Every finding on record at Rolling Hills Healthcare

Based on observation, record review, interview, and policy review, the provider failed to identify, monitor, and implement pressure ulcer (skin and/or underlying tissue injury due to prolonged pressure) healing and prevention interventions for one of one sampled resident (3) who developed a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer to his buttocks. Findings include:1. Observation on 2/10/26 at 11:09 a.m. of resident 3 in his room revealed:*There was a cushion in his wheelchair seat.*He had an air mattress on his bed.*Resident 3 was sitting in his recliner.*There was no pressure relieving cushion in his recliner.2. Review of resident 3's electronic medical record (EMR) revealed:*He was admitted to the facility from the hospital on 8/14/25.*His 11/21/25 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated his cognition was moderately impaired.*His diagnoses included diabetes (a condition involving disruptions in how the body regulates blood sugar), stage four kidney disease (severe kidney damage) with dependence on renal dialysis (blood is removed, cleaned by a machine, and returned to the body for people with kidney failure), and reduced mobility.*Resident 3's 8/14/25 discharge instructions from the hospital indicated, Wound Care Instructions Wound location: Right buttock:-Cleanse area with mild soap and water.-Apply barrier cream 3-4 times daily and with each incontinence [involuntary urine or bowel leakage] episode.-Cover open areas with Oval Mepilex [a silicone foam wound dressing].-May consider a silicone border dressing in place of the barrier cream as well due to the decrease in wound area.-Offload with repositioning every 2 hours and as needed.-Offload heels by suspending them off mattress with [a] pillow so heels float over [the] edge of [the] pillow.-Waffle cushion to chair and frequent repositioning while in the chair.*His undated baseline care plan (the admission personalized plan that addresses a resident's care needs, goals, and interventions) stated he had wounds on his sacrum (bone directly above the tailbone), left lateral (outside) foot, and the head of his penis.*Resident 3's 8/14/25 admission assessment indicated his skin was intact and his Braden Scale (a tool used to assess the risk of developing pressure ulcers) assessment score indicated he had high risk for developing a pressure ulcer.*Resident 3's 8/25/25 comprehensive care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area of At risk of alterations in skin integrity with interventions of Provide incontinent care and apply moisture barrier to help protect skin prn [as needed] and Weekly skin assessment per facility policy.-It did not include that resident 3 had an open area to his right buttocks.-It did not include the application of barrier cream 3-4 times daily and with each incontinent episode, to offload with repositioning every 2 hours and as needed, and a waffle cushion to chair and frequent repositioning while in the chair as was indicated in resident 3's hospital discharge instructions.*His 12/22/25 skin assessment stated, right buttock with small abrasion, barrier cream applied. Left buttock with 0.5 cm [centimeter] open area, erythematous [reddened] and bleeding scant amount. Area dressed with a 3 [inch] x3 [inch] Hydrocellular Foam Dressing Silicone Dressing with Border. Patient tolerated well. Notified [licensed practical nurse (LPN) /wound care nurse G].*There were no skin assessments documented between 12/22/25 and 1/1/26.*Resident 3's 1/1/26 skin assessment indicated his left buttock had an facility acquired open wound and his right buttock had an facility acquired abrasion. The wounds were Stable: previously deteriorating wound characteristics plateaued.-There were no measurements or a description of those facility acquired wounds.*There was no skin assessment documented on 1/8/26.*Resident 3's 1/15/26 skin assessment indicated his left buttock had a facility acquired open wound and his right buttock had a facility acquired abrasion. The wounds were Improving; overall wound characteristics improved.-There were no measurements or a description of those facility acquired wounds.*Resident 3's 1/22/26 skin assessment indicated his left buttock had a facility acquired open wound and his right buttock had a facility acquired abrasion.-There were no measurements or a description of those facility acquired wounds or whether his wounds were improving, worsening, or remaining stable.*Resident 3's 1/29/26 skin assessment indicated his left buttock a facility acquired open wound and his right buttock had a facility acquired abrasion.-There were no measurements or a description of those facility acquired wounds or whether his wounds were improving, worsening, or remaining stable.*There was no skin assessment documented on 2/5/26.*Resident 3 had a 2/5/26 physician's order for, Rt [right] and Lf [left] buttock apply triad [a zinc-based paste to manage draining wounds such as a pressure ulcer] daily with sactal [sacral] foam dressing [a specially formed dressing to be for the sacrum] applied till [until] healed every day shift.*His 2/10/26 care plan indicated he had a focus area that was initiated on 12/23/25 for wound management with interventions of Evaluate ulcer characteristics, Measure ulcer on at regular intervals, Monitor ulcer for signs of infection, Monitor ulcer for signs of progression or declination, and Notify provider if no signs of improvement on current wound regimen.3. Interview on 2/11/26 at 3:20 p.m. with assistant director of nursing (ADON) C revealed:*There were no measurements or descriptions of resident 3's wounds on his buttocks because they were not considered pressure ulcers, and LPN/wound care nurse G had not seen him during her weekly rounds.*A cushion was placed in his wheelchair on 11/3/25 because he was sliding down in his wheelchair.*His physician was notified of the newly identified wound on his buttock on 12/23/25 at 11:03 a.m.-The notification stated, Resident has abrasion to his RT. and LT buttock due to sliding in W/C [wheelchair].*His air mattress was placed on his bed on 1/27/26 (after the wounds were identified).4. Observation and interview on 2/12/26 at 8:23 a.m. with resident 3 in his room revealed:*He did not know when the cushion was placed on the seat of his wheelchair and he could not recall having a pressure reduction cushion on his recliner.*He was sleeping in his recliner for about the last month because the air mattress on his bed leaked.*When he would sleep on the air mattress it would deflate, and he would end up lying on the frame of the bed.*The air mattress was unplugged at the time of this observation.5. Interview on 2/12/26 at 9:34 a.m. with certified nursing assistant (CNA) O revealed:*She did not know if resident 3 slept in his recliner or bed, but each day when she arrived to work he was dressed and sitting in his recliner or wheelchair.*She did not unplug resident 3's air mattress.*She did not know when the cushion was placed in resident 3's wheelchair.*She acknowledged there was no pressure reduction cushion in resident 3's recliner.*Resident 3's buttocks did not have a wound dressing when she assisted him to the bathroom that morning (2/12/26) but stated some days there was a dressing on his buttocks.*She applied barrier cream to his buttocks each time she changed his brief or assisted him to the toilet because he was incontinent.6. Observation and interview on 2/12/26 at 9:43 a.m. with LPN/wound care nurse G and CNA O during resident 3's skin assessment revealed:*There was no wound dressing on resident 3's buttocks.*He had a six cm by three and one-half cm area on his right buttocks where the first layer of skin was missing and the top of that area had a two cm by three and one-half cm scabbed area. His left buttocks had a three and seven-tenths cm by two cm area where his first layer of skin was missing.*LPN/wound care nurse G stated she did not consider resident 3's wounds on his buttocks pressure ulcers because the skin blanched (the skin turned white when pressure was applied and then returned to pink after the pressure was released).*LPN/wound care nurse O did not apply a dressing to resident 3's buttocks. She rolled him back onto his back, and asked CNA O to assist him out of bed and back into his chair.*LPN/wound nurse care G stated she had worked as an LPN for one year and had completed additional training to be a wound care nurse on 10/13/25.*LPN/wound care nurse G did not have a designated registered nurse (RN) who oversaw her wound care role, but she would ask an RN if she had any questions related to a wound.*She monitored surgical wounds, vascular wounds, arterial wounds, and pressure ulcers for residents.*The nurse assigned resident 3 on his bath day was to perform his weekly skin checks and document in his EMR the measurements and descriptions of his wounds.*She acknowledged that resident 3's wounds were not measured or described on his weekly skin assessments.*LPN/wound care nurse G had completed resident 3's admission assessment on 8/14/25.*Within the admission assessment LPN /wound care nurse G had completed a skin assessment and documented that resident 3 did not have skin concerns.*She was not aware that resident 3's baseline care plan indicated he had wounds on his sacrum, left foot, and the head of his penis.*She did not complete resident 3's baseline care plan and did not know who had completed it.*LPN/wound care nurse G acknowledged that the location on resident 3's buttocks was an area that sustained pressure when he was sitting in his recliner and wheelchair.*She was not aware that resident 3 was sleeping in his recliner without pressure reduction cushion.7. Interview and EMR review on 2/12/26 at 11:00 a.m. with RN N revealed:*If a pressure ulcer was identified on a resident, the nurse should document the size and a description of the ulcer in a skin assessment in that resident's EMR and then notify the LPN/wound care nurse G and the physician.*A risk management form was to be completed by the nurse who identified the ulcer to notify management that a pressure ulcer was identified on a resident.*RN N would measure and document a resident's pressure ulcer in a skin assessment in that resident's EMR when it was initially identified or if she thought the pressure ulcer was increasing in size or getting worse.