SD DOH) complaint intake review, interview, document review, and policy review, the provider failed to thoroughly investigate allegations of physical, mental, and verbal abuse by certified nursing assistant (CNA) J towards two of seven sampled residents (7 and 9). Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy at F610 was given verbally and in writing via email on 1/8/25 at 3:57 p.m. to director of nursing (DON) B and division director of clinical operations (DDCO) C relating to failure to report allegations of abuse. A plan for removal of the immediacy was requested. On 1/8/25 at 4:30 p.m., DDCO C emailed a written plan for the removal of the immediate jeopardy. The removal plan was approved soon after 4:30 p.m. on 1/8/25. It was determined that the removal plan for F600 sent on 1/7/25 at 12:56 p.m. included action items to report the allegations of abuse to the required entities. F610. The provider learned about concerns regarding the care and services a CNA was providing to residents on 1/1/25 at around 1:30 p.m. The provider failed to protect the residents from potential further abuse during the investigation by allowing the CNA to keep working an overnight shift from 10:30 p.m. on 1/1/25 to around 7:30 a.m. on 1/2/25. The provider failed to get more information from the reporting party to understand the extent of the situation. The provider failed to report the incidents to the necessary entities. The provider conducted an investigation into the allegations including assessing the residents involved for injuries but nothing was documented. The CNA has been suspended as of 1/6/2025 pending investigation. The initial report to DOH was submitted on 1/6/2025. All residents had a skin assessment completed and any residents with a BIMS [Brief Interview for Mental Status] above an eight have been interviewed regarding any potential for abuse by 11 am. A total of 49 residents were interviewed with no concerns, 1 resident with a concern that was reported to DOH this morning, residents with a BIMS below eight, the responsible party was contacted, seven with no concerns and five were left a voicemail. The reporting party has had a thorough investigation/interview with re-enactment completed by 10 am on 1/7/2025 by [ED A]. Abuse education provided by [DDCO C] to [ED A and DON B] as well as validating documentation in place to monitor skin or affected body parts for injury. Several staff from nursing, day shift 4, evening shift 2, night shift 1; dietary, one from days and one from evening; maintenance, activities, therapy and HR across all shifts have been interviewed regarding if they have ever seen another staff member abuse or neglect a resident in any way on 1/7/2025, no concerns noted. Primary witness statements from other CNAs who witnessed the alleged perpetrator kick a resident in the shin twice, and a separate incident with a different resident where the alleged perpetrator put a washcloth over a resident's mouth to quiet the resident. Both those residents have dementia. Statements from staff indicate that this has been an ongoing issue and the alleged perpetrator improves their actions for a short while after being talked to by administration, but then slips back into their old ways. There is serious concern that the alleged perpetrator will potentially re-offend. The CNA's making the allegation have been interviewed and a re-enactment of events has been conducted by [ED A]. The perpetrator was suspended 1/6/2025 pending investigation. The two residents in [question] were assessed for physical harm, unable to assess for psychosocial harm due to cognition status. Both were placed on alert charting for 72 hours. The [perpetrator] had a background check completed on 10/11/2023 with negative results for abuse. The provider needs to take immediate action to prevent further potential abuse from occurring. The provider failed to report the incidents to the required entities, allowed the alleged perpetrator to work a shift following the report of alleged abuse, failed to conduct a thorough investigation, and failed to follow their abuse/neglect policy. The event was reported 1/6/2025. [DDCO C], educated [ED A and DON B] on abuse policy, abuse reporting, suspension pending investigation and investigation by 1/6/2025 via phone. All staff were re-educated on the facility abuse policy on 1/7/2025 and prior next working shift. Grievances for [the last] 30 days were reviewed for possible abuse allegations on 1/7/2025. [Nurse's] notes for residents were reviewed for the last 30 days for possible abuse allegations on 1/7/2025. An Ad hoc [meaning when necessary or needed] QAPI [quality assurance and performance improvement] is being completed 1/07/25 and the Medical Director was informed of the alleged deficient practice and current plan. Called at 10 AM by [DON B]. The immediacy at F610 was determined to have been removed on 1/7/25 at 4:30 p.m. after onsite review. After removal of the immediacy, the severity and scope was a level G. The census was 62. 2. Refer to F600 findings 2 and 3 for information about the SD DOH complaint intake forms. 3. Interview on 1/6/25 at 6:30 p.m. with executive director (ED) A revealed: *He denied that any staff had reported allegations of abuse or neglect against any other staff. *However, when asked specific questions about CNA J allegedly having kicked a resident and having held a cloth over another resident's mouth, he confirmed he had been aware of those allegations. -He explained that the staff member who brought forward those allegations was nondescript and could not describe specifically was CNA J had done. *The allegations were not investigated further. 4. Interview on 1/6/25 at 6:35 p.m. with DON B and ED A about their investigation process revealed: *They both confirmed they were aware of the allegations detailed in F600 findings 2, 3, 6, and 12. *As part of the investigation, DON B interviewed residents on different hallways to gauge if they had any concerns with the care they were receiving. -She talked to three residents (2, 8, and 10). Those residents had lived at the facility for a long time and are not afraid to speak their minds. -They felt that 3 of 62 residents was an accurate sample. -She did not document any of her interviews. *She interviewed CNA J about the allegations. CNA J denied each allegation. *Both DON B and ED A felt their investigation into the allegations was satisfactory. 5. Interview on 1/6/25 at 7:04 p.m. with DON B revealed: *She confirmed she learned about the allegations on 1/1/25 around 1:30 p.m. when registered nurse (RN) F contacted her. *She had not launched an investigation into the allegations until the next day and allowed CNA J to work an overnight shift. *She was not aware of the provider's policy on investigating allegations of abuse. 6. Interview on 1/7/25 at 2:21 p.m. with divisional DDCO C revealed she expected all allegations of abuse to have been taken seriously and reported and investigated within the required timeframe. 7. Interview on 1/8/25 at 9:53 a.m. with DON B and DDCO C revealed: *DDCO C explained that, to her understanding, the incidents between CNA J and residents 7 and 9 happened several weeks ago, and the witnesses came to ED A recently to report the incidents. -It was her expectation that all allegations should have been taken seriously, and the allegations should have been investigated thoroughly. 8. Refer to F600 finding 12 for additional details regarding when the anonymous staff members brought their concerns to ED A. It was confirmed that ED A learned about the allegations of abuse on 12/30/24 and had not reported or investigated the incidents. 9. Review of the provider's March 2012 Director of Nursing Services (DNS) job description revealed: *Job summary: Is directly accountable to the Executive Director (ED) for the day-to-day operations, activities, and success of the resident care staff, as governed by the Center policies, and state and federal regulations . *Essential Functions - .2. Manages, supervises, and develops plans of action for assigned units, providing consistent monitoring and follow-through. - .6. Demonstrates an understanding and knowledge of certification laws and requirements, survey requirements, and Medicare program. - .8. Validates that reporting departments consistently meet state and federal requirements for long-term care facilities for licensure. - .10. Maintains open communication with ED regarding resident care activities, personnel or staffing problems, and other related topics. 10. Review of the provider's November 2019 Executive Director job description revealed: *Essential Functions - .2. Quality Management -- .d. Verify the Center meets state and federal requirements for long-term care Centers for licensure. -3. Human Resource Management -- .e. Ultimately accountable for the adequate staffing of the Center. --f. Hire and manage within Federal and State laws, and Center policies and processes. -- .j. Implement a management style that embodies the company's core mission, values, and culture, and holds department managers to the same standards. -4. Compliance Management -- .b. Grievance Official: Responsible for overseeing the grievance process. Responsibilities include: receiving and tracking grievances through to their conclusion, leading any necessary investigations, and complying with federal and state regulations and company policies as they apply to the grievance process. -c. Abuse Coordinator: Oversee the implementation of policies and procedures necessary to prohibit and prevent abuse and neglect, including but not limited to: screening, training, prevention, identification, protection, and reporting/response. Coordinate abuse and neglect investigations. --d. Compliance Liaison: Oversee the facility Compliance and Ethics Program. Coordinate employee, contractor, and volunteer compliance training to include the Code of Conduct, HIPAA [Health Insurance Portability and Accountability Act] policy, and other mandatory compliance policies. *Knowledge, Skills, and Abilities -1. Familiarity with State Nursing Center rules and regulations, and applicable Federal and State laws. 11. See F600 finding 20, 21, 22, and 23 for the provider's policies on Abuse prohibition and investigation.

Based on South Dakota Department of Health (SD DOH) complaint intake report, SD DOH facility reported incident (FRI) report, record review, interview, job description and policy review, the provider failed to ensure a thorough investigation was completed for one of one sampled resident (1) identified at risk for elopement who eloped (left the facility without staff knowledge), was found and returned to the facility by staff. Findings include: 1. Review of the 10/11/24 SD DOH complaint intake report revealed: *Resident 1 had eloped. Staff found him approximately a half mile away and returned him to the facility. *Resident 1 has since moved to another facility. *The provider had completed a SD DOH FRI report. 2. Review of the provider's 7/17/24 SD DOH FRI report revealed: *Resident 1 was found in a wheelchair by staff at 12:10 p.m. on 7/17/24 on sidewalk outside facility. *Charge nurse was notified of elopement. *His vital signs were taken and were within normal limits. *Resident 1 stated he wanted to go home. *His Brief Interview for Mental Status (BIMS)assessment score was 10, which indicated he had moderate cognitive impairment. *Resident 1 had a Wanderguard [wearable door alarming device] that was functioning and in place. -His wanderguard monitoring was completed every shift. *When the alarm sounded staff investigated and found a wheelchair transit driver returning another resident from an appointment. -The driver stated, someone left. -Staff assumed that meant wheelchair transit was taking a resident to an appointment. -The alarm was turned off. -Another staff member found resident 1 on a sidewalk while he was returning from his break. -Resident 1 was last seen at 11:45 a.m. -Resident 1 was returned at 12:10 p.m. to the facility by staff. *Therapy staff were educated to return resident 1 to the second floor after his therapy sessions. *The director of nursing (DON) would be completing a performance improvement project (PIP) regarding elopement drills. *Ecare (electronic physician notification) was notified of elopement. *Family was notified of elopement. 3. Review of resident 1's electronic medical record revealed: *He had diagnoses of: -Dementia with behavioral disturbances. -Delusional disorders. -Altered Mental status. -Anxiety Disorder. -History of falling. -Weakness. *He had a BIMS score of 8 on 8/26/24 which indicated he had moderate cognitive impairment. *He was assessed on 3/21/24 and 6/20/24 and was identified as at risk for elopement. *Care Conference note dated 4/10/24 noted frequent attempts to elope. *Alert charting dated 7/9/24 noted active exit seeking behavior. *Orders administration note on 7/10/24, Resident attempted to open doors on the south hallway. *On 7/13/24 orders administration note, Resident on first floor this am, trying to get out the doors, was easily redirected. *He was an active exit seeker. *On 1/11/24 order for Wanderguard on wheelchair, monitor placement and functionality q shift. *His family was looking for a secured memory unit to transfer him to. *He was discharged on [DATE] to a memory care assisted living facility. 4. Interview on 10/30/24 at 9:24 a.m. with physical therapy assistant F revealed: *It was reported the following morning at a staff round-up meeting that resident 1 had eloped. *It was reported he was on the other side of the block on the back side of the campus. *She was told to return resident 1 to the second floor after his therapy sessions. 5. Interview on 10/30/24 at 10:15 a.m. with certified nursing assistant (CNA) D revealed: *He observed resident 1 walking behind pushing his wheelchair down the street about 3-4 blocks from the building. *He assisted resident 1 into his vehicle and returned him to the facility. *He notified DON B, registered nurse (RN) C and CNA E of the elopement, where he found resident 1 and that he drove him back to the facility. 6. Interview on 10/30/24 at 10:40 a.m. with RN C revealed: *She heard the exit alarm sound. *Resident 1 got out of the building and was walking up up the road pushing his wheelchair. *CNA D brought resident 1 back to the facility in his vehicle. *RN C completed the skin assessment on resident 1. *She notified resident 1's family and Ecare of his elopement. *Resident 1 would exit seek often. 7. Interview on 10/30/24 at 11:19 a.m. with CNA E revealed: *Resident 1 was found by CNA D by the apartments a couple of blocks from the facility. *CNA D put him in his vehicle and drove him and his wheelchair back to the facility. *There had been no other elopements since July (2024). 8. Interview on 10/30/24 at 3:20 p.m. with DON B revealed: *The elopement of resident 1 was reported by CNA D who returned him to the building. *She had become DON on July 1, 2024. *This was the first elopement that occurred since she become the DON. *CNA D stated he observed resident 1 pushing his wheelchair on the sidewalk after his break. *A wheelchair transit driver had returned another resident from an appointment. -The driver had put the code in the door to return the resident and that is how resident 1 got out of the building. *She was unaware that there was no sidewalk outside the front of the building. *She had completed the FRI report and submitted it. *She stated I guess I need to do a more thorough job of investigating. *She had heard two different reports from CNA's about the elopement. *Resident 1's family had been trying to find memory care placement for resident 1 since he was admitted . *He had been evaluated by psych and had medication adjustments numerous times. *He exits sought frequently. *He had a Wanderguard band on. *He was identified as an elopement risk. 9. Review of providers October 2009 Director of Nursing Services job description revealed: *Demonstrates an understanding and knowledge of certification laws and requirements, survey requirements and Medicare programs. *Understands the relationships with state and federal regulatory agencies, and works to maintain positive relationships. *Participates with Center ED and other departments directors in development and maintenance of practices and processes that promote infection control, fire safety and hazard reduction. *Other duties as assigned appropriate to the position. 10. Review of provider's Elopement/Wandering Policy dated May 2024 revealed: *Elopement: The resident/patient exits the Center without staff knowledge or the resident/patient enters an unsafe area without staff knowledge or presence.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of four sampled residents (12 and 30) who were at risk of skin breakdown had: *Preventative measures implemented to prevent pressure ulcers from developing. *Care plans updated to reflect the current interventions to prevent skin breakdown. Findings include: 1. Observation on 2/14/23 at 10:58 a.m. of resident 30 revealed he: *Was sleeping in a recliner in his room with his feet elevated. *Had a Prevalon boot (cushioned boot that floats the heel to reduce pressure) under his left ankle propping his heel off the footrest of the chair. Review of resident 30's medical record revealed: *He had been admitted on [DATE]. *His 12/20/22 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnosis included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, heart failure, atrial fibrillation, chronic pain syndrome, type II diabetes, and disorder of the skin and subcutaneous tissue. *His 12/20/22 Braden Scale for predicting pressure ulcer risk score showed he was at moderate risk. *He had an unstageable pressure ulcer to his left heel from 3/9/22 through 3/30/22. -No other interventions had been documented after the pressure ulcer had developed. *On 12/17/23 he was found to have re-developed the unstageable pressure ulcer to his left heel. -No other interventions had been documented after the pressure ulcer had re-developed. -The pressure ulcer was healed on 1/9/23. *He had an order for an ankle-foot orthosis (AFO) brace to his left foot as needed. *The Prevalon boot was not documented in the resident's medical record. Review of resident 30's 11/10/22 care plan revealed: *He was at risk for skin breakdown. *He had a pressure ulcer on his left heel from 3/9/22 through 3/30/22. *The goal was I want my skin to remain intact through the review date. *Interventions included: -Assess/record/monitor wound healing - Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [medical doctor]. -Encourage/assist me to apply lotion to dry skin. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. -I use a pressure relieving mattress on my bed, and pressure reducing cushion in my wheelchair. -Use bilateral assist bars with encouragement to assist with turning/repositioning in bed. Please cue me to use. *No new interventions had been implemented since 6/17/22. *The Prevalon boot was not included in the interventions. Interview on 2/16/23 at 4:30 p.m. with director of nursing (DON) B regarding resident 30 revealed: *He had COVID-19 in early December 2022 and his health had declined. *He had been hospitalized and returned to the facility on [DATE]. *He had not worn the AFO since he returned from the hospital because he was not walking. *She did not know when the Prevalon boot was implemented, but had stated it was not until after he returned from the hospital. *The skin assessment was completed on 12/15/22 when he returned from the hospital and there was not documentation that indicated a pressure ulcer to his left heel. *The care plan should have included the Prevalon boot. *His medical record should have reflected the interventions put into place after he had developed the pressure ulcer. 2. Observation on 2/14/23 at 2:45 p.m. of resident 12's room revealed he had a heel lift pillow (used to relieve pressure on heels) on the foot of his bed. Observation on 2/16/23 at 8:30 a.m. of resident 12 revealed he was laying in his bed asleep with his lower legs rested on the heel lift pillow. Review of resident 12's medical record revealed: *He had been admitted on [DATE]. *His 12/19/22 BIMS score was 6 indicating his cognition was severely impaired. *He had been admitted to hospice care on 2/1/23. *He was found to have a blister on his right heel on 1/24/23. *A physician's order had been received on 1/24/23 for dressings to the right heel and to use an egg crate boot to the right foot. *The certified nurse practitioner's note from 1/24/23 revealed he had a blister to the back of his right heel and she had questioned if it was caused from friction. *On 2/14/23 he was found to have two open areas on his right buttocks. *On 2/15/23 he was found to have a stage II pressure ulcer to his buttock. -The 2/15/23 nurses note did not specify where it was located on his bottom. -A new wheelchair cushion was implemented and an air mattress was requested from hospice. Review of resident 12's weekly skin evaluations from 1/30/23 through 2/13/23 revealed: *He had a blister on his right heel. *Did not indicate if the blister to his right heel was a pressure ulcer or caused from friction. Interview on 2/16/23 at 8:59 a.m. with registered nurse L revealed: *He had a pressure ulcer on his right heel and the dressing change had been completed. *He had a wound on his bottom she needed to assess and treat. *She stated she would have a surveyor look at the wound when she was ready to complete the treatment. *She had not let the survey team know when she had done the treatment. Review of resident 12's care plan revealed: *He was at risk for skin breakdown. *He had a wound on his right heel and open area on his buttock. *The goal was I want to be free of skin injuries through the review date. *The interventions included: -Avoid scratching and keep hands and body parts from excessive moisture. Keep fingernails short. -Educate resident/family/caregivers of causative factors and measures to prevent skin injury. -Follow facility protocols for treatment of injury. -Identify/document potential causative factors and eliminate/resolve where possible. -Keep skin clean and dry. Use lotion on dry skin. -The resident needs pressure reducing mattress on bed to protect the skin while IN BED. -Weekly treatment documentation to include measurement of each area of skin breakdown's width, length, depth, type of tissue and exudate and any other notable changes or observations. -Pressure reducing cushion in wheelchair. *No new intervention had been implemented since 11/21/22. *The egg crate boot had not been included in the care plan. *The heel lift pillow was not included in the care plan. 3. Review of the provider's October 2022 Skin Integrity policy revealed: *The nurse establishes a Plan of Care (POC) based on risk factors in an effort to limit their potential effects. *When a resident developed a skin impairment, interventions should have been implemented and documented on the care plan.