*LPN/wound care nurse G measured and documented the resident's pressure ulcers weekly in a skin assessment.*RN N had completed resident 3's wound care treatment to his buttocks that morning (2/12/26).*She did not put a dressing on his buttocks because the physician's order was for triad paste to his buttocks.*Upon review of resident 3's treatment order for his buttocks she verified the physician's order for resident 3's wound care treatment on his buttocks was to use triad paste and cover it with a foam dressing.-She stated she did not apply the foam dressing over the triad paste because the previous order did not have that on it, and she did not read the entire order before she completed his treatment that day.*RN N stated resident 3 had an ongoing issue with skin breakdown on his buttocks.*When asked what her assessment of resident 3's buttocks wound was that morning she stated he had a stage II pressure ulcer.*He was not sleeping in his bed for at least the past week. There was one night he slept in his wheelchair all night, so an air mattress was placed on his bed. She thought after that he was sleeping in his bed because the night shift nurses did not report anything different.*When she arrived at the facility to work her morning shift, he was in his wheelchair or recliner ready to go to dialysis.8. Interview on 2/12/26 at 12:11 p.m. with ADON C revealed:*ADON C was an LPN.*The CNAs were to observe each resident's skin daily and report any abnormalities to the nurse.*The nurse was to check the resident's skin and document their observation in the resident's EMR weekly on their scheduled bath day.*If the nurse observed a wound on a resident's, ADON C expected the nurse to measure the wound and then document it in the resident's EMR with a description of the wound, such as drainage and what the wound bed looked like. The nurse would then notify the resident's primary care provider.*The nurse who identified the wound was to notify LPN/ wound care nurse G to assess the resident's wound.*If LPN/wound care nurse G determined the wound was not a pressure ulcer, venous ulcer, arterial ulcer, or surgical wound she would refer the wound back to the nurses to manage the assessments and treatments of that wound.*The nurses would then be responsible for completing an alert progress note in the resident's EMR related to that wound two times a day until the wound was healed to track the progress of the wound.-ADON C acknowledged that there were no alert progress notes in resident 3's EMR related to his 12/22/25 wounds.*If the nurses felt a resident's wound had increased in size or worsened ADON C expected the nurses to notify LPN/wound care nurse G so she could reevaluate the wound.-ADON C stated there was no documentation that the nurses had notified LPN/wound care nurse G that there was an increase in the size of resident 3's wounds on his buttocks.*She expected the nurses to follow the physician's orders for the treatment of a wound.*Residents with pressure ulcers were reviewed during the provider's weekly nutrition and wound committee meetings (an interdisciplinary team meeting to discuss residents who had nutritional risks or had wounds, and to discuss possible interventions for those nutritional risks or wounds).-Resident 3 was not reviewed related to his wounds on his buttocks because they were not identified as pressure ulcers, but he was reviewed because he received dialysis.*Resident 3 had a cushion in his wheelchair before his wounds on his buttocks were identified on 12/22/25.*There was no documentation to support resident 3 having a pressure reduction cushion in his recliner.*His air mattress was placed on his bed after resident's 3's wounds on his buttocks were identified on 12/22/25 because he had stated his other mattress was too hard.*ADON C stated resident 3 had told her he did not use a cushion in his dialysis chair, which he sat in for several hours at a time three days a week, but she did not confirm that with the dialysis staff.*She acknowledged that resident 3's 8/14/25 hospital discharge instructions indicated that resident 3 had a wound on his right buttocks with orders to clean and apply a dressing over the wound, apply barrier cream, place a waffle cushion in resident 3's chair and to reposition him frequently while he was in the chair.*She acknowledged resident 3's undated baseline care plan indicated he had wounds on his sacrum, left foot, and the head of his penis but his 8/14/25 admission assessment indicated he did not have any wounds.*She acknowledged there were missing weekly skin checks in resident 3's EMR.*She acknowledged that it could not be determined if resident 3's wounds to his left and right buttocks were improving or worsening, because there were no weekly measurements or descriptions of his wounds.*She acknowledged that resident 3's care plan did not contain pressure reduction measures such as his wheelchair cushion, air mattress, or other preventative pressure reduction measures.9. The director of nursing (DON) was not in the facility or available for interview during the survey.10. Review of the provider's 6/9/25 Pressure Injury Prevention and Management policy revealed:*The facility shall establish and utilize a systematic approach for pressure injury prevention and management, including prompt assessment and treatment; intervening to stabilize, reduce or remove underlying risk factors; monitoring the impact of the interventions; and modifying the interventions as appropriate.*Examples of risk factors [for pressure injury risk] include, but are not limited to:- Impaired/decreased mobility and decreased functional ability:- Co-morbid conditions, such as end stage renal disease, thyroid disease, or diabetes mellitus;- Drugs such as steroids that may affect healing;- Impaired diffuse or localized blood flow, for example, generalized atherosclerosis or lower extremity arterial insufficiency;- Resident refusal of some aspects of care and treatment;- Resident refusal of some aspects of care and treatment;- Cognitive impairment;- Exposure of skin to urinary and fecal incontinence;- Under nutrition, malnutrition, and hydration deficits; and- The presence of a previously healed pressure injury.*Evidence-based interventions for prevention [of pressure ulcers] will be implemented for all residents who are assessed at risk or who have a pressure injury present. Basic or routine care interventions include, but are not limited to:- Redistribute pressure (such as repositioning, protecting and/or offloading heels, etc);- Minimize exposure to moisture and keep skin clean, especially of fecal contamination;- Provide appropriate, pressure-redistributing, support surfaces;- Provide non-irritating surfaces; and- Maintain or improve nutrition and hydration status, where feasible.*Treatment decisions will be based on the characteristics of the wound, including the stage, size, exudate (if present), presence of pain, signs of infection, wound bed, wound edge and surrounding tissue characteristics.*Nurse Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance and document a summary as applicable.*Nurse Manager, or designee, will review all relevant documentation regarding skin assessments, pressure injury risks, progression towards healing, and compliance and document a summary as applicable.- The presence of a new pressure injury upon identification.- The progression towards healing, or lack of healing, of any pressure injuries.Review of the provider's 6/10/25 Skin Assessment policy revealed:*A full body, or head to toe, skin assessment will be conducted by a licensed or registered nurse upon admission/re-admission and weekly thereafter.*Documentation of skin assessment:- Include date and time of the assessment, your name, and position title.- Document observations (e.g. skin conditions, how the resident tolerated the procedure, etc.)- Document wound.- Describe wound (measurements, color, type of tissue in wound bed, drainage, odor, pain).- Document if resident refused assessment and why.- Document other information as indicated or appropriate.

Based on Payroll Based Journal (PBJ) reports, interview, schedule review, and facility assessment review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours of coverage for six days in quarter four (July 1 through September 30) of fiscal year 2025 and for two of fourteen days (1/29/26 and 1/31/26) between 1/28/26 and 2/10/26. Findings include:1. Review of the PBJ report for quarter 4 of fiscal year 2025 revealed the provider did not have RN coverage for eight consecutive hours on 7/4/25, 7/19/25, 7/26/25, 7/27/25, 8/30/25, and 8/31/25.2. Interview on 2/10/326 at 8:30 a.m. with administrator A during the entrance conference revealed the provider did not have any nurse staffing waivers.3. Interview on 2/12/26 at 8:37 a.m. with administrator A revealed there were not eight consecutive hours of RN coverage on 7/4/25, 7/19/25, 7/26/25, and 7/27/25.*An RN had not been scheduled to work on 7/4/25, 7/19/25, 7/26/25, and 7/27/25.4. Interview on 2/12/26 at 10:51 a.m. with assistant director of nursing (ADON) C revealed:*There were not eight consecutive hours of RN coverage on 8/30/25 and 8/31/25.*An RN had not been scheduled to work on 8/30/25 and 8/31/25.*Recently the provider had made the daily eight consecutive hours of RN coverage a focus area for the facility and two RNs were hired to help cover those hours on 12/8/25 and 2/3/26.5. Review of the nursing schedule from 1/28/26 through 2/11/26 revealed:*On 1/29/26 RN U was scheduled from 8:30 a.m. until 11:30 a.m. and director of nursing (DON) B was scheduled 2:00 p.m. until 7:00 p.m.-These hours did not satisfy the requirement of eight consecutive hours of RN coverage.*On 1/31/26 DON B was scheduled from 9:00 a.m. until 1:00 p.m.-These hours did not satisfy the requirement of eight consecutive hours of RN coverage.6. The director of nursing (DON) was not in the facility or available for an interview during the survey.7. Review of the provider's 9/22/25 Facility Assessment Tool revealed 2-6 floor direct care RN/LPN [licensed practical nurse] per day (at least 1 RN daily, may include MDS [Minimum Data Set] for RN needs, and nurses working on medication carts).