Based on observation, interview, record review, and reference source review, the provider failed to follow outbreak testing procedures for all staff and residents. Findings include: These failures had the potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [CONDITION(S)] infection that could lead to serious harm or death. NOTICE: On 11/9/21 at 2:40 p.m. an Immediate Jeopardy was identified when the facility failed to ensure: *Residents had been tested based off potential symptoms of COVID-19, regardless of COVID-19 vaccination status. *All staff working in the building had been tested for COVID-19 prior to working with residents. *Staff who were self-testing were testing accurately and the testing process is being monitored. At the above time, executive director (ED) A and director of nursing services (DNS) B were asked for an immediate plan of correction (POC) to ensure all staff working in the facility received education and monitoring for nationally recognized infection control procedures. PLAN: On 11/10/21 at 1:40 p.m. the divisional director of clinical operations (DDCO) C, ED A, and DNS B, provided the surveyor with an email that included the final written removal plan. The written removal plan was approved by the long-term care advisor for the department of health on 11/10/21 at 1:50 p.m. The facility provided the following acceptable removal plan on 11/10/21: *1. All staff re-educated on recognizing signs and symptoms of Covid 19. Residents will be tested if they are exhibiting Covid 19 symptoms in accordance with CDC [Centers for Disease Control and Prevention] recommendations and per direction of the local health department. All residents have been continued to be tested every three to seven days during the outbreak status. Residents will also be tested upon notification of covid symptoms Staff will be re-educated on this. All staff educated by 11/9/21 at 11:59 PM. All staff not tin [in] attendance will be educated prior to their next working shift. *2. Those who conduct self-testing will continue to complete competency for self-testing by 11/9/21 at 11:59 PM. All those not competencied for self-testing will be prior to their next working shift. *3. The center will audit each shift for the above education completed as specified and observational audits for compliance with PPE, and infection control every shift 11/10/21 by ED/DNS or designee until substantial compliance is met. The immediate jeopardy had been removed on 11/11/21 at 9:40 a.m. after verification that the provider had implemented their removal plan. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. 1. Interview on 11/9/21 at 1:00 p.m. with registered nurse (RN) G revealed she: *Stated only licensed nurses were supposed to have been completing the tests. *Had been aware that had not always happened. *Had been unable to say whether tests were always read within the 15 minute window. *Was not sure if she had completed a competency on testing. *Had not tested resident 184 even though he had been exhibiting COVID-19 like symptoms. Refer to F880, finding 7. Review of the provider's testing documentation from the most recent facility outbreak beginning on 11/4/21 revealed: *They had testing documentation from 11/4/21 and 11/8/21-11/9/21. *Dietary staff Q was not on the testing records for any of the above dates. -She had been observed in the building without a shield on. Refer to F880, finding 1. *Certified nursing aide (CNA)s Y, AA, and R had not been tested and had been working in the building during the testing time. *CNA Z had testing completed on 11/8/21 but there had been no result documented. Refer to F880, findings 1, 2, 3, 4, 5, 6, and 7. Review of resident 184's electronic medical record (EMR) revealed: *He had been admitted to the facility on [DATE]. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -[CONDITION(S)]. -Chronic obstructive pulmonary disease ([CONDITION(S)]). -Hypertension. -Pulmonary fibrosis. -Dementia. -Ischemic cardio [CONDITION(S)]. *On: -11/12/21 he was noted to be sleepy and needed help putting oral medications in his mouth. -11/2/21 at 9:52 a.m. he had been noted to have an oxygen (02) saturation (sat) rate of 90 percent. -11/2/21 at 8:16 p.m. he had been noted to have an O2 sat rate of 91 percent. -11/3/21 at 11:29 a.m. he had been documented to be more short of breath (SOB) with exertion and confused. -11/3/21 at 11:47 p.m. he was documented to have diminished lung sounds. -11/4/21 at 7:00 a.m. CNAs reported resident was SOB, resident was laying on his bed with his legs dangling, skin cold to touch, resident did not respond, noted on respirations inhalations were twice as long as expirations, O2 sat 78% on room air, offered resident PRN [as needed] [MEDICATION(S)] inhaler. Vitals: O2 sat 78% on room air. -11/4/21 at 7:25 a.m., : Resident was positioned on his bed, O2 sat increased to 85%, offered resident O2 at 2L [liters] per nasal cannula, resident verbalized pain in Rt. [right] arm when Rt. arm was moved, BP [blood pressure] 104/62, T 97.6, P 87 apical [part where the beat is the loudest], R [respirations] 20 with 20 sec. [second] apnea [absence of breath], skin still cold to touch, lung sounds crackle throughout lobes, bowel sounds present in all four quadrants, abdomen is soft and non-tender, 2+[two plus] [CONDITION(S)] in Rt. lower leg and 1+ [CONDITION(S)] in Lt. [left] lower leg in the posterior leg, noted resident is a full code. Vitals: BP 104/62, T 97.6, P 87, R 20 w/ 20 sec. apnea, O2 sat 85% on room air[.] *At 8:00 a.m. on 11/4/21 registered nurse (RN) G called the hospital to get an order to transport resident 184 to the emergency room by ambulance. *He had been taken by ambulance to the hospital at 8:20 a.m. on 11/4/21. *At 2:57 p.m. on 11/4/21 DNS B documented that she had called the resident's son to notify him that the hospital informed them resident 184 had tested positive for COVID-19. Review of the provider's May 2020 provided American Healthcare Association Algorithm for Testing and Cohorting Residents documents revealed: *Older adults with COVID-19 may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or small. Additionally, more than two temperatures >[greater than] 99.0 [degrees] F [Fahrenheit] might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for COVID-19. Review of the provider's May 2021 Limiting The Spread of COVID-19 in SNF [skilled nursing facility]policy revealed: *1. Center-wide surveillance testing is completed based on the CMS [Centers for Medicare and Medicaid Services] county positivity rates determined every Monday morning or in state regulatory guidance if a more stringent frequency is required, utilizing a POC [point of care] [MEDICATION(S)] test, or PCR [Polymerase Chain Reaction] laboratory if POC [MEDICATION(S)] testing is not available. *a. Staff are required to test in accordance with the COVID-19 Testing policy. Those who do not test may be excluded from work. Staff may choose to test through other means, such as through their Primary Care Physician. *d. All staff must participate in outbreak testing regardless of vaccination status. *e. Staff may self-swab, unsupervised, according to lab directives after training has occurred. *1. All residents are continually monitored for signs/symptoms of respiratory illness. If symptoms exist, the resident is placed on Enhanced Droplet Precautions and the provider and center's state department of health are notified. -a. Monitoring of residents will occur at least daily, which includes symptom monitoring (cough, shortness of breath or difficulty breathing, fever, chills, rigors, myalgia, headache, sore throat, new olfactory and taste disorders(S); consider also rhinorrhea, diarrhea, nausea or vomiting), temperature, and other vital signs, including pulse oximetry. Review of the provider's May 2020 COVID-19 Testing Flowsheet revealed: *It included the steps that should be taken during an outbreak which included: -Resident name. -Test date. -Test Type. -Testing Consent. -If the resident was currently on transmission-based precautions. -Completion of the screening form. -Who was completing the testing. -Test result date. -Test result. -Notification of the Health Department. -Notification of positive test by five p.m. the next calendar day. -Report completed to NHSN (national healthcare safety network). -Completion of the provider's outbreak action plan. -Implementation of Isolation. -Hand Hygiene and personal protective equipment observations. -Increased screening and observations. -Resident's care plans updated. *The provider had not been utilizing this form. 2. Interview on 11/15/21 at 2:25 p.m. Minimum Data Set (MDS) coordinator I revealed: *She assisted with the COVID-19 testing. *They tested the staff today. *The list of who was tested and the results is on a clipboard at the second floor nurses station. *The nurses on duty do the staff testing. *She was not sure when the residents would be tested again as the resident who had been positive was no longer in the building. *She then stated all the residents would be tested on [DATE].

A. Based on observation, interview, policy review, and reference source review, the provider failed to implement proper infection control practices for the coronavirus (COVID-19) pandemic with the potential for exposing residents and staff to serious harm including death, by failing to ensure: *Infection control practices were followed to prevent exposure and potential spread of COVID-19. *All staff had been properly fitted for N95 masks to prevent the potential for COVID-19 exposure. *All staff had been medically cleared to wear N95 masks. *The health and safety of all staff and residents. These failures had the potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [CONDITION(S)] infection that could lead to serious harm or death. NOTICE: On 11/9/21 at 2:40 p.m. an Immediate Jeopardy was identified when the facility failed to ensure: *Staff were wearing personal protective equipment (PPE) properly during a COVID-19 facility outbreak while providing direct care to residents. *Staff had been fit-tested for N95 makes during a COVID-19 facility outbreak. *Failed to ensure one of one housekeeping staff had been aware of the proper disinfection process and chemical contact time while in COVID-19 outbreak status. *One of one housekeeping staff members cleaned resident rooms using practices to mitigate infection spread. *Quarantine residents who may have had contact with a resident who had tested positive for COVID-19. At the above time the executive director (ED) A and director of nursing services (DNS) B were asked for an immediate plan of correction (POC) to ensure all staff working in the facility received education and monitoring for nationally recognized infection control procedures. PLAN: On 11/10/21 at 1:40 p.m. the divisional director of clinical operations (DDCO) C, ED A, and DNS B, provided the surveyor with an email that included the final written removal plan. The written removal plan was approved by the long-term care advisor for the department of health on 11/10/21 at 1:50 p.m. The facility provided the following acceptable removal plan on 11/10/21: 1. Staff directly observed will be reeducated on proper mask wearing. Handwashing and glove use education will be provided to all staff. All staff will be re-educated on wearing face-shields during shifts. All staff will be re-educated on cleaning of equipment between resident use. This education completed on 11/9/21 by 11:59 p.m. All staff not educated will be educated prior to their next working shift. 2. All housekeeping staff will be educated on the disinfecting process and chemical contact time by 7:30 AM on 11/10/21. All housekeeping staff not in attendance will be educated prior to their next working shift. 3. Any residents or staff who test positive will be evaluated for close contacts who would need to be quarantined. Any close contacts for the positive resident were evaluated on 11/4/21 prior to 10 AM and no close contacts were identified. 4. All staff required to wear N95 masks will be fit-tested and medically cleared to wear N95 masks. This will be completed by 3 PM on 11/10/21. All those requiring fit-testing not in attendance will be fit-tested prior to their next working shift. 5. All nursing staff re-educated and competency done for proper PPE don/doffing by 11/9/21 at 11:59 PM. All nursing staff not in attendance will be educated prior to their next working shift. The immediate jeopardy had been removed on 11/11/21 at 9:40 a.m. after verification that the provider had implemented their removal plan. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. 1. Observation and interview on 11/9/21 at 9:00 a.m. revealed: *Surveyors entered through the facility's main entrance: *There had been an unidentified staff member walking in the building without a face shield on. *Housekeeping staff member S identified the staff member as dietary staff Q. Entrance conference on 11/9/21 at 9:30 a.m. with ED A and DNS B revealed they: *Were currently in COVID-19 outbreak status. *Resident 184 had tested positive for COVID-19 after being transferred to the hospital. *They had expected staff to wear N95 masks and face shields while in outbreak. 2. Interview on 11/9/21 at 9:40 a.m. with DNS B revealed: *They were currently testing all residents in the facility because they had been unable to identify close contacts to resident 184. *They were testing residents and staff on Mondays and Thursdays. *No residents were being quarantined. 3. Observation on 11/9/21 at 9:45 a.m. of the facility's west second floor hallway revealed: *Licensed practical nurse (LPN) T had been coming out of resident 3's room. -Her N95 was down underneath her nose. *She had then walked into resident 182's room and the shared room of resident 21 and 14. -Her N95 mask was still down underneath her nose. *She had performed hand hygiene when she arrived back at her medication cart, but not in between resident 3, 182, and 21 and 14's room. 4. Observation on 11/9/21 at 9:47 a.m. revealed certified nursing assistant (CNA) R wearing an N95 mask that had visible gaps around her nose and sides of her mouth. 5. Observation on 11/9/21 at 9:48 a.m. of CNA O revealed she: *Came out of resident 3's room with her N95 underneath her chin, pushing a stand lift. -Did not disinfect the lift or sanitize her hands. *Then went into resident 182's room with soiled hands and her N95 mask underneath her chin. *Went from resident 182's room to resident 18 and 6's shared room. -Had not sanitized her hands and her N95 mask was underneath her chin. 6. Observation and interview on 11/9/21 at 9:50 a.m. of housekeeping staff V cleaning resident 182's room revealed she: *Had sprayed Virex on all surfaces in the bathroom. *Believed the contact time for the disinfectant was five minutes. *Wiped the surfaces off with her blue rag. *Stated the blue rag she used in the bathroom, the red rag was used in the bedroom. *Finished cleaning the bathroom and with the same soiled gloves she had been wearing to clean the bathroom. *Began moving resident 182's breakfast juices, tv remote and other personal items. *Had a red rag in one hand and a blue rag in the other hand. -Touched his drinking glasses and remotes with the soiled gloves and blue rag. *Had the same process when cleaning COVID-19 rooms, although sometimes they will use bleach. Interview on 11/9/21 at 10:03 a.m. with CNA O revealed: *Surveyor mentioned that she noticed her N95 was under her chin while caring for residents. *She stated, that's because I can't breathe with it on. *Surveyor asked if she had been fit-tested for the N95 mask that she had been wearing, she thought she had. 7. Observation on 11/9/21 at 10:05 a.m. of registered nurse (RN) F revealed she had not been wearing a face shield. Interview on 11/9/21 at 10:30 a.m. with ED A and DNS B revealed: *They were not short on PPE supplies or testing supplies. *DNS B stated they were not sure where resident 184 had contracted COVID-19. *Surveyors shared their infection control concerns and lack of hand hygiene being performed by staff members. Further interview on 11/9/21 at 12:45 p.m. with DNS B revealed: *They have a COVID-19 outbreak strategy action plan. *They had not filled it out for the COVID-19 outbreak that began on 11/4/21. Review of the provider's November 2020 COVID-19 Outbreak Strategy Action Plan form revealed: *The Immediate actions that were to be put into place included: -Transmission-based precautions implemented with door closed and appropriate signage. -The shared bathroom would be closed and residents were to use separate bedside commodes. -All recent transfers or discharges are notified of COVID-19 Center outbreak. -The Center-wide testing strategy has been implemented. (All staff and residents must be tested immediately upon receiving the first positive result, testing all the negative staff and residents should occur at a minimum of every 7 days thereafter until 14 days have passed with no new positive cases identified. -Consistent staff should be assigned to infected/symptomatic residents. -Line listing would be initiated and updated. -Infection Preventionist maintains mapping and trending of unit/room outbreak. -Patient cases placed on alert/change of condition charting each shift and infection control care plan in place. -Increased active monitoring/screening to every 2 hours implemented for positive symptomatic resident and roommate. -Increased active monitoring/screening for all residents to every 4 hours during active outbreak. -The PPE capacity strategy has been reviewed. -Restrict communal activities. -Suspend activities on affected unit. -Restrict communal dining. -Restrict visitation per state and health department guidelines. (Except in cases of compassionate care/end of life visits.) Encourage virtual visitation. -The Center has reviewed and is in compliance with the Covid-19 Focused Survey for Nursing Homes. *There were three other pages of the outbreak plan that went through the steps that should be implemented or looked at when an outbreak in the facility occurs. Interview on 11/9/21 at 1:00 p.m. with RN G revealed she: *Had not tested resident 184 for COVID-19. *Agreed that the symptoms he had been experiencing were known COVID-19 symptoms. *Stated that licensed nurses are supposed to complete the testing. -Acknowledged that does not always happen. *Resident 184 had been known to wander the facility. Refer to F880, finding 2. Review of the provider's fit-testing records revealed: *Staff were last fit-tested in May of 2020. *The N95 masks they had been fit-tested for were not the masks they were currently wearing. *None of the staff fit-tested had been medically cleared to wear an N95 respirator. *ED A and DNS B did not have a timeline for when they would have fit-testing completed. Review of the provider's May 2015 Infection Control Policies and Practices policy revealed: *The objectives of our infection control policies and practices are to: -a. Prevent, detect, investigate, and control infections in the Center; -b. Maintain a safe, sanitary, and comfortable environment for personnel, residents, visitors, and the general public. -c. Establish guidelines for implementing Isolation Precautions, including Standard and Transmission-Based Precautions; -d. Establish guidelines for the availability and accessibility