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding the storage of oxygen equipment for four of four sampled residents (1,18, 49, and 69) who required the use of oxygen. Findings included: Observation and interview on 2/10/26 at 10:02 a.m. with resident 1 in his room revealed: *He was lying in bed with his nasal cannula on which was connected to his oxygen concentrator (a device that filter room air into purified oxygen) beside him. *His wheelchair was positioned next to his bed and had a portable oxygen tank hanging on the back. There waws a nasal cannula connected to the oxygen tank that was laying on the floor underneath the wheel of the wheelchair. *The resident stated that the staff assisted him with removing and reapplying his nasal cannula. 2. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *His 12/15/25 Brief Interview of Mental Status (BIMS) assessment score was 12, which indicated his cognition was moderately impaired. *His diagnoses included chronic obstructive pulmonary disease (COPD), acute respiratory failure with hypoxia (where tissues are deprived of adequate oxygen), adult failure to thrive, hypotension (low blood pressure), cachexia (irreversible metabolic syndrome, severe loss of skeletal muscle mass and body fat, resulting in extreme weakness), and ischemia cardiomyopathy (the heart muscles become weakened and cannot pump blood efficiently). *He had a 1/16/26 physician's order, Oxygen: Oxygen at 1-5 L [liter] per NC [nasal canula] every shift for oxygen use. 3. Observation on 2/10/26 at 10:15 a.m. of resident 18's room revealed: *Resident 18 was lying in bed with a nasal cannula on that was attached to her oxygen concentrator. *On the back of resident 18's wheelchair was a portable oxygen tank. *Attached to the portable oxygen tank was a nasal cannula that was draped over the back of the wheelchair and lying on resident 18's wheelchair seat that had dry white flakes on the cushion. 4. Observation on 2/10/26 at 10:20 a.m. of resident 69's room revealed: *Resident 69 was not in her room. *There was an oxygen concentrator (a device that filters room air into purified oxygen) by the wall with a nasal cannula coiled up and placed under the handle of the oxygen concentrator. 5. Observation on 2/10/26 at 2:04 p.m. of resident 69's room revealed: *She was lying in bed wearing a nasal cannula that was attached to her oxygen concentrator. *The nasal cannula attached to her portable oxygen tank on the back of her wheelchair was hanging on the handle of resident 69's wheelchair. *The portion of the nasal cannula that would be put into resident 69's nose was in touching the handle of the wheelchair where someone's hands would be placed to push the wheelchair. 6. Observation on 2/10/26 at 2:50 p.m. in resident 49's room revealed: *He was sitting in his recliner with his feet elevated. *His wheelchair was next to his bed, and it had a portable oxygen tank on the back of it. *The nasal cannula attached to the portable tank was draped over the back of the wheelchair and rested on the wheel of the wheelchair. 7. Observation on 2/10/26 at 4:45 p.m. of resident 18's room revealed: *Resident 18 was not in her room. *Her oxygen concentrator was on, and the attached nasal cannula was draped over the head of resident 18's unmade bed. 8. Observation on 2/11/25 at 3:27 p.m. of resident 18's room revealed: *Resident 18 was not in her room. *Her oxygen concentrator was on, and the attached nasal cannula was hanging on the siderail (bar/bars attached to the bed) attached to the head of her bed and the prongs that are placed in [NAME] resident's nose were lying against the base of the side rail and mattress. 9. Interview on 2/11/26 at 2:01 p.m. with certified nursing assistant (CNA) O revealed: *Resident 18 required staff assistance to switch between using her oxygen concentrator in her room and her portable oxygen tank on her wheelchair. *Resident 69 required staff assistance to switch between using her oxygen concentrator in her room and her portable oxygen tank on her wheelchair. *Nasal cannulas were to be stored in plastic bags and attached to the oxygen concentrator or portable oxygen tank when they were not being used by the residents. *She acknowledged that the residents' nasal cannulas were not stored in plastic bags on 2/10/26 because there were no plastic bags on the residents' oxygen concentrators or portable oxygen tanks. She tried to store them in places where they were not at risk of touching the floor. *She had asked for plastic bags to hang on the residents' oxygen concentrators and portable oxygen tanks on 2/10/26, but the plastic bags were not brought to her from supply. 10. Observation on 2/12/26 at 9:36 a.m. in resident 49's room revealed: *He was not in his room. *There was an oxygen concentrator in his room with a nasal canula connected to it, and the nasal canula was lying on the floor. 11. The director of nursing (DON) was not in the building and was not available for interview. 12. Interview on 2/12/26 at 9:41 a.m. with assistant director of nursing (ADON) C revealed: *When a resident was admitted to the facility and required oxygen the admitting nurse was responsible for obtaining a storage bag and placing the resident's nasal cannula in the bag. *The staff were expected to use the bag to store the nasal cannula when it was not in use. *If the residents did not have a storage bag, the staff were responsible for obtaining one for the residents. 13. Review of the provider's 5/16/25 Oxygen Administration policy revealed: *Change oxygen tubing and mask/cannula weekly and as needed if it becomes soiled or contaminated. *Keep delivery devices covered in a plastic bag when not in use.