of supplies and equipment necessary for Standard Precautions. -e. Maintain records of incidents and corrective actions related to infections; and -f. Provide guidelines for the safe cleaning and reprocessing of reusable resident-care equipment. *5. The Executive Director (ED) or Governing Board, through the QAPI and the Infection Control Committees, have adopted our infection control policies and practices, as outlined herein, to reflect the Center's needs and operational requirements for preventing transmission of infections and communicable diseases as set forth in current OBRA [omnibus budget reconciliation act], OSHA [Occupational Safety and Health Administration], and CDC [centers for disease control and prevention] guidelines and recommendations. Review of the provider's March 2018 Handwashing/Hand Hygiene policy revealed: *Personnel follow the handwashing/hand hygiene procedures to help prevent the spread of infections to the other personnel, residents, and visitors. *Hand sanitizer should be used: -Before and after coming on duty. -Before and after direct contact with residents; -Before preparing or handling medications; -Before performing any non-surgical invasive procedures; -Before donning [putting on] sterile gloves. -Before handling clean or soiled dressings, gauze pads, etc. -Before moving from a contaminated body site to a clean body site during resident care. -After contact with a resident's intact skin. -After contact with blood or bodily fluids. -After handling used dressings, contaminated equipment, etc. -After contact with objects (e.g. [for example] medical equipment) in the immediate vicinity of the resident; and -After removing gloves. -Before and after entering isolation precaution settings; -Before and after eating or handling food; -Before and after assisting a resident with meals; and -After personal use of the toilet or conducting your personal hygiene. Review of the provider's May 2015 Standard Precautions policy revealed: *Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status. Standard Precautions presume that all blood, body fluids, secretions, and excretions (except sweat), not-intact skin and mucous membranes may contain transmissible infectious agents. *3. Masks, Eye Protection, Face Shields -a. Wear a mask and eye protection or a face shield to protect mucous membranes of the eyes, nose, and mouth during procedures and resident-care activities that are likely to generate splashes or sprays of blood, body fluids, secretions, and excretions. Review of <https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html> September 2021, CDC Strategies for Optimizing the Supply of N95 Respirators, accessed 11/9/21 revealed: *N95 respirators are the PPE most often used to control exposures to infectious pathogens transmitted via the airborne route, though their effectiveness is highly dependent upon proper fit and use. N95 respirators are intended to be used once and then properly disposed of and replaced with a new N95 respirator. The optimal way to prevent airborne transmission is to use a combination of interventions from across the hierarchy of controls, not just PPE alone. Applying a combination of controls can provide an additional degree of protection, even if one intervention fails or is not available. *While engineering and administrative controls should be considered first when selecting controls, the use of personal protective equipment (PPE) should also be part of a suite of strategies used to protect personnel. Proper use of respiratory protection by HCP requires a comprehensive program (including medical clearance, training, and fit testing) that complies with OSHA's Respiratory Protection and a high level of HCP involvement and commitment. The program should also include provisions for the cleaning, disinfecting, inspection, repair, and storage of respirators used by HCP on the job according to manufacturer's instructions. Proper storage conditions can maximize shelf life of respirators. The following strategies in this section are traditionally used by some healthcare systems. If not already implemented, these strategies can be considered by healthcare settings in the face of a potential N95 respirator shortage before implementing the contingency strategies that are listed further below. Review of <https://www.cdc.gov/coronavirus/2019-ncov/hcp/long-term-care.html>, updated September 2021, Interim Infection Prevention and Control Recommendations to Prevent [CONDITION(S)]-CoV-2 Spread in Nursing Homes, accessed 11/9/21 revealed: *Older adults living in congregate settings are at high risk of being affected by respiratory and other pathogens, such as [CONDITION(S)]-CoV-2. *A strong infection prevention and control (IPC) program is critical to protect both residents and healthcare personnel (HCP). *Even as nursing homes resume normal practices, they must sustain core IPC practices and remain vigilant for [CONDITION(S)]-CoV-2 infection among residents and HCP in order to prevent spread and protect residents and HCP from severe infections, hospitalization s, and death. *Testing: Anyone with even mild symptoms of COVID-19, regardless of vaccination status, should receive a [CONDITION(S)] test as soon as possible. *Asymptomatic HCP [health care personnel] with a higher-risk exposure and residents with close contact with someone with [CONDITION(S)]-CoV-2 infection, regardless of vaccination status, should have a series of two [CONDITION(S)] tests for [CONDITION(S)]-CoV-2 infection. In these situations, testing is recommended immediately (but not earlier than 2 days after the exposure) and, if negative, again 5-7 days after the exposure. Criteria for use of post-exposure prophylaxis are described elsewhere. *Evaluate residents at least daily. *Ask residents to report if they feel feverish or have symptoms consistent with COVID-19 or an acute respiratory infection. *Actively monitor all residents upon admission and at least daily for fever (temperature =100.0°F) and symptoms consistent with COVID-19. Ideally, include an assessment of oxygen saturation via pulse oximetry. If residents have fever or symptoms consistent with COVID-19, implement precautions described in Section: Manage Residents with Suspected or Confirmed [CONDITION(S)]-CoV-2 Infection. *Older adults with [CONDITION(S)]-CoV-2 infection may not show common symptoms such as fever or respiratory symptoms. Less common symptoms can include new or worsening malaise, headache, or new dizziness, nausea, vomiting, diarrhea, loss of taste or smell. Additionally, more than two temperatures >99.0°F might also be a sign of fever in this population. Identification of these symptoms should prompt isolation and further evaluation for [CONDITION(S)]-CoV-2 infection. *Because some of the symptoms are similar, it may be difficult to tell the difference between influenza, COVID-19, and other acute respiratory infections, based on symptoms alone. Consider testing for pathogens other than [CONDITION(S)]-CoV-2 and initiating appropriate infection prevention precautions for symptomatic older adults. *A respirator is a personal protective device that is worn on the face, covers at least the nose and mouth, and is used to reduce the wearer's risk of inhaling hazardous airborne particles (including dust particles and infectious agents), gases, or vapors. Respirators are certified by CDC/NIOSH, including those intended for use in healthcare. B. Based on observation, interview, and policy review, the provider failed to ensure two of two observed RN (F and H) maintained infection control practices during two of two resident dressing changes (1 and 183). Findings include: 1. Observation on 11/15/21 from 9:40 a.m. through 9:56 a.m. of RN F during a dressing change for resident 1 revealed she: *Removed the dressing supplies out of the treatment cart that included: a large amount of gauze 4 X 4's, [MEDICATION(S)] II (alginate dressing), [MEDICATION(S)] Gentle, chux as a barrier, and a small red zippered case with resident 1's name on it. *Placed the other dressings on the overbed table. *Had not sanitized the overbed table or placed a barrier down. The dressings were next to two urinals, one contained urine. *Washed her hands for approximately 10 seconds and put on gloves. *Spread the barrier out on the bed. *Placed the wound cleanser and [MEDICATION(S)] moisturizing cream on the left top corner of the barrier. *Placed the two packages of dressings and gauze 4 X 4's to the right upper side of the barrier. She moved the wound cleaner to the right upper side of the barrier. *Opened the packages that contained the dressings. *Took her pen out of her pocket and put the date on the dressing and put the pen back in her pocket. *Had resident 1 place his feet with shoes on top of the barrier in the middle. *Removed her gloves, moved the garbage can, and then washed her hands for approximately ten seconds. *Answered her walkie talkie that was in the same pocket as her pen. *Removed her gloves and without any hand hygiene she put on a new pair of gloves. *Removed the soiled dressing from the top of his left foot. *Applied skin barrier around the open wound on top of his left foot. *Removed scissors from the red zippered bag, cut a very small piece of the alginate with scissors that were in the red zippered bag. (Had wiped the scissors with wet gauze) *Removed [MEDICATION(S)] cream from the container several times with her same gloved hands and applied it to his feet and legs. *Put his socks and shoes on him. *Returned the red zippered bag to the treatment cart. *She had not sanitized the scissors after she had used them. Interview on 11/15/21 at 10:00 a.m. with RN F revealed: *That was how she always completed his dressing change. *Did not feel resident 1's shoes and socks had contaminated anything, as the supplies were in the corners. *Agreed she had missed some hand hygiene opportunities. 2. Observation on 11/16/21 at 11:20 a.m. of RN H during the wound dressing changes for resident 183 revealed she: *Washed her hands. *Put on clean gloves and laid clean 4x4's on the resident's bed without providing a clean barrier. *Removed dressing from resident's sacral area. *Removed her gloves and washed her hands. *Put on clean gloves and used wound cleanser and 4x4's from resident's bed to cleanse wound. *Removed gloves and washed her hands. *Put on clean gloves and dipped 4x4's from resident's bed in to Vashe wash and packed wound with soaked 4x4's. *She removed her gloves and washed her hands. *Put on clean gloves and removed ace wrap and dressing from resident's left heel. *Left resident's room with gloves on. *Had not removed her gloves and performed hand hygiene. *She returned and cleansed wound to left heel with wound cleanser. *Removed gloves and washed her hands. *Put on clean gloves and applied [MEDICATION(S)] soaked 4x4's to left heel and covered with more 4x4's. *She rewrapped dressing with the dirty ace wrap. Review of the provider's July 2014 Licensed Nurse Competency Dressing, Technique Aseptic revealed: *Provide a clean surface, such as a paper towel, to place treatment supplies in room and a plastic bag for disposal. *Remove soiled dressings and dispose in plastic bag with gloves. *Wash hands if visibly soiled or use gel hand sanitizer if not. *Open dressing supplies, leave in sterile packages, and place on aseptic field. *Apply new gloves. *Perform treatment as ordered. *Date and initial dressing according to Center procedure. *Remove gloves and wash hands if visibly soiled or use gel hand sanitizer. Interview with DNS B would have given an opportunity to review the observations and verify if the dressing changes had been completed in a clean manor to prevent a break in infection control. On 11/18/21 at 9:00 a.m. the survey team had requested ED A and DNS B to meet with the team anytime after 11:00 a.m., to discuss findings. They had not come to discuss as of 11/18/21 at 3:00 p.m. when ED A came and requested the team to leave the building without finishing all survey tasks and interviews or conducting an in person exit interview.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (12 and 183) had received care in a manner to prevent abuse and/or neglect for residents who were dependent on staff to meet their needs. Findings include: Surveyor : 1. Interview on 11/15/21 at 8:30 a.m. with licensed practical nurse (LPN) E revealed she did not have any dressing changes for the surveyors to observe that day. Surveyor : Observation on 11/15/21 at 8:53 a.m. of resident 183 revealed he had: *Been in a hospital gown. *Only had a thin draw sheet covering him. *Been laying on his back. *A phlegmy cough. *His bed lowered to the floor and had a fall mat on the floor, next to his bed. *His catheter bag was on the floor. Observation on 11/15/21 at 10:22 a.m. of resident 183 revealed: *He had been lying on his back. *His catheter bag was still touching the floor. *He had still been wearing a hospital gown. *Only had a thin sheet covering him. *He did not have any food or drinks near him. Observation and interview on 11/15/21 at 1:35 p.m. with resident 183 and registered nurse (RN) D revealed: *She was going to give resident 183 a suppository because Hospice told her to. *Resident 183 was lying in bed, wearing only a disposable brief. *His thin sheet had not been covering him. *His room door was opened, his curtain had been pulled back. *Surveyor asked RN D if resident 183 had clothes. -She was unsure if resident 183 had clothes or where the clothes might be. -She thought they were in the laundry. *RN D stated that his mouth was full of crud. -She used a toothette to moisten his lips. -She had not used the toothette to clean out his mouth. *Surveyor asked who his hospice provider was. -RN D was not quite sure who his hospice provider was. -There was no information about him in their hospice binder. Surveyor : Observation and interview on 11/16/21 at 8:25 a.m. of resident 183 with RN H revealed: *He had many dry patches of skin in his mouth. *His tongue had been dried and cracked. *His lips were dry. *Surveyor asked RN H about observing his dressing changes. She replied, If I get to it, it will be this afternoon. *Dressing change was completed on 11/16/21 at 11:20 a.m. Observation on 11/16/21 at 9:29 a.m. of resident 183 revealed: *His mouth was still dry. *His tongue was still dry and cracked. *He was laying on his back with only a brief on. *His lips were still dry and chapped. Surveyor : Phone interview on 11/16/21 at 8:52 a.m. with hospice RN M about resident 183 revealed: *He had been admitted to Hospice care while he was at the hospital on 11/12/21. *He had been admitted to the facility on [DATE]. *Hospice providers had not seen him in the facility since his admission. *RN M was on her way to the facility to see resident 183. *She stated they received a call from the facility yesterday about holding medications and giving him a suppository for constipation. -They had not received any other calls from the facility regarding resident 183. *She would touch base with the surveyors after she visited with resident 183. Interview on 11/16/21 at 11:30 a.m. with hospice nurse RN M revealed: *She ended up getting eight toothettes of old ground-up food and gunk out of his mouth. *It had appeared that oral care had not been done as he had a lot of ground beef packed in his mouth and he had not been eating recently. *With all the ground meat and gunk she wiped out of his mouth she could understand why he had trouble swallowing. *His mouth was so dry the left side of his lip had split open. *They gave him orange juice which is acidic and would irritate his already sensitive mouth. *He had been on his back when she arrived. *She asked staff about his order to turn and reposition every two hours. -Staff were not sure about the order. *His back had been red from being on it for so long. *In [AGE] years of nursing she had never seen what she determined was such a bad case of neglect from a lack of cares. *Nursing informed her today that he was very restless yesterday, she inquired if they had given him anything. -They gave him one dose of his lorazepam medication. -He can have it every hour. *She had to go over the dressing and wound care orders with RN H. -It had been apparent that she was not aware of the orders. *His dressings had not been changed at all on 11/15/21. *The wound on his sacrum had leaked necrotic fluid through the dressing and to his brief. *She provided education to RN H stating that the dressings were for comfort, it was not for treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] *RN H had changed his dressing with RN M in the room. *He had been in pain while this dressing change was being completed. *The odor was very strong and pungent of necrotic tissues. *RN M inquired about the resident having a blanket and clothes. *He had only been wearing an incontinence brief when she arrived. *RN H had not been aware if he had clothing. *Resident 183's catheter had been wrapped around the bed and pulled super tight at the insertion site. *RN M found out that they had not been giving resident 183 his pain medication as ordered. *His hair appeared greasy and had not appeared to have received a bath. *RN M stated she would call and update his family. *RN M called and received a verbal order for a [MEDICATION(S)] patch for resident 183. -She applied the patch and let RN H know that it would take about 12 hours to start working so they would need to supplement his other pain medication. Interview on 11/16/21 AT 2:02 p.m. with divisional director of clinical operations (DDCO) C, executive director (ED) A, and director of nursing services (DNS) B revealed: *Regarding ensuring residents had clothing to wear: -If a family was admitted without clothes, they have a surplus they can use. -Social services would reach out to the family to see if they could bring in items. -ED A will also buy items if they are unable to obtain any clothes. *As far as ensuring admission assessments are completed: -DNS B states that they do not have a very good admission process. -The nurses are expected to take care of the admission assessments within 24 hours of admission. -Typically, there is a dashboard that pops up in the electronic medical record (EMR) to let them know they need to complete the admission assessment. -DNS B is responsible for ensuring admission assessments are completed. -DNS B admits this process has not been great due to the COVID-19 survey last week and they have had admissions and hospitalization s. *Regarding how hospital orders are implemented into resident's plans of care: -They document in the resident's progress notes. -They follow the hospital admission orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Regarding the newly admitted baseline care plans: -DNS B tried to get them done as soon as possible. -All staff can add to the 48 hour baseline care plan. -DNS B usually trys to talk to the families about the resident's care plans. --She then waits until the families come into the facility to have them sign the baseline care plan. -The care plan is placed in a binder that staff can look at every day. *Regarding communication between shifts: -There is a tape recorder that nurses record shift reports on. -There is a communication binder that is kept at the nurses' station. *Regarding ensuring residents are receiving