Based on observation, interview, record review, and policy review, the provider failed to ensure the resident's medications were labeled and discarded for: Two of two sampled residents (7 and 18) who had opened boxes of nasal spray (Flonase) which that were not kept available for use after their use-by date. Two of two sampled residents (18 and 62) whose pain medications (hydrocodone and oxycodone) were not labeled according to their physician's order. One of one sampled resident's (15) inhaler that was expired and was not stored in a secure location. Findings include:1. Observation and interview on 2/10/26 at 10:15 a.m. of the 400 hall medication cart with certified medication aide (CMA) K revealed: *There were two opened boxes of residents' Flonase nasal sprays. *Resident 7's nasal spray had a use-by date of 6/25/25, and resident 18's nasal spray had a use-by date of 12/29/25. *CMA K stated that nasal sprays were labeled with use-by dates, and the staff were expected to review those dates before administering the spray. Those expired nasal sprays should have been discarded by the staff. *Review of residents 7 and 18's medication administration records (MAR) revealed both residents had orders for PRN (as needed) Flonase. 2. Observation, interview and medication administration record (MAR) review on 2/10/26 at 12:10 p.m. with CMA K who was preparing resident 18's medications for administration revealed: *The resident's hydrocodone blister pack (a hand-held card from which individual pills or capsules are dispensed into medication cups for administration) label indicated one pill was to be administered every four hours PRN. *The resident's MAR indicated one pill was administered four times daily. CMA K then administered one hydrocodone pill to the resident. *CMA K knew she was expected to compare the resident's blister pack label to the resident's MAR order for any discrepancies between the two before she administered the hydrocodone pill. She did not do that. 3. Observation, interview and MAR review on 2/11/26 at 11:40 a.m. with CMA L who was preparing resident 62's medications for administration revealed: *The resident's oxycodone blister pack label indicated one 5 mg (milligram) pill was to be administered three times daily and another 5 mg pill was to be administered one time daily PRN. *The resident's MAR indicated that one 5 mg oxycodone pill was administered four times daily. There was a second, separate order on that MAR for one 5 mg pill to be administered one time daily PRN. *CMA L recognized the discrepancy between the resident's blister pack label and the resident's MAR order. She knew the resident's MAR was updated on 1/30/26 to reflect four scheduled oxycodone administrations (8:00 a.m., noon, 4:00 p.m., and 8:00 p.m.). She thought there should have been a change order sticker affixed to the resident's blister pack to alert staff to the updated oxycodone order. 4. Interview on 2/11/26 at 4:45 p.m. with assistant director of nursing (ADON) C regarding medication labeling revealed: *That a resident's blister pack label was expected to be compared to their MAR for any discrepancy by the staff before administering that medication. Any discrepancy was expected to be brought to her attention or to another licensed nurse for follow-up. *The licensed nurse was responsible for affixing any change order stickers to the blister pack based on order changes and for notifying the pharmacy of the blister pack label discrepancy. 5. Review of the provider's revised 5/7/25 Medication Administration policy revealed: 11. Review MAR to identify medication to be administered. 12. Compare medication source (bubble [blister] pack, vial, etc.) with MAR to verify resident name, medication name, form, dose, routine, and time. There was no indication of what process to follow if a discrepancy was found between the medication source and the MAR. Review of the provider's revised 5/16/25 Labeling of Medications and Biologicals policy revealed 12. The pharmacy must be informed of any order changes or changes in directions for the use of the medication. 6. Observation on 2/10/26 at 10:55 a.m. of resident 16's room revealed he had an inhaler lying on his bedside table. 7. Observation and interview on 2/11/26 at 8:31 a.m. with resident 16 in his room revealed: *The inhaler on his bedside table was albuterol (a medication used to treat shortness of breath or wheezing) 90 mcg (micrograms) per inhalation. -It expired on 6/30/23. *Resident 16 stated he did not use an inhaler but his roommate resident 15 did. *He did not know if resident 15 had recently used that inhaler. *He stated a nurse had brought the inhaler into his room, set it on his bedside table, and then left the room and never came back to get it. 8. Review of resident 16's EMR revealed he did not have a physician's order for an inhaler or for the self-administration of medications. 9. Review of resident 15's EMR revealed: *She was admitted to the facility on [DATE]. *Her 1/28/26 BIMS assessment score was 8, which indicated her cognition was moderately impaired. *She had a 9/18/25 physician's order for Albuterol Sulfate HFA Inhalation Aerosol Solution 108 (90 Base) MCG/ACT [micrograms per actuation (per puff)] 4 puff inhale orally every 4 hours as needed for wheezing. *She did not have a physician's order to have medications stored at her bedside. 10. Interview on 2/11/26 at 11:09 a.m. with resident 15 revealed she did not know if she had used the inhaler that was on resident 16's bedside table. 11. Interview on 2/11/26 at 2:10 p.m. with CMA K revealed: *She was not aware there was an inhaler on resident 16's bedside table. *He did not have a physician's order for an inhaler but his roommate resident 15 did. *She stated that there should not be any medications stored in that room. *If she had seen the inhaler she would have brought it to the nurse. 12. Interview on 2/12/26 at 11:58 a.m. with RN N revealed: *The nurse who worked the during the night shift was supposed to check the medication room and the medication carts for expired medications monthly. *An inhaler was not to be left in a resident's room unless there was a physician's order and an assessment was completed to determine if a resident was able to safely self-administer their own medications. *She expected the staff to bring any medications found in a resident's room to the nurse. *She stated resident 15 would not be able to safely self-administer her medications. 13. Interview on 2/12/26 at 12:11 p.m. with ADON C revealed: *Medications were not to be stored in a resident's room without a physician's order and an assessment completed for the self-administration of medications. *She expected the staff to bring any medications found in a resident's room to the nurse. *Resident 15 would not be able to safely self-administer her medications. *Expired medications were not to be administered to the residents. *The medication room and medication carts were to be checked monthly for outdated medications by the director of nursing (DON), ADON, and the CMAs and then destroyed. *The provider's consultant pharmacist checked the medication room and medications carts for expired medications and to be sure items were stored according to the manufacturer's instructions and compliant with the state and federal regulations.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed infection prevention and control practices regarding:*Hand hygiene (handwashing) by two of two certified medication aides (CMA) (K and L) during medication administration for three of three sampled residents (46, 55 and 65).*An indwelling urinary catheter (flexible tubing inserted into the bladder to drain urine) being kept off the floor for one of one sampled residents (49).*The use of enhanced barrier precautions (EBP), glove and gown use when providing contact care, by the staff for three of three residents (3, 7, and 9) who were on enhanced barrier precautions (EBP), and one of one sampled resident (3) who was transferred by two of two staff members (certified nursing assistant (CNA) O and care assistant W) without using EBP.Findings include:1. Observation and interview on 2/10/26 at 1:45 p.m. with CMA K revealed: *She had prepared resident 55's nebulizer (a device that converts liquid medications into inhalable mist) treatment after using her laptop computer to check the nebulizer order, she retrieved the nebulizer medication from inside the medication cart. *She entered resident 55's's room, and without first performing hand hygiene, she assembled the nebulizer tubing, nebulizer medication cup, and mask. *She placed the medication into the nebulizer cup and turned on the nebulizer machine. CMA K then put the nebulizer mask over the resident's nose and mouth and ensured the elastic band attached to the mask was placed behind the back of the resident's head to keep the mask in place. *CMA K stated she would return to the resident's room in 10 minutes to remove the mask from the resident's face, turn off the machine, and clean the nebulizer equipment. *After she exited resident 55's room, CMA K returned to the medication cart, and without performing hand hygiene, she prepared resident 46's medications for administration. *Following the above observation, CMA K acknowledged she should have performed hand hygiene upon entering resident 55's room before she handled the resident's nebulizer equipment and medication. *She agreed that after exiting resident 55's room, she should have but did not perform hand hygiene before she prepared resident 46's medications for administration. 2. Observation and interview on 2/11/26 at 8:00 a.m. with CMA L revealed: *That without first performing hand hygiene, she prepared resident 65's medications for administration to the resident. *After those medications were administered, CMA L performed hand hygiene. *CMA L stated it was expected that hand hygiene was performed both before and after medication administration for each resident. 3. Interview on 2/11/26 at 5:00 p.m. with assistant director of nursing (ADON) C regarding infection prevention and control practices revealed: *That hand hygiene was expected to be performed by all caregivers before and after all transitions in residents' care performed. *She confirmed that was not demonstrated by CMAs K and L in the above observation but it should have been. 4. Review of the provider's revised 5/15/25 Nebulizer Therapy policy revealed: 2. Gather appropriate equipment and ordered medication. 