required cares: -Certified nursing assistants (CNAs) are to be documenting their tasks in the resident's EMR. -Things on the medication administration record (MAR)/ treatment administration record (TAR) is to be completed by nurses. *They have daily monitoring of pain. *They have daily rounds. *If someone were to be restless or agitated, they receive pain medication. *Nurses are supposed to oversee the aides to ensure residents are receiving the care they deserve. *They have mostly all senior nurses on shift. *DNS B believed nurses had been monitoring baths, skin checks, vitals, and blood pressure checks. *CNAs document baths and bed baths in the residents' EMR. *The main bath aide completes the skin checks, baths, vitals, and blood pressures during the resident's baths. *Licensed nurses are supposed to go in to observe the resident's skin while they are receiving their baths. *Oral care, bathing, and dressing was also documented in the residents' EMR. *DDCO C stated if residents are non-compliant, the non-compliance would be documented. *Regarding resident 183, he was already on hospice due to the hospital contacting hospice. *Hospice has always been very quick with getting back to the facility regarding orders. *In order to communicate with hospice, they have a special hospice binder. On 11/16/21 at 2:52 p.m. while surveyor was conducting a staff interview for a separate investigation, the staff member's walkie talkie sounded with a staff member stating resident 183's family member was on the phone and wanted to see how he was doing. RN H said into the walkie talkie, Good, he's been in bed all day. IMMEDIATE JEOPARDY HARM Resident had food debris impacted in his mouth making him unable to take in food or swallow his medications and resulted in a split lip on the left corner of his mouth. The resident exhibited pain with dressing changes, grimacing, groaning, and restlessness. His back was red from being left lying on his back. His catheter was wrapped tightly around the bed and was pulling at the insertion site. Two unstageable wounds had not been treated in 36 hours with a moderate amount of green exudate that leaked through the dressing down to his brief. A strong odor was present. He was noted to only have an incontinent brief on covered by a thin sheet. IMMEDIATE JEOPARDY NOTICE On 11/16/21 at 5:06 p.m. and immediate jeopardy had been determined when the facility failed to ensure: *Physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] -Oral care. -Pain, agitation, and restlessness. -Personal hygiene. -Repositioning. -treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] -Professional standards for other quality of care needs to achieve his highest practicable level of well--being. ED A, DNS B and DDCO C were asked for an immediate removal plan. IMMEDIATE JEOPARDY REMOVAL PLAN: On 11/17/21 at 12:37 p.m. the DDCO C, ED A, and DNS B provided the survey team with an email that included the final written removal plan. The written removal plan was approved by the long-term care advisor for the department of health on 11/17/21 at 12:58 p.m. The facility provided the following acceptable removal plan on 11/17/21: 1. Educate ED and DNS on auditing that physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . The ED/DNS or designee will educate all licensed nurses on the following physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] . documentation of supply in-availability, admission evaluations are completed, pain assessments are completed, recognizing signs/symptoms of pain, ADL cares, catheter care, dressing in regards to dignity, grooming, bed baths, oral care in regards to pocketing of food, catheter care, dressing in regards to dignity, grooming, bed baths, oral care in regards to pocking of food, catheter care and treatment of [MEDICAL RECORD OR PHYSICIAN ORDER] . Educated all nursing staff on turning and repositioning for residents at risk with breakdown. Educate CNA's and NA's on recognize the signs/symptoms of pain, ADL cares, catheter care, dressing with dignity, grooming, bed baths, oral care specifically pocketing of food, and catheter care. Education provided by Divisional Director of Clinical Operations to ED and DNS. They, in turn, will educate all nursing staff prior to their next working shift by 11/16/21 at 11:59 p.m. 2. An audit will be conducted on ensuring preventative measures are in place to prevent skin breakdown on residents with and without wounds, peri-care completed timely and resident is clean and dry residents with incontinence are checked every one to two hours, treatments done as ordered and changed if no improvement in wound noted per provider direction or every 14 days as stated in policy, family notification, physician notification, and dietician notification with assessment and knowledge of staff of who has wounds on their unit, admission evaluations are completed, pain assessments are completed, recognizing signs/symptoms of pain, ADL cares, catheter care, dressing with dignity, grooming, bed baths, repositioning, oral care specifically pocketing of food, catheter care, and knowledge of the report process. The DNS or designee will be responsible for the audits. The audits will be completed 4 times weekly times four weeks, bi-monthly times two months or until substantial compliance is met. 3. Compliance date 11/16/2021. The immediate jeopardy had been removed on 11/18/21 at 3:00 p.m. after verification that the provider had implemented their removal plan. After removal of the Immediate Jeopardy, the scope/severity of this citation is level G. Review of resident 183's nursing notes in his EMR revealed: *He arrived at the facility on 11/12/21 at 2:45 p.m. via ambulance. -He was documented to be in pain from the ride to the facility. *He was administered pain and anxiety medication seven hours later at 11/12/21 at 9:49 p.m. *On 11/12/21 at 10:23 p.m. documentation reflected: -He had eaten 15 percent of his supper. -He was pocketing his food. *On 11/13/21 at 3:31 p.m. and 3:32 p.m. he received medication for pain and axiety. *On 11/13/21 at 11:39 p.m. documentation reflected he had taken a few bites Refuses his meals & he pocketed . *On 11/15/21 documentation reflected he was to be repositioned and given some good skin care. *There had been no documentation of communication with hospice or phone calls to hospice. Review of resident 183's November 2021 MAR revealed he had orders for 19 medications for pain, anxiety, cramping, and constipation. *The Wong- Baker pain assessment had not been added to his MAR. Review of resident 183's hospital documentation revealed: *He had been admitted to the hospital on 11/6/21. *The physician documented: - .admitted for 2 decubitus ulcers one on his sacrum as well as one on his left heel both which are unstageable. Based on the size and degree of the ulcers this is likely been going on for sometime and he is likely receiving suboptimal care at his facility . *He also had: *Deep vein [CONDITION(S)] (DVT). *Acute Kidney Injury. *Cellulitis infection surrounding the sacrum ulcer. *On 11/9/21 the hospital debrided the sacrum ulcer and heel ulcer. *On 11/9/21 the physician spoke with resident 183's family member and they opted to go comfort cares/palliative care. *The family member had to find a new facility, and had not wanted to send him back to the facility he was at previously. *They found placement and discharged him to new facility on 11/12/21. *They noted that he would be transported by ambulance because trying to transport him in a car would put too much pressure on his sacrum ulcer and would be exceptionally painful. Review of resident 183's discharge orders revealed: *He was to receive: -Sacrum: Packing/Dressing, change twice daily. Remove previous dressing, cleanse with wound spray and gauze. Pack wound cavity and cover entire wound with Vashe-moistened gauze. Cover with ABD [army battle dressing] and secure with [MEDICATION(S)] tape. -Turn and reposition Q2-4H [every 2 to 4 hours] as tolerated by patient. Apply isogel air mattress with pump. Apply chair cushion if up to chair. -Left heel: Dressing change daily. Apply [MEDICATION(S)]-soaked gauze over left heel wound, then cover with loosely rolled on kerlix or roll gauze and loosely applied ACE wrap. Offload heels at all times. Review of resident 183's admission assessment revealed: *His 11/12/21 at 2:45 p.m. admission assessment vitals had been documented. *The remaining 13 pages were blank. *As of 11/16/21 at 12:16 p.m., his admission assessment had not been completed. Review of resident 183's November TAR revealed: *Turning and repositioning was not listed for staff to complete. *He had not received any dressing changes on 11/15/21 to his heel or to his sacrum ulcer. Review of resident 183's bathing documentation revealed as of 11/16/21 at 12:31 p.m. no baths had been documented. Review of resident 183's EMR revealed turning and repostioning had not been added so staff could ensure that resident 183 had been turned and repositioned every two to four hours. Phone interview on 11/17/21 at 1:25 p.m. with resident 183's power of attorney (POA) revealed: *His grandfather (resident 183) had been transferred to the facility on [DATE]. -This had been after they found out he was not receiving adequate care at another facility. *He said he was stuck between a rock and a hard place and had to pick a new skilled nursing facility for his grandfather to live. *He saw his grandfather on Saturday 11/13/21. -He was sitting up in bed, eating beef pot roast or beef roast or beef pot pie. *His grandfather had not been wearing any clothes so he and his wife ran to the store to buy him three shirts and three pairs of pants. *He calls the facility every day, if not twice per day. -He verified he called on 11/16/21 around 2:45 p.m., and was told everything was good. *He received a call from the hospice provider yesterday to update him. *The facility called him today to let him know his grandfather was declining so he was on his way to the facility during the phone interview. Surveyor reached out to medical director HH. He was unavailable for a phone interview. Review of the provider's Admission/Readmission Nursing Evaluation form for resident 183 revealed document that consisted of 14 pages that when completed was a head-to-toe assessment and multiple body system review. The only area that had been completed for resident 183 was a portion of the general assessment that included the resident's vitals, the remain 13 pages had not been completed. Review of the provider's June 2016 Pain Management policy revealed: *Residents' pain level is evaluated every shift by the LN [licensed nurse]. Noted pain is evaluated and treated accordingly by the LN. Pain is also evaluated quarterly and PRN [as needed]using the RAI [resident assessment instrument]/nursing process. Pain level is monitored and documented on the MAR using the Wong-Baker pain scale. *When pain is not adequately controlled by current regimen, or if there is newly identified pain, the LN contacts the physician for consideration of new or modified treatment orders. *The information on the Pain Evaluation Record is used in conjunction with the Center's other evaluation and data collection tools to develop an individualized care plan, including non-pharmaceutical interventions, if appropriate. *If the resident is a hospice client or receiving palliative care/comfort care, the LN and hospice personnel collaborate to develop and evaluate the pain management Plan of Care (POC). Review of the provider's September 2017 Hospice Provision of Care by Outside Providers policy revealed: *Centers collaborate with outside providers to coordinate the provision of hospice care as directed by each resident's physician. *The hospice and Center communicate, establish, and agree upon a coordinated Plan of Care (POC) reflecting the hospice philosophy and based on an evaluation of the individualized needs of the resident. The POC includes: directives for managing pain and other uncomfortable symptoms, the care and services the Center and hospice provide in order to be responsive to the unique needs of the resident and his/her expressed desire for hospice care. The hospice retains overall professional management responsibilities directing the implementation of the POC related to the terminal illness and associated conditions. The POC is updated quarterly and as needed. *The Center offers the same services to residents who have elected hospice benefits as to residents who have not elected hospice benefits. Residents have the right to refuse hospice services. *Prior to admission of a resident receiving hospice services by an outside provider, service coordination is agreed upon indicating each party's responsibilities. This may include, but is not limited to: medications, DME, laboratory services, and notifying physicians. *The Center immediately notifies hospice of all allegations of: a. Mistreatment. b. Neglect. c. Verbal, mental, physical, or sexual abuse. d. Injury of unknown origin. e. Misappropriation of property by hospice personnel. f. Exploitation. Review of the provider's 10/19/18 hospice agreement with the hospice provider revealed: *WHEREAS, The Facility desires to assure that the highest quality and level of services are provided to such individuals with respect to the care and management of their terminal illness. *The facility shall furnish to the individual who is both a resident of The Facility and a Hospice client all of those services which normally would have provided in the absence of The Hospice Program, as provided for in The Facility policies, procedures, protocols, and agreements with the resident and the resident's family. It is understood and agreed that because of the eligible resident's place of residence is The Facility, The Facility shall provide those services which approximate the kind of services which would have been provided by family members. *With respect to the management of the resident's terminal illness, The Facility shall: -1. Notify The Hospice in the event of changes in the resident's condition; and -2. Provide usual and customary services of The Facility subject to The Hospice Plan of Care for such a resident including: Performing personal care services, Assisting with ADL [activities of daily living], Administering medication, Socializing activities, Maintaining the cleanliness of the resident's room, Supervising and assisting with the use of DME[durable medical equipment] and prescribed therapies. -3. Make records pertaining to care and services furnished by The Facility to a Hospice client available to The Hospice subject to the resident/client's consent. Review of the provider's September 2017 Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, Misappropriation of Resident's Property, and Exploitation policy revealed: *Each resident has the right to be free from abuse, including verbal, mental, sexual, or physical abuse, corporal punishment, involuntary seclusion, mistreatment, neglect, misappropriation of resident property, exploitation, and any physical or chemical restraint not required to treat the resident's medical condition. The Center implements policies and processes so that residents are not subjected to abuse by staff, other residents, volunteers, consultants, family members, and others who may have unsupervised access to residents. These policies address screening, training, prevention, identification, investigation, protection, and reporting/response. *Deprivation of Goods or Services by Staff: The deprivation by staff of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. In these cases, staff has the knowledge and ability to provide care and services, but choose not to do it, or acknowledge the request for assistance from a resident(s), which result in care deficits to a resident. *Neglect: Failure of the Center, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *Mental abuse: The use of verbal or non verbal conduct which causes or has the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. It includes but is not limited to, coercion, harassment, inappropriately isolating a vulnerable adult from family, friends, or regular activity, and verbal assault that includes ridiculing, yelling, or swearing. Examples of verbal or nonverbal conduct that can cause mental abuse, include but are not limited to, staff taking photographs or recordings of residents that are demeaning or humiliating using any type of equipment (e.g. cameras, smart phones, and other electronic devices) and keeping or distributing them through multimedia messages or on social media networks. *Verbal Abuse: May be considered to be a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communications, or sounds, to residents within hearing distance, regardless of age, ability to comprehend or disability. Examples of mental and verbal abuse include, but are not limited to: Harassing a resident; Mocking, insulting, ridiculing; Yelling or hovering over a resident, with the intent to intimidate; Threatening residents, including but not limited to depriving a resident of care or withholding a resident from contact with family and friends; and isolating a resident from social interaction or activities. 2. Interview on 11/16/21 at 8:20 a.m. with resident 12 regarding her insulin administration and interaction with nurses revealed: *She stated that she had to argue with nursing staff to get her blood sugar and insulin given at the right time. *She had been experiencing shaking when her insulin was given at 8:30 a.m., 12:30 p.m. and 4:30 p.m. *Staff had not rechecked her blood sugar. *Mealtimes were: -7:00 a.m. continental breakfast (juice and a muffin). -10:00 a.m. breakfast. -1:00 p.m. lunch. -5:00 p.m. supper. -8:00 p.m. evening snack. *She spoke with nursing about her shaking and how she should not be given her insulin 1 hour before meal times. *She stated staff were rude and upset with her when she refused to let them administer insulin too early. *Staff would make remarks about her snacking and her blood sugar being elevated. Interview on 11/16/21 with licensed practical nurse (LPN) E revealed: *Had been a been a nurse for [AGE] years. *Received yearly training on medication administration and insulin. *Had not received any advanced diabetic education. *Had not received any customer service training and thought that referring to residents as customers was a cold term. Review of 9/12/21 at 7:55 a.m. nursing progress note for resident 12 composed by LPN E revealed: *Resident's blood sugar was 234. *She had a lot of regular coke on her bedside stand. *Was instructed she should drink diet coke. *She was instructed to watch what kind of snacks such as crackers which are full of carbohydrates. *Resident was already aware of this information. Review of 11/5/21 at 1:15 p.m. nursing progress note for resident 12 composed by LPN E revealed: *Resident was in her wheelchair by the nurses desk. *Acknowledged LPN E coming with the charge cart. *Informed LPN E she was not going to eat and did not need that. *Her husband was there and she was going out to smoke. *Informed resident that she should make her diabetes the priority instead of smoking, and skipping meals and insulin was not a good idea. *Resident wheeled by with no comment. Review of resident 12's care plan initiated on 9/22/21 revealed: *I have inappropriate snacks in my room and have been educated about correct. *I prefer to continue to eat my snacks. Review of providers Abuse Policy dated September 2017 revealed: *Mental abuse is the use of verbal and nonverbal conduct which causes or the potential to cause the resident to experience humiliation, intimidation, fear, shame, agitation, or degradation. *Verbal abuse is a type of mental abuse. Verbal abuse includes the use of oral, written, or gestured communication, or sounds, to residents within hearing distance. On 11/18/21 at 9:00 a.m. the survey team had requested executive director (ED) A and director of nursing services (DNS) B to meet with the team anytime after 11:00 a.m., to discuss findings. They had not come to discuss as of 11/18/21 at 3:00 p.m. when ED A came and requested the team to leave the building without finishing all survey tasks and interviews or conducting an in person exit interview. Interview with DNS B would have included: *How staff were expected to communicate with residents who make questionable choices about their health conditions. *What actions she would take regarding the manner in which LPN E interacted with resident 12.