4. Perform hand hygiene. 5. Review of the provider's revised 5/7/25 Medication Administration policy revealed: 4. Perform hand hygiene prior to administering medication per facility protocol and product. 18. Observe resident consumption of medication. 19. Wash hands using facility protocol and product. 6. Observation and interview on 2/10/26 at 2:50 p.m. with resident 49 in his room revealed: *He was sitting in his recliner with his feet elevated. *He stated that he was unable to transfer from his wheelchair to his recliner without the staff's assistance. *He had a urinary catheter, and the drainage bag was lying directly on the floor. *There was no dignity bag (a specialized cover to conceal urinary drainage bags from the public view) or other cover around the drainage bag. There was no barrier between the drainage bag and the floor to protect it from potential contamination. *He said he did not put the drainage bag on the floor, and then said, I guess they [staff] put it on the floor when they got me in my chair. 7. Observation and interview on 2/11/26 at 10:30 a.m. with resident 49 in his room revealed: *He was sitting in his recliner with his feet elevated. *His catheter drainage bag was lying directly on the floor without a cover or a protective barrier. *He did not remember which staff member helped him get into his recliner that morning. 8. Observation and interview on 2/11/26 at 4:16 p.m. with CNAs P and Q in resident 49's room revealed: *Resident 49 was in his recliner with his feet elevated. *The catheter drainage bag was hanging on the elevated footrest of the recliner. *Neither CNA P or Q had hung the drainage bag on the recliner's footrest. *When asked about the previous observation of the drainage bag lying on the floor, both CNAs P and Q said that the drainage bag should not be lying directly on the floor. CNA Q stated, That is unacceptable, and indicated there should be a barrier between the drainage bag and the floor to prevent potential contamination. 9. Interview on 2/12/26 at 10:09 a.m. with assistant director of nursing (ADON) C revealed: *Their policy was to place a resident's catheter drainage bag into a dignity bag. *She expected the staff to secure the dignity bag to the resident's bed when a resident was resting in a recliner or bed. *The catheter drainage bags were not be directly on the floor due to infection control concerns. 10. Review of the provider's 6/6/25 Indwelling Catheter Use and Removal policy revealed: *Insertion, ongoing care and catheter removal protocols that adhere to professional standards of practice and infection prevention and control procedures. *Keeping the catheter anchored to prevent excessive tension on the catheter, which can lead to urethral tears or dislodgement of the catheter; *Securement of the catheter to facilitate flow of urine, prevention of kinks in the tubing and positioning below the level of the bladder. 11. Review of the provider's 5/2/25 Catheter Care policy revealed: *Privacy bags will be available and catheter drainage bags will be covered at all times while in use. 12. Review of the provider's undated Catheter Care Competency Assessment revealed: *The purpose of this procedure is to prevent catheter-associated urinary tract infections. *Infection Control -Be sure the catheter tubing and drainage bag are kept off the floor. 13. Observation and interview on 2/10/26 at 2:44 p.m. with resident 9 in her room revealed: *There was no personal protective equipment (PPE), which would include a gown or gloves, or sign on resident 9's door indicating she was on EBPs. *Resident 9 stated the staff did not wear a gown or gloves when they assisted her with toileting, getting dressed or transferring her. 14. Review of resident 9's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *Her 12/17/25 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact. *She had a 12/19/25 physician's order for Enhanced Barrier Precautions r/t [related to] MDRO [multi drug resistant organism (an organism that is resistant to most antibiotics)]: Hx [history] of E. coli [Escherichia coli (a bacteria that lives in the intestine, with some strains of these bacteria causing diarrhea, urinary tract infections, and pneumonia)] per standing orders. *Her 2/10/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated Enhanced barrier precautions r/t infection or colonization with CDC [Center for Disease Control] -targeted MDRO initiated on 12/19/25. -Gown and gloves [were to be worn by staff] during high-contact personal care activities. 15. Observation on 2/10/26 at 4:39 p.m. revealed there was no PPE or an EBP sign on resident 3's door to indicate he was on EBP. 16. Observation on 2/11/26 at 8:24 a.m. of resident 3 in his room revealed: *CNA O and care assistant W transferred resident 3, using a sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) from his wheelchair to the toilet. *CNA O and care assistant W were not wearing PPE. 17. Observation and interview on 2/11/26 at 3:24 p.m. with resident 3 in his room revealed: *He had a dialysis port in his right upper chest. *Resident 3 stated the staff did not wear a gown or gloves when they assisted him to the toilet, getting dressed, or transferred him. 18. Review of resident 3's EMR revealed: *He was admitted to the facility on [DATE]. *His 11/21/25 BIMS assessment score was 10, which indicated his cognition was moderately impaired. *He had a 11/19/25 physician's order for Enhanced Barrier Precautions d/t [due to] dialysis port [a surgically implanted catheter that allows blood to be removed, cleaned by a machine, and returned to the body for people with kidney failure]. *His 2/10/26 care plan stated, Enhanced barrier precautions d/t dialysis port initiated on 11/19/25. 19. Observation and interview on 2/11/26 at 10:04 a.m. with resident 7 in her room revealed: *There was no PPE or EBP sign on resident 7's door that indicated she was on EBP. *Resident 7 stated the staff did not wear a gown or gloves when they assisted her with toileting, bathing, or getting dressed. 20. Review of resident 7's EMR revealed: *She was admitted to the facility on [DATE]. *Her 12/22/25 BIMS assessment score was 10, which indicated her cognition was moderately impaired. *She had a 2/27/25 physician's order for Enhanced Barrier Precautions r/t MDRO. *Her 2/10/26 care plan stated, Enhanced barrier precautions r/t infection or colonization with CDC-targeted MDRO SPECIFY: hx of ESBL [Extended-spectrum beta-lactamase (an enzyme produced by bacteria that makes the resistant to many antibiotics)] (1/2/2020) initiated on 11/18/24. -Don [put on] gown and gloves during high-contact personal care activities. 21. Review of the provider's undated resident care sheet (an abbreviated resource for staff members to refer to when providing resident care) revealed: *Resident 3 was not indicated as being on EBP. *Resident 7 was indicated to require EBP due to a wound and a line (an intravenous line, a feeding tube, or a dialysis port). *Resident 9 was indicated to require EBP due to an MDRO. 22. Interview on 12/11/26 at 2:01 p.m. with CNA O revealed: *She would know if a resident was on EBP if there was PPE and an EBP sign hanging on the outside of the door. *Residents 3 and 7 were not on EBP because there was no PPE or an EBP sign hanging on the outside of their rooms that indicated they were on EBP. *Resident 3 was admitted to the facility with a dialysis access port. *CNA O stated resident 3 probably should have been on EBP, since his admission, due to his dialysis access port. 23. Interview on 2/12/26 at 12:11 p.m. with ADON C revealed: *The staff knew a resident was on EBP when there was PPE and an EBP sign hanging on the outside of the resident's door. *The residents were to be on EBP if they had a urinary catheter, a feeding tube, a wound, a history of or a current MDRO, or a dialysis access port. *A gown and a pair of gloves were to be worn anytime the staff provided direct care for residents on EBP. *Resident 3 had a dialysis access port when he was admitted to the facility. *Resident 3 was supposed to be on EBP, but when he moved rooms, his EBP sign and PPE must not have moved with him. *Resident 7 was to be on EBP for her history of ESBL in her urine. *She was not aware that resident 7 did not have PPE or an EBP sign on her door to indicate to the staff that she was on EBP. *On 12/19/25 medical director V ordered resident 9 to be on EBP, ADON C stated she did not know why he had written that order. *She was not aware resident 9 did not have PPE or an EBP sign on her door. 24. The director of nursing (DON) was not in the facility or available for an interview during the survey. 25. Review of the provider's 4/11/25 Enhanced Barrier Precautions (EBP) policy revealed: *'Enhanced barrier precautions' (EBP) refer to an infection control intervention designed to reduce transmission of multi-drug resistant organisms that employes targeted gown and gloves during high contact resident care activities. *The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high- [contact resident care activities.] *The facility will have the discretion in using EBP for residents who do not have a chronic wound or indwelling medical device and are infected or colonized with an MDRO that is not currently targeted by CDC but may be considered epidemiologically important. *Implementation of Enhanced Barrier Precautions: -Make gown and gloves available immediately near or outside of the resident's room. -Ensure access to alcohol-based hand rub in every resident room (ideally both inside and outside of the room). -The Infection Preventionist will incorporate periodic monitoring and assessment of adherence to determine the need for additional training and education. *High -contact resident care activities include: -Dressing[.] -Bathing[.] -Transferring[.] -Providing hygiene[.] -Changing linens[.] -Changing briefs or assisting with toileting[.] -Device care or use: central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes, hemodialysis catheters, PICC [peripherally inserted central catheter] lines, midline catheters[.] -Wound care: any skin opening requiring a dressing[.]

Based on observation, interview, record review, manufacturer's recommendations for use, and policy review, the provider failed to ensure residents were evaluated for the ability to safely administer their medications or had a physicians order for two of two sampled residents (55 and 65) who were observed self-administering their medications and for 0ne of one sampled resident (62) observed with a medication left at her bedside by one of one certified medication aide (CMA) (M). Findings include: 1.Observation and interview on 2/10/26 at 1:45 p.m. with CMA K in resident 55's room revealed CMA K administered resident 55's nebulizer (a device that converts liquid medication it an inhalable mist) treatment. After placing the nebulizer medication inside the medication cup, CMA K attached the face mask to the medication cup and secured the nebulizer mask over resident 55's nose and mouth. CMA K started the nebulizer machine, and turned the machine on to start the treatment. CMA K stated she would return to the resident's room in 10 to 15 minutes when the treatment was completed which was CMA K's usual practice. Observation and interview on 2/10/25 at 2:40 p.m. with CMA K revealed she returned to resident 55's room to turn off the nebulizer machine, remove and clean the face mask. CMA K had spaced it [forgotten] and dd not return to resident 55's room [ROOM NUMBER]-15 minutes after she had started the treatment. Review of resident 55's electronic medical record (EMR) revealed her Brief Interview for Mental Status (BIMS) assessment score was six. That indicated the resident had severe cognitive impairment. She had a medication self-administration assessment completed on 6/9/25. It indicated the resident was safe for neb [nebulizer] self administer [self-administration] after [the nebulizer was] set up [by staff.] Staff will return to monitor usage and shut off [the] machine. There was no physician's order that indicated resident 55 was safe to self-administer her nebulizer treatment. 2. Observation on 2/11/26 at 8:00 a.m. of CMA L administering resident 65's inhaler revealed CMA L turned the base of the inhaler until it clicked, opened the inhaler cap and handed it to the resident. The resident shook the inhaler, placed her lips around the mouthpiece and dispensed one puff into her mouth. She opened her mouth after she took that puff, and the inhaled medication drifted out of her mouth. The resident self-administered the second puff from the inhaler in the same manner. Interview on 2/11/26 at 8:05 a.m. with CMA L regarding resident 65's inhaler self-administration revealed she knew the resident did not properly self-administer the inhaler. She thought the resident would have been able to correctly self-administer the inhaler with verbal instruction, but CMA L did not provide that instruction to the resident. Review of resident 65's EMR revealed she was admitted to the facility on [DATE]. Her BIMS assessment score was 15. That indicated the resident's cognition was not impaired. She was not assessed to determine her ability to safely self-administer her inhaler. There was no physician's order that indicated the resident was safe to self-administer her inhaler. Review of the manufacturer's instructions for use of the Stiolto respimat inhaler revealed: 3. Exhale: Breath out fully, away from the inhaler.4. Inhale: Seal lips around the mouthpiece, avoiding covering the air vents. While taking a slow, deep breath, press the dose-release button.5. Hold: Continue breathing in and hold breath 5-10 seconds. 3. Observation and interview on 2/11/26 at 11:40 a.m. with resident 62 while CMA L administered her medications revealed that on top of her over-the-bed table, there was a clear plastic cup with an amber colored liquid in it. The resident stated that the cup contained a get well soon medication. She was not able to remember who had given her that cup or how long the cup had been there. CMA L removed the cup from the resident's room after she administered the resident's medications. Interview on 2/11/26 at 11:45 a.m. with CMA L revealed she thought the liquid inside the cup removed from resident 62's room was Prostat, a physician-ordered nutritional supplement that was administered to the resident each morning. CMA L had administered the resident's scheduled Prostat earlier that morning. Review of resident 62's EMR revealed she was admitted to the facility on [DATE]. Her BIMS assessment score was 11. That indicated resident 62 had moderate cognitive impairment. A medication self-administration assessment was not completed with the resident. There was a physician's order for one ounce of Prostat to be administered each morning to promote wound healing. That order did not indicate that the Prostat was able to be left at the resident's bedside. 4. Interview and EMR review on 2/11/26 at 10:00 a.m. and at 12:10 p.m. with assistant director of nursing (ADON) C revealed that resident 55's medication self-administration assessment was not current and was to be updated quarterly, but that did not occur. Resident 55 did not have a physician's order to self-administer her nebulizer treatment, but she should have. CMA K should not have left resident 55 unattended during her nebulizer administration. There was no medication self-administration assessment or a physician's order that supported resident 65's ability to self-administer her inhaler. She expected CMA L not have allowed resident 55 to self-administer her inhaler.Regarding resident 62's Prostat, ADON C had determined that on the morning of 2/10/26, CMA M had left resident 62's Prostat on her over-the-bed table without confirming if she was safe to self-administer that medication. There was no medication self-administration assessment or a physician's order that supported resident 62's ability to self-administer her Prostat. She expected CMA M to not have left resident 55's Prostat on her over-the-bed table without confirming she had consumed it. ADON C was responsible for ensuring medication self-administration assessments were completed for appropriate residents upon a resident's admission to the facility, quarterly, and with a significant change in the resident's condition. ADON C was responsible for ensuring there was a physician's order for a resident to self-administer a medication. 5. Review of the provider's revised 5/16/25 Resident Self-Administration of Medications policy revealed A resident may only self-administer medications after the facility's interdisciplinary team has determined which medications may be self-administered safely and has a provider order to do so. 4. A self-administration of medication assessment will be completed to determine if a resident is safe to self-administer medications prior to allowing them to do so.16. A re-assessment for safety at a minimum should be considered by the interdisciplinary team for the following: a. Significant change in resident's status. b. Medication errors occur. c. Quarterly.

Based on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan was reviewed with the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of six newly admitted sampled residents (3, 61, and 69). 1. Review of resident 3's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *His baseline care plan scanned into his EMR on 9/22/25 and was not dated or signed by the staff member who completed it. *There was no signature from resident 3 or their representative to indicate resident 3's baseline care plan was reviewed with them. 2. Review of resident 69's EMR revealed: *She was admitted to the facility on [DATE]. *Her 1/30/26 baseline care plan signed by LPN/wound care nurse G. *There was no signature from resident 69 or their resident representative to indicate resident 69's baseline care plan was reviewed with them. 3. Interview on 2/11/2026 at 3:00 p.m. with ADON C revealed: *She had reviewed resident 3's and 69's care plans and there was no documentation that the residents' baseline care plans were reviewed with the resident or the resident's representative, that a copy was offered to them within 48 hours of admission to the facility. *She was not aware that documentation of the resident or resident's representative review of the baseline care plan or that they were offered a copy of it was required. 4. Review of resident 61's EMR revealed: *She was admitted to the facility on [DATE]. *Her 1/16/26 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated her cognition was moderately cognitively impaired. -There was no documentation that the baseline care plan was reviewed with the resident or the resident's representative, or that a copy was provided to them. -The staff member who completed the baseline care pan did not sign or date it. 5. Interview on 2/12/26 at 9:36 a.m. with ADON C revealed: *The facility's process for completing residents baseline care plan begins before the resident's admission to the facility which included an interdisciplinary team (IDT) meeting being conducted to review and discuss the admission huddle checklist (checklist that described what the resident needed or liked while being at the nursing home). *Once the resident arrived and was settled in their room, the admission nurse would meet with the resident and their family to review the admission huddle checklist. *When the baseline care plan was completed it waw placed in a binder located at the nurse's station. *When the physician conducted their initial assessment of the resident, the resident's baseline care plan was presented by the facility to the physician for review. 6. Review of the provider's 5/5/25 Baseline Care Plan policy revealed: *The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: a. Be developed within 48 hours of a resident's admission. *A supervising nurse shall verify within 48 hours that a baseline care plan has been developed. *A written summary of the baseline care plan shall be provided to the resident and representative in a language that the resident/representative can understand. *A supervising nurse or MDS [Minimum Data Set] nurse/designee is responsible for providing the written summary of the baseline care plan to the resident and representative. *The person providing the written summary of the baseline care plan shall: a. Obtain a signature from the resident/representative to verify that the summary was provided. b. A copy of the summary will be maintained in the medical record. *If the summary was provided via telephone, the nurse shall indicate the discussion, sign the summary document, and make a copy of the written summary before mailing the summary to the resident/representative.