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (12) had not experienced adverse effects from insulin administered at the incorrect time. Findings include: 1. Interview on 11/15/21 at 8:25 a.m. with resident 12 revealed: *She had been in the facility since May of 2021 for physical and occupational therapy. *She had been an insulin dependent diabetic for years. *She received Novolog 15 unit insulin subcutaneously scheduled for breakfast, lunch, and supper. *She also received sliding scale Novolog 3 times per day with meals depending on blood sugar. *She would start shaking from her blood sugar being low. *Staff did not recheck her blood sugar when she was shaking. *She would eat something to help with her shaking due to her low blood sugar. Interview on 11/15/21 at 1:30 p.m. with resident 12's husband revealed: *His wife was having issues with low blood sugars. *Nurses would give her insulin at 8:30 a.m. and then she did not eat until 10:00 a.m. *She had to see her endocrinologist to get an order to administer her Novolog insulin 15 minutes before meals. *She had her blood sugar checked four times per day. *Insulin was scheduled for 9:00 a.m., 12:00 p.m., 5:00 p.m., and 9:00 p.m. Interview on 11/16/21 at 8:20 a.m. with resident 12 regarding her insulin administration and interaction with nurses revealed: *She had to argue with nursing staff to get her blood sugar and insulin given at the right time. *She had been experiencing shaking when her insulin was given at 8:30 a.m., 12:30 p.m. and 4:30 p.m. *Mealtimes were: -7:00 a.m. continental breakfast (juice and a muffin) -10:00 a.m. breakfast -1:00 p.m. lunch -5:00 p.m. supper -8:00 p.m. evening snack *She spoke with nursing about her shaking and how she should not be given her insulin 1 hour before mealtimes. *She stated staff were rude and upset with her when she refused to let them administer insulin too early. *Staff would make remarks about her snacking and her blood sugar being elevated. Interview on 11/16/21 at 8:27 a.m. with registered nurse (RN) H revealed: *She used the treatment administration record (TAR) scheduled times to check blood sugar and administer sliding scale insulin. *She checked resident's blood sugars then would administer insulin. *She tried to give insulin within half hour of meal. *She would reference the provider's insulin policy for administration of certain types of insulin. Telephone interview on 11/17/21 at 12:25 p.m. with certified nurse practitioner N revealed: *She had seen resident 12 on 10/21/21 regarding her insulin dosage. *She had increased her Novolog insulin and instructed insulin to be administered 15 minutes before meals. *She requested the provider to fax resident 12's blood sugars for the next two weeks after the insulin dose had been increased. *She had not received any information since resident's clinic visit on 10/21/21. Surveyor: Interview on 11/18/21 at 11:43 a.m. with licensed practical nurse E revealed: *Resident 12 did not want her insulin until her food was in front of her. *Resident 12 had gone to her physician and received an order not to administer her insulin sooner than fifteen minutes before eating. *Resident 12 received Novolog insulin. *She was not aware of the peak times for different types of insulin. *She stated I need to know that? Surveyor: Review of resident 12's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *In October 2021, the insulin was administered at the incorrect time 89 out of 164 administration times. *On 11/1/21-11/18/21, the insulin was administered at the incorrect time 46 out of 89 administration times. Review of the provider's September 2014 insulin administration policy revealed rapid acting insulin onset 10-15 minutes of administration, peak half hour to three hours and duration is three to six hours. On 11/18/21 at 9:00 a.m. the survey team had requested executive director (ED) A and director of nursing services B to meet with the team anytime after 11:00 a.m., to discuss findings. They had not come to discuss as of 11/18/21 at 3:00 p.m. when ED A came and requested the team to leave the building without finishing all survey tasks and interviews or conducting an in person exit interview.

Based on observation, interview, record review, and policy review, the provider failed to maintain dignity for four of four sampled residents (4, 17, 22, and 183). Findings include: 1. Observation on 11/9/21 at 11:00 a.m regarding resident 22 revealed: *Her pants were soiled. *She was walking with her walker down the hallway crying. *Staff encouraging her to keep walking to her room. *Staff did not drape anything around her or walk behind her to cover her soiled pants. Record review of resident 22's care plan revealed: *I tend to be a Hypochondriac. *I often think I have chest pain. *I am taking antianxiety/antipsychotic/antidepressant medication for anxiety, depression and [CONDITION(S)]. *Resident 22 did not have a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Observation and interview on 11/15/21 at 8:42 a.m. with licensed practical nurse (LPN) E and resident 4 revealed: *LPN E was completing medication pass outside of resident 4's door. *Resident 4 was asking for help locating her drink. *LPN replied to resident 4 by stating, It's right in front of you [resident 4's first name]. Review of resident 4's electronic medical record revealed resident 4: *Was legally blind. *Had a [NAME] Bonnet syndrome, which causes a person to have hallucinations or see things that were not real. 3. Observations made throughout the survey of resident 183 revealed he had been lying in bed without a brief on. Refer to F600, finding 1. 4. Observation on 11/15/21 at 10:37 a.m. of resident 17 revealed: *She was sitting on the edge of the bed in her room, leaning to her right side with her pants down around knees, exposing her incontinent brief and skin on her upper thighs. *The privacy curtain was not pulled and the room door was open, which provided a clear view of the resident through the doorway from the hallway. At 10:40 a.m., certified nursing assistant (CNA) O wheeled resident 17's roommate in her wheelchair into the room. CNA O turned her head to observe resident 17 but continued to assist her roommate. CNA O had no interaction or acknowledgement of resident 17 and left the room while resident 17 remained sitting on the edge of her bed with her slacks down around knees. Review of resident 17's electronic medical record revealed: *On the 10/25/21 quarterly minimum data set (MDS) assessment, her cognitive status was scored as moderately impaired. *Her 11/15/21 care plan identified bladder incontinence, incontinent brief use, and the need for staff assistance with incontinence and clothing change. On 11/18/21 at 9:00 am., administrator A was requested to provide a copy of the provider's policy on dignity. Administrator A replied at 1:46 p.m. that there was no provider policy as dignity was a standard of practice. On 11/18/21 at 9:00 a.m. the survey team had requested executive director (ED) A and director of nursing services (DNS) B to meet with the team any time after 11:00 a.m., to discuss findings. They had not come to discuss as of 11/18/21 at 3:00 p.m., when ED A came and requested the team to leave the building without completing all survey tasks and interviews or conducting an in person exit interview.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (28 and 182) with facility acquired pressure ulcers received care, on-going assessments, and interventions to prevent wounds from worsening. Findings include: 1. Phone interview on 11/15/21 at 3:40 p.m. with resident 182's representative revealed: *Resident 182 had informed her that he had many sores on his bottom. *The facility had never called to let her know that he had sores on his bottom. *He has also lost both of his lower legs due to sores. Review of resident 182's electronic medical record (EMR) revealed: *He had been admitted to the facility 12/8/20. *His diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Type II Diabetes. -[CONDITION(S)]. -Dependence on [CONDITION(S)]. -Chronic Lymphocytic [CONDITION(S)]. *When he was admitted he had half of a right foot, and had been missing two toes on his left foot. -He had a wound vacuum (vac) applied to his right foot. *He had many various ulcers on his feet and legs throughout his stay at the facility. *On of the areas he developed at the facility was a skin tear to his right heel. *He ended up having a right below the knee amputation because of the right heel wound. Review of resident 182's nursing progress notes revealed: *He had an open spot to his right heel. -This had been caused when the nurse removed the tape to his wound vac and it caused a skin tear. *On 7/16/21, the physician had been notified: -The area around the skin tear has developed a darkened bruise like area. -There was serosanguinous (blood and liquid) drainage and the skin tear had a black scab. -Nursing had asked to treat with [MEDICATION(S)] to the wound bed, hydrogel gauze, cover with oil [MEDICATION(S)], cover with Opti-foam and change three times per week with the wound vac changes. *On 7/20/21 a wound consultant recommended using calcium alginate silver and negative pressure dressings. *On 7/27/21 the order was changed to [MEDICATION(S)] to the wound daily. *7/30/21 through 8/10/21 he was in the hospital for [CONDITION(S)]. *He had new orders on 8/17/21 to change dressing to right heel every day, apply calcium alginate silver and secure with kerlix. *He was out of the facility from 9/14/21 to 9/23/21 due to having a left below knee amputation. *On 9/30/21 he returned from an appointment with his orthopedic doctor with orders to: - .Paint right heel with [MEDICATION(S)] twice daily, and cover with gauze. *On 10/19/21 there was a note for him to continue to [MEDICATION(S)] treatments. Review of resident 182's wound assessments revealed: *The wound was noted to be an in-house acquired skin tear on 6/19/21. *The first wound assessment was not completed until 7/15/21. *On 7/15/21 the wound was: -12.3 centimeters squared (cm2) by (x) 4.6 centimeters (cm) x 3.7 cm. -Marked as healable. -being treated with generic wound cleanser and a compression wrap. *On 7/15/21 there was not documentation that the provider had been informed. *On 7/22/21 the wound was: -9.6 cm2 x 3.9 cm x 3.4 cm. -treatments and interventions the same as the 7/15/21 assessment. *On 7/29/21 the wound was: -11 cm2 x 3.6 cm x 4.2 cm -Marked as healing not achievable. *He was in the hospital until. 8/10/21. *On 8/10/21 the wound was: -26.1 cm2 x 6.9 cm x 5.2 cm. -Being cleaned with Iodine. -Had now been changed from a skin tear to a diabetic ulcer. *His next wound assessment was on 8/24/21 the wound was: -35.2 cm2 x 7.8 cm x 6.5 cm. -Being cleaned with generic wound cleanser and calcium alginate dressing. -Had now been changed from a diabetic ulcer to a venous ulcer. *On 8/31/21 the wound was: -32.7 cm2 x 9.2 cm x 5.7 cm. -Being cleaned with generic wound cleanser *On the 8/31/21 assessment there is a note that mentions: -The resident was being seen by infectious disease for wounds as well as wound care for treatment plan. The current treatment was paint eschar with [MEDICATION(S)] and cover with kerlix. *On 9/8/21 the wound was: -24.0 cm2 x 7.7 cm x 4.1 cm. -Being treated with generic wound cleanser and calcium alginate dressing. *The next wound assessment was on 10/1/21: *The wound was now: -61.3 cm2 x 10.1 cm x 7.8 cm. -Marked as improving. *Many of his wound documentation had not been marked for physician or power of attorney (POA) notification. Review of resident 182's medication administration record (MAR) and treatment administration records (TAR) revealed: *There had been many gaps with treatments related to resident 182's wounds. *In august 2021 he had not received 5 out of 15 dressing changes for his right heel. *He did not receive one out of three weekly skin audits. *In September 2021: -There had been no weekly skin audits documented on the MAR/TAR -There had missing documentation for offloading of heels, wound vac therapy. -Many gaps in applying skin protectant to buttocks. *In October 2021: -He missed three treatments to his right heel. -Painting the area twice daily with [MEDICATION(S)] had never been added to the MAR/TAR as the orthopedic doctor ordered. Review of resident 182's [CONDITION(S)] communication forms revealed: *On 10/4/21 the [CONDITION(S)] unit notified the long term care provider that: -Resident 182 had arrived at [CONDITION(S)] with a saturated dressing that was falling off. His heel had been actively bleeding as well. -The [CONDITION(S)] unit secured that dressing with a chux pad and Coban dressing so the nursing home staff could address the wound as ordered. *On 9/29/21 his right heel had been bleeding through his dressing upon arrive to the [CONDITION(S)] unit. *On 6/18/21 his would vac began beeping low battery and there was not a charge cord sent with the unit so it ended up shutting down. *The [CONDITION(S)] unit noted that he had a central line dressing that had not been changed in month, they had inquired about the status of this as it was not something that they were using. *On 1/1/21 the wound vac began beeping low battery a few hours after he arrive to the [CONDITION(S)] unit, the pump ended up shutting down because of the low battery. 2. Review of resident 28's skin and wound evaluations revealed: *On 11/11/21: -He had a blister on his right heel. -It has been listed as present on admission, which was 10/14/21. -It measured 2.1 centimeters (cm) long by 2.2 cm wide. -The dietician and therapist had been notified. -There was no indication the physician had been notified. -Interventions included: compression, cushion, foam mattress, incontinence management, mobility aide, moisture barrier, moisture control, repositioning device, and other. -It did not include any interventions to protect his heel. *On 11/17/21: -He continued with a blister to his right heel. -It measured 2.5 cm long by 2.4 cm wide. -It was described as a serum filled blister. -The dressing was intact, cleansing solution was listed as soap and water, and generic wound cleanser. -Primary dressing was listed as other. -New interventions since the 11/11/21 assessment included customized shoe wear. -Progress was listed as deteriorating. -Nursing note: Area is softer to the touch than last week. Area is intact with no redness or drainage noted. Review of resident 28's 10/14/21 admission - readmission nursing evaluation revealed it had not been completed. The only section with documentation was his vital signs. Those had all been from 10/8/21 when he had been transferred to the hospital. Review of resident 28's interdisciplinary (IDT) progress notes revealed on; *10/14/21 at 2:45 p.m. he had returned to the facility. *10/14/21 at 10:23 p.m. his great left and right toes were red. *10/15/21 at 1:24 p.m. his right heel was blistered and spongy. Skin prep and a gripper sock was applied. *10/18/21 at 11:03 a.m. he had a right heel had an intact blister. Skin prep was applied per treatment order. *10/28/21 at 1:42 p.m. he had a right heel blister. *11/8/21 at 10:27 a.m. applying skin prep to L [left] heel -area dry, dark in color, no drainage, denies pain to touch. The assessment completed at 11:12 p.m. stated he had no open skin areas. *Review of the other IDT progress notes from 10/14/21 through 11/15/21 revealed twenty-nine out of the thirty-three days there had been no documentation regarding his right heel blister. Observation and interview on 11/18/21 at 9:37 a.m. of resident 28's right heal with registered nurse (RN) D revealed a closed deflated blister with dry edges at the top. RN D applied skin prep to the blister. He did not wear any special shoes. He wore diabetic socks instead of the anti-embolism stockings he was to have worn. She was worried when the anti-embolism stockings were put on the blister would be opened. Continued interview on 11/18/21 at 9:37 a.m. with RN D revealed she: *Was the designated skin and wound nurse. *Had been absent from work between 8/15/21 and 11/11/21. *Found out about the blister and did the measurements on 11/11/21. *In her absence director of nursing service (DNS) B was to have covered the completion and documentation of any skin concerns. Review of resident 28's current care plan revealed it had not been updated with his right heel blister and any interventions that were in place. Interview on 11/18/21 at 12:33 p.m. with minimum data set (MDS) coordinator I confirmed his right heel pressure injury had not been added to his care plan. Review of the provider's May 2019 Skin Integrity policy revealed the following: *The center had a systematic approach and monitoring process for evaluating and documenting skin integrity. *Care was to have provided interventions to treat, heal, and prevent, if possible, and prevent the further development of skin ulcers/pressure ulcers/wounds. *Skin evaluations were to have continued on a weekly basis. *For skin impairment identified when admitted or after admission the following should have been completed including: -Skin impairments would have included measurements of size, color, presence of odor, exudates, and presence of pain associated with the skin impairment in Nurse's Notes and on the Weekly Wound Evaluation. -The physician would have been notified and orders for treatment received. -Interventions would have been initiated. -The registered dietitian would have been notified for a nutritional needs evaluation. -The DNS and/or designee would have completed a comprehensive review of the resident's medical record to evaluate if the pressure ulcer was avoidable or unavoidable. *All wounds were to have been evaluated weekly. Interview with director of nursing services B would have inquired about implementation of the above policy. On 11/18/21 at 9:00 a.m. the survey team had requested executive director (ED) A and DNS B to meet with the team any time after 11:00 a.m., to discuss findings. They had not come to discuss as of 11/18/21 at 3:00 p.m., when ED A came and requested the team to leave the building without completing all survey tasks and interviews or conducting an in person exit interview.