Based on record review, interview, and policy review, the facility failed to ensure a resident's advance directives (a legal document that expresses a person's health care wishes if they become unable to speak for themselves)/code status (specifies the type of emergent treatment a person wishes to receive if their heart or breathing would stop) was accurately documented for staff to implement the resident's chosen wishes for one of one sampled resident (20) with documented code status discrepancies.Findings include: 1. Review of resident 20's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 7, which indicated her cognition was severely impaired.*There was a banner displayed in her EMR, which indicated that she did not want CPR (cardiopulmonary resuscitation, an emergency procedure to provide chest compression and often rescue breathing to preserve brain function and maintain blood circulation).*Her care plan had a [DATE] initiated advance directive focus area that indicated I have a DNR [do not resuscitate] order.*There was a [DATE] physician's order for DNR.*Her signed [DATE] advance directive indicated that she wanted CPR/Full resuscitative measures. 2. Interview on [DATE] at 2:45 p.m. with social services director (SSD) R revealed:*She was responsible for obtaining the residents' advance directives when they were admitted to the facility, and advance directives were reviewed periodically during care conferences.*She acknowledged that resident 20's code status did not match her advance directive.*She acknowledged that resident 20 had a physician's order for DNR that did not match her advance directive for over four years.*She did not have an explanation for how this occurred. 3. Observation and interview on [DATE] at 12:18 p.m. with certified nursing assistant (CNA) T revealed:*There was a cheat sheet that listed all the residents in each hall. It had information about how to care for each resident, including the resident's code status, how they were able to transfer, their scheduled bath days, and which dining room they ate in.-Resident 20 was listed as having a DNR code status on that sheet.*He stated there was another way to know a resident's code status, and that was by looking at the icons posted next to the residents' name plates outside of their room door. There would either be a heart icon (indicating a CPR code status) or a flower icon (indicating a DNR code status).-Resident 20 had a flower icon next to her nameplate. 4. Review of the provider's [DATE] Residents' Rights Regarding Treatment and Advance Directives policy revealed:* On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulate an advance directive.* Upon admission, should the resident have an advance directive, copies will be made and placed on the chart as well as communicated to staff.* During the care planning process, the facility will identify, clarify, and review with the resident or legal representative whether they desire to make any changes to any advance directives.* Decisions regarding advance directives and treatment will be periodically reviewed as part of the comprehensive care planning process, the existing care instructions and whether the resident wishes to change or continue these instructions.* Any decision making regarding the resident's choices will be documented in the resident's medical record and communicated to the interdisciplinary team and staff responsible for the resident's care.

Based on observation, interview, record review, and policy review, the provider failed to ensure the staff followed nursing professional standards of practice for following physician's orders for insulin administration for one of one sampled resident's (67) who was administered according to the physician's order by one of one observed licensed practical nurse (LPN) (H). Findings include:1. Observation and interview on 2/11/26 at 8:20 a.m. with LPN H in resident 67's room revealed she was checking the resident's blood sugar level. The amount of Novolog (insulin) she would administer to the resident was contingent upon the resident's blood sugar level.Resident 67's blood sugar level was 232. LPN H was not surprised that the number was a little high because the resident had already eaten two breakfasts that morning.2. Interview and review of resident 67's medication administration record (MAR) on 2/11/26 with LPN H revealed there was a 5/24/25 Novolog insulin physician order that indicated, based on the resident's blood sugar level of 232, that she was to receive three units of Novolog. The order also indicated that Novolog was to be administered before meals.LPN H acknowledged she did not follow the physician's order to administer resident 67's Novolog before the resident had eaten breakfast. LPN H knew that Novolog was a rapid-acting insulin (starts working within five to ten minutes of administration) and was used to improve blood sugar control, which was why it was ordered to be administered before meals. She stated it was difficult to ensure that morning blood sugar testing and insulin administrations for residents occurred at their scheduled times due to the number of residents who required morning blood sugar testing and insulin administration.3. Interview on 2/11/26 at 5:00 p.m. with assistant director of nursing (ADON) C revealed she expected LPH H to administer resident 67's Novolog according to the physician's order, but that did not occur.Review of the provider's revised 5/7/25 Medication Administration policy revealed 10. Ensure that the six rights of medication administration are followed. Those rights included administering medication at the e. Right time.

Based on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, interview, record review, and policy review, the provider failed to ensure staff implemented interventions for one of one sampled resident (1) identified with risk for burns from hot liquids, who subsequently sustained a burn from hot coffee. Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: Her admission date was 4/15/25.The resident's Hot Liquid Safety Evaluation with an effective date of 9/8/25 indicated she required a cup with a lid or other adaptive cup and a clothing protector and/or lap protector when she drank hot liquids.Resident 1's 9/8/25 revised care plan revealed: I am at risk for hot liquid spills, please ensure I use a cup with a lid and am sittingupright for all hot beverages.Her 9/10/25 Brief Interview for Mental Status (BIMS) assessment score was 14. That indicated she had no cognitive deficits.2. Review of the provider's 9/10/25 FRI regarding resident 1 revealed:On 9/10/25, resident 1 had requested certified nurse aide (CNA) H to fill her personal Thermos cup with coffee. Neither the facility's bistro kitchen nor the primary kitchen had coffee available to serve.Cook E told CNA H there was coffee in the employee breakroom. He was not aware that CNA H would not have known to cool the breakroom coffee before she had poured it into resident 1's cup.The lid on the Thermos cup of coffee was tightened before CNA H handed the cup to resident 1. A short time later, resident 1 was heard calling out for help from her room. She stated that when the coffee in her cup reached her mouth, it was too hot. She expelled the coffee from her mouth onto her chest. Small blisters had formed on her upper chest where she had been burned. Resident 1 was not wearing a clothing protector at the time of the incident. The resident's medical provider was notified of the incident and ordered Lidocaine (a topical analgesic) to be applied to the resident's burn.The provider's post-incident interview with CNA H revealed she did not know there were temperature differences between the kitchen and bistro coffee and the breakroom coffee. Residents were not expected to be served coffee from the employee breakroom because the temperature of that coffee was not monitored. Through the provider's secure electronic messaging system, all staff were immediately reminded that residents were not to be served coffee from the employee breakroom. Additional staff education was provided during the provider's 9/12/25 Nursing Department Meeting. Hot beverage education was also added to the provider's new staff orientation checklist.Resident 1's care plan was updated after the above accident to include: any hot beverage served to resident 1 was expected to be served in a lidded cup. The use of her lidded Thermos remained appropriate. 3. Interview on 9/29/25 at 12:37 p.m. with cook E revealed resident 1 was currently using her lidded Thermos cup to drink coffee. If that cup was not available or if she preferred, her coffee was served in one of the kitchen's insulated coffee mugs. Those mugs had no fitted lids.Cook E stated that the kitchen did not maintain a list of residents who required specific accommodations, such as lids, when they were served hot beverages.4. Interview on 9/29/25 at 1:35 p.m. with dietary manager D revealed that the kitchen had no coffee mugs with fitted lids for residents' use. 5. Interview on 9/29/25 at 2:00 with director of nursing (DON) B revealed that after resident 1's 9/10/25 burn, she had observed the resident between 9/11/25 and 9/16/25 to ensure her coffee was being served in a lidded mug. Those audits ended after 9/16/25.DON B had not seen resident 1 use anything other than her lidded Thermos cup to drink hot beverages.6. Observation on 9/29/25 at 2:05 p.m. of resident 1 in her room with DON B and interview with resident 1 revealed the resident was lying in her bed. The resident's Thermos was not seen. Resident 1 did not know where her Thermos was or when she last saw it.Resident 1 stated that she sometimes used an unlidded coffee mug from the kitchen to drink her coffee from.Interview on 9/29/25 at 2:10 p.m. with DON B confirmed that neither the recommendations from resident 1's above Hot Liquid Safety Evaluation nor the intervention on her above care plan to ensure she used a cup with a lid for hot beverages were followed to mitigate resident 1's risk for burns from hot liquids.Review of the provider's Quarter 3, 2018 Safety of Hot Liquids policy revealed:4. Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk from burns. Such interventions may include b. Serving hot beverages in a cup with a lid;Review of the providers' revised 5/16/25 Incidents and Accidents policy revealed:Policy Explanation: The purpose of incident reporting can include: Assuring that appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care.