Based on observation, interview, and record review, the provider failed to ensure residents received treatment and care in accordance with professional standards of practice to: *Ensure two of two residents (12 and 183) were free from abuse and neglect. Refer to F600. *Ensure a comprehensive skin care program had been followed to the prevent the development of skin ulcers for three of three residents (28, 37, and 182). Refer to F686 for residents 28 and 182. *Perform cardio-pulmonary resuscitation (CPR) for one of one resident (185) who had an advance directive requesting CPR. *Ensure one of one resident (20) was safe from accident hazards. Refer to F689. *Ensure one of one resident (182) who was receiving [CONDITION(S)] had consistent communication and collaboration of care. Refer to F698. *Ensure staff followed precautions to prevent the potential for spreading COVID 19 and other illnesses to all residents. Refer to F880. *Conduct routine COVID 19 testing for residents and staff to identify the presence of symptoms putting all residents at risk. Refer to F886. Findings include: 1. Interview on [DATE] at 4:24 p.m. with resident 37 revealed he: *Developed an open sore on his heel that he did not know he had. *A nursing assistant discovered it. *The staff are supposed to check his skin but, I don't think they are. *Felt the meals provided limited options of food he wanted to eat. He had not had fried chicken or steak in a long time and asked for it to be added to the menu. Review of the [DATE] annual minimum data set (MDS) assessment in the electronic medical record (EMR) for resident 37 revealed he: *Had no difficulties with cognitive function or communication. *Needed supervision of one staff for moving about in bed. *Was coded as not at risk for developing pressure ulcers and had no current pressure, venous, or arterial ulcers. Review of the weekly skin and wound evaluations revealed two evaluations during the assessment window for the [DATE] MDS noted a wound that should have been coded on the MDS as a pressure ulcer and/or a venous ulcer. (Refer also to F636, finding 3.) Review of the Pressure Ulcer/Injury care area assessment (CAA) worksheet completed on [DATE] revealed: *This condition triggered due to assist needed with bed mobility. *Extrinsic risk factors had just pressure and special mattress. *Other factors that were not automatically selected based on the coding of the MDS were not checked. *There was no note to evaluate the effectiveness of supervision with bed mobility to prevent ulcers. (Refer also to F636, finding 3.) Review of the resident 37's current care plan revealed the following focuses and interventions: *History of venous stasis ulcers on his legs and feet, revised on [DATE] with an added statement dated [DATE], I have a venous ulcer on my lateral aspect of R) [ right] foot and an intervention to provide snacks and extra one oz [ounce] protein with meals to help with healing, initiated on [DATE] and revised on [DATE]. -[CONDITION(S)] (PVD), initiated on [DATE] and revised on [DATE], with and intervention that did not specify how to monitor/document/report PRN (as needed) any s/sx (signs/symptoms) of skin problems, initiated [DATE] and revised on [DATE]. *Hygiene/ADL's/Skin, initiated on [DATE] with an intervention initiated on [DATE] and revised on [DATE] directing the cleaning and trimming of nails after baths, but does not address monitoring of skin condition. (Refer also to F656, finding 3.) Review of the quarterly MDS dated [DATE] revealed no changes in resident 37's cognitive or physical function, but one venous ulcer was coded as present. Review of weekly skin and wound evaluations revealed the progress of the venous ulcer noted on the care plan: *On [DATE], a new venous ulcer identified to the right side of his foot, measuring 7.3 centimeters (cm) by 4.1 cm by 2.3 cm with eschar (dark scab), a light amount of purulent (thick yellow) drainage that was faintly odorous. The physician and dietitian were notified. *On [DATE], the ulcer measured 8 cm by 2.7 cm by 4.1 cm with 10% (percent) of the wound bed with slough and 90% with eschar, and a moderate amount of purulent drainage. *On [DATE], the ulcer measured 6.4 cm by 2.5 cm by 3.1 cm with 90% slough and 10% granulation (red connective tissue) in the wound bed and a moderate amount of purulent drainage with no odor. *On [DATE], the ulcer measured 6.6 cm, by 2.5 cm by 3 cm, with 50% granulation (red connective tissue) and 50% slough, serosanguineous (watery light red) drainage with no odor. Review of a nursing progress note dated [DATE], related to the quarterly MDS dated [DATE], written by MDS coordinator I revealed: *The resident needed supervision of one person to be reminded and assisted to reposition in bed. *Had a vascular ulcer to his right foot. Review of nutrition/dietary notes written by registered dietitian (RD) EE revealed: *On [DATE], the resident appears to not be motivated to eat or come out to meals, and told RD EE that he does not want to and food is not good. *On [DATE], The wound nurse says the new vascular ulcer to right side of the resident's foot is healable. -The resident takes in ,d+[DATE]% of regular food. -RD EE recommended magic cup at dinner to provide 30 calories and 9 grams of protein. *On [DATE], The resident was noted as no longer coming out of his room for meals and not eating them in his room. Weight loss is continuing. -The resident refused Cal Dense Med Pass last month so it was discontinued. -RD EE talked with resident but would not answer why he has not been coming out (for meals) or why he has been eating less. -The resident agreed with receiving chocolate i.e. cream shake with protein powder to give 600 calories and 18 grams of protein. *On [DATE], RD EE asked resident about the ice cream shake and resident 37 said he has not been getting it. Educated dietary staff about making and providing this every day at 3:00 p.m. Review of treatment administration records revealed a weekly skin audit was to be documented every Tuesday with a plus (+) sign denoting a new skin impairment and a minus (-) for no new impairment. *In [DATE], there were - signs on every Tuesday except [DATE] had a + sign. *In [DATE], there were - on every Tuesday. *In [DATE], every Tuesday had - except on [DATE] the field was blank, the skin audit was not done. *In [DATE], every Tuesday's fields were blank. *In [DATE], the timing for the skin audit changed from 11 am to D 6-, and the coding changed to Yes and No instead of + and - signs. -,d+[DATE] was marked as NA. -,d+[DATE] was marked with a +. -,d+[DATE] was marked as NO. -,d+[DATE] was left blank. *In [DATE], -,d+[DATE] was marked as X. -,d+[DATE] and ,d+[DATE] were marked a n. 3. Review of closed EMR and paper record for resident 185 revealed: *He had passed away in the facility. *He had a signed advance directive dated [DATE] that stated he wanted limited treatment but still wanted to receive CPR. *His documentation had not revealed any CPR had been performed. *There was not another advance directive in his paper or electronic record. Interview with the director of nursing services (DNS) B would have inquired about: *The skin care system to monitor for the development of wounds. *The system for auditing the accuracy of assessment and TAR documentation. *The reason CPR was not performed on resident 185. On [DATE] at 9:00 a.m. the survey team had requested executive director (ED) A and DNS B to meet with the team any time after 11:00 a.m. to discuss findings. They had not come to discuss as of [DATE] at 3:00 p.m., when ED A came and requested the team to leave the building without completing all survey tasks and interviews or conducting an in person exit interview.

Based on observation, record review, interview, manufacturer's instructions review, and policy review, the provider failed to provide the necessary care and services for one of one sampled resident (1) with chronic venous stasis wounds to his lower legs and feet who required hospitalization [MEDICAL CONDITION] and maggot infestation related to: *Not following physician's orders for treatment. *Incomplete documentation regarding the status of his wounds and his refusals for care. *Inappropriate infection prevention for his skin and facility processes for: -Pest control -Garbage disposal. -Sanitation. Findings include: 1. Review of resident 1's medical record revealed:*He had originally been admitted in 2013. *He was alert and oriented with no memory problems. *His [DIAGNOSES REDACTED]. *He required extensive assistance from staff for personal hygiene and transfers. -He utilized a stand lift for transfers and a wheelchair for mobility. *He had chronic wounds on his lower legs and feet for the last few years. *On 3/30/18 he was seen by the physician and received orders to: -Cont. (continue) current tx (treatment) of feet but dressing changes daily in AM. Appt. with wound specialist . *On 3/30/18 the facility faxed the physician to clarify which wound specialist he should see. -On 4/2/18 the physician responded whoever you have that does wound/feet care either in house or via telemed. *There were no wound specialist notes or orders until he was seen on 5/14/18 in another town. -That was almost a month and a half later. *On 5/14/18 the wound consultant report indicated to: -Discontinue the Dakin's solution cleanses. -Complete a specific treatment to his toes and between his toes daily and as needed. -Continue his bilateral Unna Boots with zinc twice weekly. Cover them with self adhesive wrap. *On 5/18/18 he was hospitalized related to: -[MEDICAL CONDITION] due to beta [DIAGNOSES REDACTED] streptococcus. -[MEDICAL CONDITION] of his right lower leg. -Acute kidney injury. *He returned on 5/29/18 and was on skilled services for therapies and wound care. -He received intravenous antibiotics daily through 6/8/18. *On 6/5/18 there was a physician's order for the Unna boots bilaterally to be changed twice a week. -There were no other order changes related to his skin treatments until he was hospitalized again on 7/18/18 [MEDICAL CONDITION] and maggot infestation. *He was re-admitted on [DATE] with [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Acute kidney injury. -Open leg wound. -Peripheral [MEDICAL CONDITION]. Review of resident 1's hospitalization record revealed: *A 7/18/18 history and physical note stated:- .Patient (resident) was admitted for [MEDICAL CONDITION] .source is secondary to lower extremity, more prominent in the right lower extremity compared to the left . -Problem list included:[MEDICAL CONDITIONS], open wound, and [MEDICAL CONDITION]. -Chief complaint was: Fever, open foot wounds with maggots. -Details included: .He is a resident at a nursing home. He has had some open areas of bilateral feet and lower legs. He developed fever. Was evaluated in the emergency department on 7/17/18 for this fever but refused care at that time. Return to the nursing home and temperature spike to 104.6. Presented back to the emergency department .was found to have a WBC level of 33.5 .He states that he has had a fever for about a week. States that he has these bilateral foot wounds that they have been doctoring at the nursing home. They do dressing changes every couple of days. He states that he has noted maggots coming from his foot wounds. This occurs when they do not do the dressing changes as they are supposed to .*A 7/19/18 infectious disease consultation report stated:- .multiple medical problems including bilateral lower extremity [MEDICAL CONDITIONS] and [MEDICAL CONDITION]. Patient has bilateral feet and lower extremity open area with some drainage. Patient developed fevers requiring evaluation in the emergency roiagnom on (MONTH) 17, (YEAR). Patient subsequently has developed high-grade fevers up to 104.6 and presented back to the emergency room .Patient was noticed to have right foot great toe maggot infestation .Patient today underwent whirlpool therapy with removal of maggots under the right great toe . - .history of [MEDICAL CONDITION] of the lower extremities in the past . Random observations and interviews with resident 1 on 8/6/18 from 3:30 p.m. through 6:30 p.m. and on 8/7/18 from 8:45 a.m. through 6:00 p.m. revealed he: *Was not overly talkative or friendly and became frustrated with staff and this surveyor when asking questions. *Was not seen being combative with staff during his care or treatments. -He just made verbal comments to them. *Spent most of his time in his wheelchair. *Liked to go outside and smoke. *Had staff supervision while smoking now. *Stated before he went to the hospital he went outside by himself to smoke. *Had blue Rooke boots to both his lower legs and feet. -Those were new boots from his last hospitalization . *Used to have different boots with openings in the toe area. *Stated he had sore areas on his legs and feet for a long time. *Had gotten maggots in his wounds in the past before he got them in (MONTH) (YEAR). *Was not sure what the specific treatments were that the nurse did for his legs and feet. -He just let them do what they needed to do. Observation and interview on 8/7/18 at 3:15 p.m. during resident 1's dressing change in his room by registered nurse (RN) G and licensed practical nurse (LPN) H revealed: *RN G was training LPN H. -RN had worked there for about five months. *A fly was in and around the resident's lower legs and feet while the staff were completing his dressing change. -They attempted to swat it away several times. *On more than one occasion that fly landed directly on the resident's opened areas of skin. *RN G stated there had been several flies in the facility lately. -She confirmed the resident had wounds and a history of infections including maggots, so they needed to be careful of flies landing on those opened areas of his skin. *His lower legs and feet had a large amount of scarring with darkened areas and no visible hair consistent with vascular disease. *RN G thought his skin was much better, since he had returned from the hospital this last time. *She stated frequently his wounds seemed to get a little better and then worse again. *She was aware of his history of maggots in his wounds, and that he had them again with his recent hospitalization . -She had not seen the maggots herself prior to the last hospitalization . *She stated he went outside to smoke frequently and spent a lot of time out in the patio area. -His previous boots had opened toe areas, she was unsure what happened to those. -The new Rooke boots completely covered his feet. --She thought the flies might have gotten on his feet when he was outside which contributed to the maggots. *She stated his wounds also went from being dry at times to having a large amount of drainage. *Sometimes he avoided or refused getting his treatments done, but if staff continued to attempt or accommodated his schedule he would usually allow them to complete them. *She agreed not getting his treatments completed as ordered by the physician could cause worsening of his wounds or contribute to infections. Review of resident 1's (MONTH) (YEAR) medication administration and treatment administration records (MAR/TAR) revealed:*He had a daily treatment to his toes with an initiated date of 5/29/18 that had only been completed thirteen out of thirty days. -There was a C documented on the days the treatment was not done which was a code for refused. *He had another treatment with a start date of 2/22/18 that stated: When flies are out - please wrap feet and wear Rook boots. -A handwritten note stated Rook Boot not available. -There was a letter B listed for all thirty days of the month which was a code for unavailable. *A treatment of [REDACTED]. -A handwritten note stated start 6-27-18 magots (maggots) again poss. (possible) (with) summer here. -Initials indicated it was done on 6/27/18 and 6/30/18 only. --That was the only mention of maggots in his medical record until the hospital documentation on 7/18/18. *A treatment to wrap his feet and lower legs with Unna boots covered with kerlix on Tuesdays and Saturdays after baths. That was initiated on 6/5/18. -The treatment was refused on 6/5/18 and on 6/26/18 but completed the day after. *There were no notes to support they continued attempts at completing his physician ordered treatments for his wounds when he refused. Review of resident 1's (MONTH) (YEAR) MAR/TARs revealed:*He refused the 5/29/18 ordered treatment to his toes and legs ten out of the eighteen days until he was re-hosptalized on [DATE]. *His 6/5/18 ordered Unna boot treatment for [REDACTED]. -There was no date to indicate when it had been changed to Monday and Thursday. -The treatment was initialed as completed on 7/3/18 (Tuesday), 7/7/18 (Saturday), 7/9/18 (Monday), 7/12/18 (Thursday), 7/13/18 (Friday), and 7/15/18 (Sunday). -It was documented as refused on 7/16/18 (Monday) and an unreadable entry on 7/17/18 (Tuesday). --There were no physician's orders to change those Unna boots as needed, and his order had not been followed as written. *His 2/22/18 order for wrapping his feet and wearing Rook boots was initialed as completed every day from 7/1/18 through 7/19/18. -He was hosptalized on [DATE], so it should not have been signed as completed on 7/19/18. -There was no mention of those boots being unavailable like they had been the whole month of (MONTH) (YEAR). *The as needed treatment for [REDACTED]. -It had been completed on 7/3, 7/9 and 7/15 only. Review of resident 1's (MONTH) (YEAR) MAR/TARs revealed from his hospital return on 8/1 through 8/6 he had not refused his daily wound treatments at all. On 8/8/18 at 9:30 a.m. copies of resident 1's bathing and weekly skin condition flow sheets were requested from the director of nursing (DON) for (MONTH) and (MONTH) (YEAR) and revealed: *In (MONTH) (YEAR) had he received baths on 6/2, 6/5, 6/9, 6/12, 6/16, 6/19, and 6/23. -There was no documentation of: --Him ever refusing to take a bath. --Him getting a bath from 6/23 through 6/30. -The handwritten comments were the same for every entry and stated gen (general) areas (with) redness. open to his toes (L & R) and redness to his bottom. --There was no mention of his wounds worsening or of maggots. *No sheet was received for (MONTH) (YEAR). -There was no documentation to support him having or refusing a bath through his hospitalization on [DATE]. Interview on 8/8/18 at 10:20 a.m. with certified nursing assistant A regarding resident 1 revealed:*He sometimes avoided getting his personal care completed by staff. -They would just keep trying and work around his schedule to get them done. *He was supposed to get baths twice a week. -At the minimum they should have been done once a week. *She had not known him to refuse baths, but they sometimes had to work out a scheduled time for him to get it done. -If he took a bath or refused it they would have documented that on the weekly skin condition sheet. Review of resident 1's weekly Wound Assessment Flow sheets from 5/31/18 through his 7/18/18 hospitalization revealed:*He had wounds on his left heel, right posterior calf, right anterior foot (top of toes), and left anterior foot (top of toes). *There was no weekly wound assessment completed on the left heel area from 6/12/18 through 6/27/18. *The 7/12/18 notes for the left and right anterior feet areas included: -The color and description were: pink/grey wound bed (with) intact tissue surrounding. -The drainage was scant. *The documentation had not mentioned any worsening in the condition of his wounds or maggots. -The (MONTH) (YEAR) TAR supported the development of maggots on 6/27/18. Review of resident 1's interdisciplinary progress notes from 6/1/18 through 8/7/18 regarding his skin revealed:*There was minimal documentation to support his refusals or if the staff continued to attempt his skin treatments when he refused all those dates on the (MONTH) and (MONTH) (YEAR) MARs/TARs. *The only mention of his resistance to care was: -On 6/7/18 .resident stated he did not want to be bothered by staff . -On 6/11/18 .behaviors are almost always verbal, both with staff and other residents . -On 6/24/18 .refused to allow writer to check his blood pressure, O2 at 86%, resident refused O2 and stated 'don't mess around in here,' legs draining fluids through UNO (Unna) boot dressing. -On 7/11/18 .resident lets staff know he does not like to be disturbed . *On 7/11/18 the physician examined both his lower legs and feet during rounds and recommended to continue the same treatment. *On 7/15/18 Resident was c/o (complained of) tightness of the ace wrap on his R) (right) great toe, adjusted and feeling better after, breathing is easy. -There was no mention of the area being assessed for signs or symptoms of infection or worsening. *On 7/16/18 Uneasy on his recliner, using lift to get him position properly, feet elevated and more water.-There was no mention of an assessment to determine what was making him uneasy. *On 7/17/18 at 6:00 p.m. he was sent to the emergency room . -There was no mention of what signs or symptoms they were sending him for. *On 7/17/18 at 8:00 p.m. he returned after refusing treatment in the emergency room . *On 7/17/18 at 10:09 p.m. took temp at 10pm and resident's temp is 104.6 tympanic. Given 650 mg tylenol and one [MEDICATION NAME]. Recheck in 4 hours. -There was no further assessment related to that elevated temperature or concerns with his skin. *On 7/18/18: -At 12:49 a.m. T101.5 .O2 sat 83% on room air, resident refuses to wear O2 .lungs sounds coarse through all lobes, resident stated he wanted staff to let him sleep, resident verbalizes he is cold, resident has a blanket over him . -At 5:54 a.m. Resident sitting up in his recliner. Temp at this time 101.1. -At 7:50 a.m. .lab tech (laboratory technician) here & drew for BMP & CBCD (basic metabolic panel and complete blood count with differential). -At 1:40 p.m. Transfer paper, Psaar, code status, faxed to Flandreau hospital. -At 3:40 p.m. Call rec'd from Flandreau hospital, resident being transferred to (another hospital) . --There was no mention of any concerns with his skin during any of the above notes on 7/18. *During the above time frame there was no mention of: -Him refusing the physician ordered treatments to his wounds. -His Rook boots being unavailable or why those were not being utilized as ordered. -Maggots being seen prior to his hospital admission notes. -Worsening or changes in his skin and wounds or signs/symptoms of possible [MEDICAL CONDITION] including: --Change in the color or size of his wounds. --Change in the amount or color of the drainage. --Change in the temperature of his skin around the wounds. --If he had any increase in his pain. --If there was a change in the odor of his wounds. Review of resident 1's skilled status notes from 7/10/18 through 7/18/18 revealed:*He was on skilled care for [MEDICAL CONDITION] and beta [DIAGNOSES REDACTED] strep infection. *Other skin conditions present were documented as: - .Unna boots/kerlix dry et (and) gripper socks . on 7/10, 7/12 and 7/13 morning, 7/14 evening, 7/15 evening. -Chronic open oozing type blisters on both LE (lower extremities) on 7/13 evening. -Venous stasis (B) (bilateral) LE's are very weepy right now & dressed daily on 7/14 morning. -Venous stasis ulcers (B) LE's. UNNA boot is changed 2x week & toes are dressed daily on 7/15 morning. -Venous stasis ulcers (B) LE's. He has a 2x/week UNNA Boot change & daily drsg. (dressing) change to toes on 7/16 morning. -Nothing for skin conditions was listed on 7/16 evening. -On 7/17 at 12:09 p.m. Lower extremities and toes. With unna boots/kerlix et gripper socks dry. -On 7/17 at 6:29 p.m. Has a chronic open pustular type oozing rash over both LE. Gets drsg changes with bath days. Legs stayed wrapped and covered. *On 7/17 at 6:29 p.m. documentation included: -no bp (blood pressure) taken. 103.6 tympanic 120 pulse 32 (respirations) 86% (oxygen saturation) RA (room air). -Other findings and changes to the treatment plan were: fever of 103.6. Given tylenol for pain at 515pm MD updated with changes. -There was no mention of him being sent to the ER for evaluation. *On 7/18 at 11:32 a.m. documentation included: - .Lower extremities et toes, treatment done unna boots/kerlix gripper socks dry with boot left foot . - .Resident has T 104.1. MD updated with changes. 12P (12:00 noon) 7/18/18 resident was sent to clinic per RHCC van. *The only mention of his refusal of care was on 7/16 evening when he refused his vitals signs or lung sounds to be assessed. *There was no mention of: -Him refusing his physician ordered wound treatments as indicated on the MARs/TARs. -Maggots being seen prior to his hospital admission notes. -The condition of his skin at the time of his 7/18 transfer to the hospital. -Worsening or changes in his skin and wounds or signs/symptoms of possible [MEDICAL CONDITION] including: --Change in the color or size of his wounds. --Change in the amount or color of the drainage. --Change in the temperature of his skin. --If he had any increase in his pain. --If there was a change in the odor of his wounds. Review of resident 1's 8/7/18 printed care plan revealed: *Two focus areas related to his refusal of treatment to his venous stasis ulcers and history of maggots that were created on 7/24/18. -Those were added after he was hosptalized on [DATE]. *A focus area of: I refuse treatment for [REDACTED]. -Interventions included: Staff will return to (name) when he refuses treatment. explain importance of treatments for healing. Allow him to set a time for treatment to be done (if possible). Have supplies ready in a timely manner. -That focus area and interventions were created on 7/24/18. *A focus area of: I have had maggots in the past. I can become angry when staff want to cover my feet to prevent the maggots. -Interventions included: Make sure feet are covered when going outside to smoke. Uses plastic bags on feet during warm weather to prevent maggots. I sometimes refuse to have the plastic bags on my feet. Monitor for signs of maggots. Treatment with Dakin's solution as ordered. Treatments as ordered for ulcers. Explain importance of keeping feet covered and having treatments done. -That focus area and interventions were created on 7/24/18. *A focus area of: I have a venous stasis ulcer on my L) foot, occ. (occasional) skin breakdown R) foot/leg r/t (related to) [MEDICAL CONDITIONS]. Tends to be non compliant with elevating legs. Areas close and open. -Interventions included: measure areas weekly, keep doctor informed of progress, prescribed treatment, report any signs of infection. -That was initiated and revised on 8/1/16. *A goal for bathing: .I would like staff to anticipate my needs and complete bathing tasks for me . -Interventions included: Staff monitor (name) skin during bath and cares for signs of irritation or breakdown and further evaluates. *A focus area for activities of daily living that mentioned venous stasis ulcer with interventions including: Please have the nurse measure and evaluate active wounds and treatment protocols weekly and as needed, and update MD/NP (nurse practitioner) with progress. -Staff monitor (name) wound site bandages/treatment coverage for soil and exudate, and report to nurse for follow up. *There was no mention of his physician ordered Rook boots or when he should have worn them. Interview on 8/7/18 at 4:10 p.m. with resident 1's physician who was also the medical director at the facility revealed: *He confirmed the resident had [MEDICAL CONDITION] and had a long history with venous wounds. -He had sent him to a wound specialist, infectious disease, and dermatology specialties in the past. *The resident had been hospitalized in (MONTH) (YEAR) and (MONTH) (YEAR) with [MEDICAL CONDITIONS] infections related to his wounds. -The last hospitalization in (MONTH) included maggots found in his right great toe wound. -Those could have been caused by him being outside frequently and the wounds having been exposed to flies at those times. *The resident had a history of [REDACTED]. *Other facility related infection control concerns were discussed at that time. Those concerns related to: -Pest control. -Maintaining the facility garbage in a sanitary manner. -Overall cleanliness and sanitation of: privacy curtains in resident rooms, the cat litter box, the whirlpool rooms, and multi-use resident equipment such as mechanical lifts and nail equipment. *He confirmed: -Infection prevention and control should have been an important step in all residents' health and safety. -The infection control program should have identified and corrected concerns in those areas. Interview and record review on 8/8/18 at 10:30 a.m. with the RN/Minimum Data Set (MDS) assessment coordinator regarding resident 1 revealed:*She: -Completed all the residents' MDS assessments and also oversaw the infection control program. -Filled in as a shift nurse as needed. -Was aware of the resident's hospitalization s in (MONTH) and (MONTH) (YEAR) related to [MEDICAL CONDITIONS]. *His most recent hospitalization included maggots being found on his right great toe wound. *They had not been aware of his maggots prior to the 7/18/18 hospitalization . -They had known he had a history of [REDACTED]. *She confirmed his care plan related to his refusals of wound care and his history of maggots had not been updated until 7/24/18 that was after he was hospitalized . -Interventions should have been on his care plan prior to that time. *She thought the 6/27/18 entry on his (MONTH) TAR related to maggots was just to say there had been a possibility of them happening. -She did not think he had them at that time. -It was difficult to distinguish based on the handwritten entry. *She could not explain why his Rook boots had been considered unavailable for all of (MONTH) on the TAR. -They had been physician ordered for him to wear along with wrapping his feet when flies were out. *She thought: -Maybe the boots had not come back with him when he returned from the hospital on [DATE]. -They had ordered him a new pair of boots and were just waiting for them to be delivered in June. --They should have documented in the progress notes what the status of those were. *His previous boots were no longer available, but they had an opened toe area. *Prior to his hospitalization in (MONTH) he was able to go outside to smoke without supervision. -Since he went in and out by himself it was difficult for them to keep his wounds covered when he went outside. -With his previous boots being opened in the toe area that might have contributed to the flies/maggots getting to his wounds. *She stated it was difficult to get his wound treatments done, because he liked to be outside so much, and he frequently refused his wound care. *She confirmed his wound specialist appointment had not occurred for almost one and one-half months after it had been ordered by the physician on 3/30/18. -She thought that was the soonest they could get him an appointment, and that had not been completed timely. *She agreed his medical record had not had documentation to support: -Why his Rook boots were unavailable all of June. -If or when new Rook boots had been ordered. -If the physician had been notified he was not wearing the boots for all of June. -The missing weekly wound assessment in (MONTH) for his left heel wound. -That he had gotten or refused a bath in July. --Bathing would have been an important step in assisting with his infection prevention. *She agreed the only documentation of him refusing treatments frequently was on the MARs/TARs. -The notes had not mentioned his refusals or staff attempts to complete his wound treatments. *His progress notes and skilled assessments notes leading up to his hospitalization had a lack of documentation related to his change in condition and skin conditions. -The notes primarily focused on his elevated temperature and lungs. *His transfer records on 7/17/18 and 7/18/18 to the ER and clinic had not mentioned skin concerns and should have since he was admitted for [MEDICAL CONDITION] and had a history of [REDACTED]. *He had a history of [REDACTED]. -Sometimes the wounds would worsen and then get better. *His wound treatment orders of the bilateral Unna boots to be changed twice weekly had started on 6/5/18. -That treatment continued through when he was admitted to the hospital on [DATE]. -There was no set time frame to update the physician or request a change in wound treatments. -The physician had seen him on 7/11/18, assessed the areas, and kept the treatment the same. *She stated the resident would go from okay to sick very fast. *She confirmed: -He had a history of [REDACTED]. -He was at higher risk for infection due to his history, multiple medical diagnoses, and refusals for care. -His medical record had missing documentation and information related to his overall skin conditions and care. Further interview on 8/8/18 at 11:30 a.m. with the RN/MDS assessment coordinator and the DON regarding resident 1 revealed:*His refusals and the staff attempts at completing his wound treatments had not been documented as well as it should have been. -They should have made entries when they had attempted several times throughout the day to get his treatments done, and he had not allowed it. *There was no specific staff that oversaw the wounds in the facility. -All nurses participated in the wound assessments and treatments according to their assigned residents each shift. *They were unsure why there was a month and one-half delay in him seeing a wound specialist. -It might have been related to their contracted service for wound consultants changing at that time. *They confirmed his medical record had not included some important information regarding his wound care and skin conditions including: -Why his Rook boots were unavailable. -What his skin status was when he had a change in condition with his elevated temperature. -Concerns with his skin on his transfer sheets to the hospital and clinic on 7/17/18 and 7/18/18. -That they had been aware of maggots prior to his 7/18/18 hospitalization . *They confirmed the overall infection control program was an important step in all residents' health and safety. -There were concerns with infection control practices, pest control, and with garbage maintenance and disposal identified during the survey. 2. Concerns were identified with the provider's pest control program which might have contributed to the amount of flies in and around resident 1. Refer to F925, finding 1. 3. Concerns were identified with the provider's garbage and waste disposal processes. Refer to F814, finding 1. 4. Concerns were identified with infection control practices related to resident care items including privacy curtains, mechanical lifts, whirlpool tub room, and nail care supplies that could have had an effect on resident 1. Refer to F880, finding 1. 5. Review of the provider's revised (MONTH) (YEAR) Skin Program policy revealed: *To provide care and services to prevent pressure ulcer development, to promote the healing of pressure ulcers/wounds that are present, and prevent development of additional pressure ulcers/wounds. *Comprehensive skin assessments should have been completed on admission, readmission, annually, and with a change of condition or surface. *When a skin ulcer was identified an assessment included: -The site, size, and appearance of the wound bed including depth and drainage. --Drainage included the amount, color, type, consistency, and odor. -A critical review of the resident's currect P[NAME] (plan of care) and medical status . -To reassess the wound at least weekly. *If the wound had not improved within two to three weeks the physician should have been contacted for a change in treatment. *Completed comprehensive skin aseessments and record of any resident (or resident's family/representative) training will be placed in the medical record. Review of the provider's revised (MONTH) (YEAR) Infection Prevention and Control Program Overview policy revealed: *Goals included to: -A. Decrease the risk of infection to residents/patients and personnel. -B. Prevent, to the extent possible, the onset and spread of infection. -E. Identify and correct problems relating to infection prevention practices. -F. Maintain compliance with state and federal regulations and standards of practice relating to infection prevention and control. * .Policies, procedures and aseptic practices are followed by personnel in performing procedures . Review of the provider's undated copy of The Rooke Boot manufacturer's instructions revealed:*Designed to completely surround the foot, heel and calf . *Protection of an ischemic or healing limb is an essential aspect of the patient's medical management. Placing a Rooke Boot on the patient will provide the optimal protection the healing limb requires. Review of the provider's revised (MONTH) (YEAR) Care Planning policy revealed:*Individual, resident-centered care planning be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence . *Care planning is constantly in process . *Care plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur. When changes are made in the EHR (electronic health record) Care plan dates, time and name/initials are automatically entered . Review of the provider's (MONTH) (YEAR) Physician Order Procedure revealed there was no mention of following physician's orders. Review of the provider's revised (MONTH) 2013 Documentation System policy revealed: *To document in the resident's medical record all services provided to the resident and any changes in the resident's medical or mental condition. *8. The resident's medical record should be up-to-date at all times reflecting the current status of the resident. *11. The plan of care is documented and reflects current standards of professional practice, including measures to facilitate the medical care prescribed that will restore, maintain or promote the resident's highest practicable level of functioning . *12. The resident's care plan is to be up-to-date at all times.

Based on observation, interview, and record review, the provider failed to: *Care for and treat a pressure ulcer to prevent infection for one of two sampled residents (1) with pressure ulcer. *Provide appropriate treatment and services to promote healing of a pressure sore (4). Findings include: 1. Review of resident 1's entire medical record revealed: *She had developed a pressure ulcer on the heel of her left foot on 12/28/12 after having a fractured left hip repaired. *A culture of her pressure ulcer on 1/21/13 came back positive on 1/25/13 for two organisms: citrobacter braakii and [MEDICATION NAME] faecalis. Interview on 2/12/13 at 4:56 p.m. with registered nurse A who also served as the infection control nurse regarding resident 1's left heel pressure ulcer infection revealed: *She believed the resident had acquired the pressure ulcer as a result of rubbing her heal on the bed. *She had been utilizing the provider's whirlpool tub since sometime after 12/20/12. Refer to F441, finding 3 related to the improper disinfection of the provider's whirlpool tub. *Sometime before 1/21/13 it had been noted by staff foul smelling drainage was coming from the pressure ulcer. *As noted above a culture of that pressure ulcer had come back positive for two organisms citrobacter braakii and [MEDICATION NAME] faecalis. The physician was contacted and antibiotics had been ordered to treat the resident's infection. *She confirmed [MEDICATION NAME] faecalis was associated with feces and the intestinal tract of humans. She was not aware what the other organism was associated with. *As the infection control nurse she had not investigated the cause of the resident's left heel infection nor had made any observations of the resident's wound care. *She was unable to explain how gastrointestinal bacteria had gotten into the resident's pressure ulcer. *No wound culture was ordered or requested after the completion of the ordered antibiotics. *The resident continued to be submerged in the whirlpool tub during the course of her infection. Observation on 2/13/13 at 8:02 a.m. of licensed practical nurse (LPN) C providing pressure sore care to resident 1 revealed: *No clean field was established for the pressure ulcer care. *Supplies for the dressing change and care were placed and opened on the resident's bedside table with food and other personal items. *The non-[MEDICATION NAME] opened saline container used to cleanse the pressure ulcer had no date or time on it. *The un-dressed cleansed pressure ulcer was allowed to rest on the resident's bedding. *The ointment used on the pressure ulcer was stored in the provider's treatment cart with other residents' tubes of ointment. *She was not aware the saline she had used was only only good for twenty-four hours after it had been opened. She further was not aware of when the bottle of saline she had used was opened. Upon following LPN C to the treatment cart it was found that multiple bottles of saline were stored in that cart. Some of the bottles had dates on them as far back as November 2012. Interview on 2/13/13 at 10:45 a.m. with the director of nursing revealed she agreed proper steps had not been taken to prevent the infection of resident 1's left heel pressure ulcer as well as prevent future infection as evidenced above. Review of the University of Marylands, "[MEDICATION NAME] Summary" http://www.life.umd.edu/classroom/bsci424/PathogenDescriptions/[MEDICATION NAME].htm, (Fall 2000) revealed: *[MEDICATION NAME] faecalis was a nosocomial (healthcare acquired) infection. *Infections were related to exposure to intestinal material. 2. Review of resident 4's Wound assessment flow sheet from October 2012 through 2/8/13 revealed: *On 10/29/12 he had a stage II pressure ulcer on the left elbow. -It measured 1.5 centimeters (cm) and was a circle. -They had treated it with [MEDICATION NAME] (a dressing). *On 11/16/12 he still had the stage II pressure ulcer on the left elbow. -The treatment had been changed to Exenoderm. -An elbow protector was used. *On 11/23/12 the size ranged from 2.0 cm long by 1.8 cm deep. *On 1/11/13 the size was 0.6 cm by 0.3 cm and it was drying up *On 2/8/13 the size of the pink open area was .5 cm by 0.1 cm, and there was a small amount of drainage. Observation and interview on 2/12/13 at 9:55 a.m. with licensed practical nurse/treatment nurse C regarding resident 4 revealed: *He had that pressure area on his elbow for several months. *When she had put the Exenoderm on his elbow, she covered it with a bandage just to protect it. *There were no physician's orders to cover the open area on his elbow. *She was not sure what other nurses had done, but when the area was draining she liked to keep it covered. *He had elbow protectors, but the ones he had on were too big and slid down his arm. *He continually sat in his chair putting pressure on his elbows on the arms of the chair. *He used to have elbow protectors that were snug, but she had not seen them for several weeks. *The pressure ulcer some days looked better than others. *A later interview with the same nurse and observation of the treatment to his left elbow on 2/12/13 at 2:15 p.m. revealed: -The measurement of the pressure ulcer on his left elbow taken by the nurse at the time was 1.0 cm by .5 cm wide with some drainage. *She confirmed the treatment they were doing had not been making any progress in healing the ulcer. *She confirmed for the length of time they had been treating this area with no results, the physician should have been consulted. Review of resident 4's 12/13/12 care plan revealed: *He had a potential for skin breakdown related to decreased mobility. -An open area on the left elbow had been identified. *The goals were to be free of skin breakdown. *The approaches included: -Repositioning every two hours, minimizing pressure to boney prominences. -Prescribed treatments till areas were healed. -Keep pressure off those areas. Interview on 2/12/13 at 1:10 p.m. with the assistant director of nursing regarding resident 4 revealed: *His pressure ulcer on his left elbow had started out as an abrasion. *They could not get it healed, they were calling it a pressure ulcer. *His physician had seen him on 1/9/13, but they did not have the progress notes from that visit. Review of resident 4's physician's orders revealed: *11/12/12 - "Hold [MEDICATION NAME] left (Lt)elbow; (NS) Normal saline cleanse Extender to open area left elbow BID (twice a day) till healed." -There were no directives on the use of a protective barrier such as a bandage. *There were no further orders addressing the treatment of [REDACTED]. Review of resident 4's renewal physician's orders revealed: *12/1/12-"General TX (treatment) AM (morning) [MEDICATION NAME] LT (left) elbow, change every 3-5 days PRN (as needed). This order was dated 10/28/12. *2/1/12 "General treatment for [REDACTED]. This order was dated 1/23/13. *There was not an order specifically addressing the pressure ulcer on the left elbow. Review of the provider's January 2012 physician services policy revealed: *"The purposed of physician services it to achieve for each resident the highest level of good health possible for the individual in his circumstance, by establishing an accurate diagnosis, instituting and supervising an appropriate medical, surgical, or dental therapy plan". *"Each attending physician shall see his residents at least once every 60 days. *The residents total program of care is reviewed and revised as necessary during the routine visits. *Progress notes will include exam findings and any recent abnormal lab/[DIAGNOSES REDACTED].)."

A. Based on record review, interview, and policy review, the provider failed to appropriately assess, monitor, intervene, transport, and document on one of two sampled residents (1) who had fallen and sustained an injury. Findings include: 1. Review of resident 1's interdisciplinary progress notes from 11/25/12 revealed: *She had been found after a un-witnessed fall in her room at 9:10 a.m. *She had been found with her head up against her television stand on her left side with her left arm under her. *She had bleeding from her head and was complaining of left arm pain when she had been found. The bleeding was controlled with pressure and stopped shortly thereafter. *She was unable to move her left arm or wiggle her fingers at the time she had been found. *Two blood pressures were obtained at the time the resident was found, the first was 177/123 and the second was 164/98. *She was moved from the floor to a chair with the assistance of three staff at 9:25 a.m. She was noted as not being able to bear weight on her left leg at the time of that transfer. *The physician was called and ordered the resident to go to the emergency room . *No ambulance was contacted to transport the resident to the emergency room . *Her son in-law was contacted to transport the resident to the emergency room and arrived at 10:00 a.m. He was unable to transport his mother in-law to the hospital due to he was in a pick-up truck. *At 10:30 a.m. the maintenance man and the son in-law transported the resident per the facility van. *At 11:40 a.m. the hospital had contacted the provider to inquire if the resident had lost conscious and the nurse replied no not that she was aware of. Review of resident 1's 11/25/12 physician's orders [REDACTED]. Review of resident 1's neurological follow sheet from 11/25/12 revealed: *Between 9:10 a.m. and 10:30 a.m. the time of her transfer neurological examination and vital signs had been documented one time at 9:30 a.m. *The motor activity noted by the nurse in her left arm was "None noted." The motor activity in the rest of her extremities were "Spontaneous and purposeful." *Vital signs were blood pressure 177/123, temperature 97.8 degrees Fahrenheit, pulse 93, and respirations 28. Interview on 2/13/13 at 10:45 a.m. with licensed practical nurse (LPN) B who had been the nurse in charge of resident 1 on the morning of 11/25/12 revealed: *She had been an LPN for multiple years. *She had found the resident in the condition described above in the interdisciplinary notes. *She was unable to initially reach the resident after she had fell , as the resident had been blocking the main doorway to her room. LPN B had to enter the room through the resident's bathroom to reach her. *Once she had reached the resident she had found her with her head up against her television stand and blood coming from her head. The resident was crying and appeared to have been in considerable pain. *She had made the decision to move the resident off the floor to the chair with the assistance of two certified nursing assistants (CNA). She was moved without a lift and was in considerable pain during the move. The resident's head and potential fracture sites were not stabilized during the transfer. *The ambulance was not contacted in this case as the provider generally contacted the resident's family first due to the cost of transporting residents per ambulance. *When asked by this surveyor if she had thought the basic tenants of first-aid were followed in this case she stated "No." When asked why she stated "No" she stated because the resident had significant injury that included potential head, neck, and bone fracture. *When asked why only one set of vitals and neurological signs had been done she stated she was unsure. *She confirmed the resident's assessed condition at the time of the fall on 11/25/12 had warranted emergency intervention that included calling the ambulance immediately and stabilizing the resident's head, neck, and potential fracture sites. Interview on 2/13/13 at 10:45 a.m. with the director of nursing regarding resident 1's 11/25/12 fall revealed: *She agreed the basic tenants of first aid had not been followed by the nursing staff. *She also confirmed the resident's assessed condition at the time of the fall on 11/25/12 warranted emergency intervention that included calling the ambulance immediately and stabilizing the resident's head, neck, and potential fracture sites. *She confirmed sufficient monitoring and documentation of the resident's vitals and neurological status were not present. Review of the provider's March 2012 emergency procedures policy revealed: *A resident with suspected spinal injury or fracture should have been left lying. *If suspected fracture the affected area should have been immobilized. Review of Medline Plus Encyclopedia, "Head Injury and Neck Injury", Service of the National Institute of Health, http://www.nlm.nih.gov/medlineplus/ency/article/ 8.htm, (June 27, 2011) revealed: *In the case of a serious head or neck injury 911 should be contacted immediately. *Persons with suspected significant head and neck injuries should not be moved. All attempts should be made to immobilize the injured persons neck and back to prevent further injury. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pg. 477, revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice." Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with direct supervision when providing nursing care in a complex nursing situation; *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary." B. Based on observation, interview, and record review, the provider failed to: *Have dietary and nursing processes in place to accurately monitor fluid intake for four of four sampled residents (1, 6, 7, and 9) when care plans called for monitoring fluid intake. Findings include: 1. Review of resident 1's 12/3/12 care plan revealed she: *Was currently being treated for [REDACTED]. *Received liquid supplements daily. The intake of those supplements were to have been monitored every day and then recorded. *Both food and fluid intakes were to have been monitored. *Decreased food and fluid intake were to have been reported promptly. Interview on 2/12/13 at 3:30 p.m. with the assistant director of nursing and the dietary manager revealed: *No documentation of the fluid intake of resident 1 was kept in her clinical record. All documentation for fluid intake was kept by dietary services. That documentation was only for meal intake. *Intake of fluids were not monitored for the resident outside of meal intake. The dietary department did not document fluid intake in milliliters rather it documented in fractions (i.e. 1/4, 1/2, and so on). *They confirmed fluid intake documentation was not readily available to nursing staff if the need arose nor did it adequately reflect the resident's fluid consumption. *No process was in place to document fluid intake in the nursing care areas. 2. Review of resident 9's care plan dated 1/23/13 revealed the following approaches addressing the potential for dehydration: *"Monitor and ensure consumes >75% of foods and fluids offered at meals and snacks; Report decreased intake promptly." *"Monitor food/fluid intake daily." *No documentation of food/fluid intake was found in resident 9's medical record. *All documentation for food/fluid intake was kept by dietary services. That documentation was only for meal intake. 3. Review of resident 7's care plan dated 1/30/13 revealed approaches addressing the potential for dehydration: *"Monitor and ensure consumes >75% of foods and fluids offered at meals and snacks; Report decreased intake promptly." *"Water within reach at bedside and assist/remind to drink 30-50 cc (cubic centimeters) fluids each time caregiver in room to provide cares." *No documentation of food/fluid intake was found in resident 7's medical record. *All documentation for food/fluid intake was kept by dietary services. That documentation was only for meal intake. 4. Review of resident 6's temporary care plan dated 1/29/13 revealed the approach to "encourage fluids - UTI (urinary tract infection) - Report hematuria promptly." *No documentation of fluid intake was found in resident 6's medical record. *All documentation for food/fluid intake was kept by dietary services. That documentation was only for meal intake. 5. Interview on 2/13/13 at 1:00 p.m. with the DON revealed dietary maintained records of food and fluid intake after the residents completed their meals. Food/fluid intake was not documented in the resident's medical record. Review of the provider's revised 1/10/12 Resident Care Plans policy revealed the purpose of the resident care plan was: *"To provide a guide to resident-centered care, rather than job-centered care. The resident is always considered first. The plan is an outgrowth of discussion during which every person on the team and the resident or resident's guardian focus their attention on the problems and needs of the resident as an individual and suggests ways for the provision of the care he needs." *"A plan helps to insure the continuity of safe, individualized nursing care on a 24-hour per day basis." Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, p. 1152, revealed "Recording I&O is essential for obtaining an accurate database. This information helps maintain an ongoing evaluation of the client's hydration status to prevent severe imbalances."