Based on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, summary of investigation review, record review, interview, and policy review, the provider failed to ensure a resident's medication needs were met, which included ensuring:A physician-ordered PRN (as needed) medication for the treatment of prolonged seizure activity was available for administration to one of one sampled resident (1).A physician-ordered PRN medication was accurately transcribed in one of one sampled resident's (1) electronic medical record (EMR).Findings include: 1. Review of the provider's 8/5/25 FRI revealed:On 8/4/25, resident 1 fell out of her bed and onto the floor. The fall was not witnessed. Staff heard the noise of the fall and responded by finding [resident 1] next to her bed. She continued to seize [a sudden burst of abnormal electrical activity in the brain that may include uncontrolled muscle movement and changes in a person's level of awareness] for many more seconds. [The] Nurse who discovered her [resident 1] called for support. [That nurse] Attempted to grab PRN [as needed] Diazepam nasal spray [a medication used to stop prolonged seizing] but it [that medication] was not present in [the medication] cart. This nurse grabbed PRN Ativan [an anti-anxiety medication that can be used to treat prolonged seizure activity] 0.5 mg [tablet] and administered it buccal [the space between the cheek and the teeth]. Within 10-15 seconds of buccal administration, [the] resident's seizure stopped and she began communicating with staff. The facility had determined that the PRN Diazepam nasal spray was not available to administer to resident 1 because the pharmacy was waiting for the resident's medical provider to complete and return pre-authorization paperwork that was needed to order that medication. According to the facility's investigation, the facility staff contacted resident 1's medical provider and asked that either he promptly complete and return the pre-authorization paperwork or that the provider discontinue the order for the PRN Diazepam nasal spray. The facility's response to not having resident 1's PRN nasal spray available for administration was to ask the pharmacy to notify the facility staff anytime a medical provider failed to promptly complete and return the pre-authorization paperwork to the pharmacy. The facility would then follow up directly with that medical provider.2. Review of resident 1's electronic medical record (EMR) revealed:A 6/18/25 physician's order: Diazepam intranasal 10 mg, 1 spray in each nostril PRN for status epilepticus [prolonged seizure activity]. A 9/22/25 progress note completed by that same physician included the above PRN Diazepam nasal spray on resident 1's active medication list.Review of resident 1's July 2025 through September 2025 medication administration records (MAR) revealed:A 7/24/25 order for Ativan, 0.5 mg every 24 hours as needed (PRN) for anxiety, seizure disorder. On 9/10/25, that order was discontinued, and Ativan 0.5 mg every 24 hours as needed for anxiety was ordered. A seizure disorder was no longer identified as a clinical indication for administering resident 1's PRN Ativan. 3. Interview on 9/29/25 at 2:10 p.m. with certified medication aide (CMA) F revealed resident 1 did not have PRN Diazepam nasal spray available in the medication cart for administration if the resident had a prolonged seizure. 4. Interview on 9/29/25 at 2:20 p.m. with licensed practical nurse (LPN) C regarding resident 1's PRN Diazepam nasal spray revealed that spray was ordered on 6/27/25 by the resident's medical provider, but the facility did not receive the medication.5. Interview on 9/29/25 at 4:00 p.m. with DON B revealed resident 1's 9/10/25 PRN Ativan physician's order was incorrectly transcribed in resident 1's EMR to not include that it could be administered to resident 1 for prolonged seizures.DON B confirmed that without an available supply of resident 1's PRN Diazepam nasal spray or physician's orders to administer PRN Ativan for prolonged seizures, resident 1 had no medication to treat a prolonged seizure since 9/10/25. Resident 1 has had no prolonged seizure since that time.DON B stated she had sent a secure electronic message in mid-August 2025 to resident 1's medical provider. An order for an alternative seizure medication for resident 1 and the discontinuation of the PRN Diazepam nasal spray. She had not received any response to that request.DON B confirmed that resident 1's primary medical provider or other medical providers within that medical practice group were in the facility for resident visits no less than three times weekly. DON B did not speak face-to-face with any of those providers regarding an alternate seizure medication option for resident 1 and the discontinuation of the PRN Diazepam nasal spray.Review of the provider's revised 6/15/25 Medication Orders policy revealed:3. Elements of the Medication Order: [included] j. Diagnosis or indication for use.4. Documentation of Medication Orders: [included] b. Clarify the order.Review of the provider's revised 6/15/25 Medication Reordering policy revealed:2. Acquisition of medications should be completed in a timely manner to ensure medications are administered in a timely manner.5. In the event of new orders, the facility is allowed (24) hours to begin a medication unless otherwise specified by the physician.

Based on a South Dakota Department of Health (SD) (DOH) facility-reported incident (FRI) review, record review, interview, job description review, and policy review, the provider failed to implement comprehensive trauma-informed care for one of one sampled resident (1) with post-traumatic stress disorder (PTSD-a disorder in which an individual has difficulty recovering after experiencing or witnessing a traumatic event). Findings include: 1. Review of the provider's 9/10/25 FRI revealed resident 1 had requested certified nurse aide (CNA) H to fill her Thermos cup with coffee. Shortly after filling and returning that cup to the resident, the resident was heard calling out for help from her room. She stated that when the coffee reached her mouth, it was hot, and she expelled the coffee from her mouth onto her chest, resulting in a hot liquid burn.When director of nursing (DON) B spoke with resident 1 after the incident, the resident became upset. She told DON B that, as a child, her mother had burned her. The facility was aware that resident 1 had experienced childhood abuse, but did not know she was intentionally burned by a family member. Resident 1 stated that the above burn incident had triggered her to have thoughts of harming herself. The resident's medical provider was updated, and resident 1 was transferred to a nearby hospital for evaluation related to those thoughts of self-harm.2. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the nursing home from a hospital on 4/15/25. Before the hospitalization above, the resident was a participant in a community-based service agency that served individuals with developmental disabilities (conditions that begin in childhood and result in physical, learning, language, and/or behavior impairments that last a lifetime) (DD).Her 4/15/25 hospital discharge summary and physician's orders had included the following diagnoses: DD, anxiety, major depressive disorder, post-traumatic stress disorder (PTSD), and a seizure disorder.A psychiatrist's name was beside PTSD on the problem list in that same report.Her 9/10/25 Brief Interview for Mental Status (BIMS) score was 14, which indicated her cognition was intact.Resident 1's 4/16/25 Trauma Assessment score was zero. A trauma screen was considered positive for scores of 14 or greater. Her 6/21/25 Trauma Assessment score was eight. It included that the resident felt upset and was bothered a little bit when something reminded her of a stressful experience from the past. She also had avoided activities or situations a little bit because they had reminded her of a stressful experience from the past. A 6/16/25 psychiatry progress note indicated that resident 1 wanted to speak with a therapist like the one she had talked to regularly at the community-based DD program. That same note stated resident 1 had past psychiatric hospitalizations and suicidal thoughts at times, but had not acted on them and did not have a plan to act on them. A trauma-informed care plan was not initiated for resident 1 until after her 9/10/25 burn incident.A 9/16/25 Social Services Designee (SSD) progress note indicated that resident 1 was seen by a counseling service on that day and was given different exercises to perform when she was anxious.3. Interview on 9/29/25 at 3:00 p.m. with SSD G regarding resident 1's trauma-informed care revealed:She agreed that the above Trauma Assessments failed to identify the resident's trauma history, her developmental and functional history, her support network, or her strengths and coping mechanisms.SSD G stated that resident 1 had not shared much information with her regarding her trauma history. All SSD G had initially known about resident 1's PTSD was that the resident had experienced abuse by her parents in her childhood.SSD G agreed she should not have waited until resident 1's 9/10/25 burn incident to initiate resident 1's trauma-informed care plan. She felt, during the five months since the resident's admission, that the staff had gotten to know resident 1 better. Resident 1's individualized trauma information was appropriate to have included in a trauma-informed care plan and would have helped staff care for and interact with the resident to address her PTSD needs. SSD G confirmed she could have, but did not attempt to obtain psychiatric information regarding resident 1 from either the psychiatrist identified in the resident's 4/15/25 hospital discharge summary or the therapist referred to in the 6/16/25 psychiatry progress note.She did not request a copy of the resident's individual service plan that the DD agency had followed to manage the resident's PTSD and mental health concerns from resident 1's contact person, who was also the resident's caseworker at the DD program. SSD G had not followed up with the counselor referred to above, whom the resident 1 saw on 9/16/25, regarding the exercises the resident was encouraged to use when she was anxious. She agreed that those exercises may have been appropriate to have been carried over and implemented by the nursing home staff. SSD G felt that resident 1 would have no problem signing a release of information to allow SSD G to obtain records from the above individuals. Review of the provider's revised 6/16/25 Trauma Informed Care policy revealed:2. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a previous traumatic event, as well as screening and assessment tools such as the Resident Assessment Instrument (RAI), admission Assessment, the history and physical, the social history/assessment, an others.4. The facility will collaborate with resident trauma survivors, and as appropriate, the resident's family, friends, the primary care physician, and any other health care professionals (such as psychologists and mental health professionals to develop and implement individualized care plan interventions.10. In situations where a trauma survivor is reluctant to share their history, the facility will still try to identify triggers which may re-traumatize the resident, and develop care plan interventions which minimize or eliminate the effect of the trigger on the resident.Review of the provider's undated Social Services Director (SSD) job description revealed it was the responsibility of that SSD to assure that the medically related emotional and social needs of the resident are met and maintained on an individual basis.

Based on record review, interview, observation, job description review, and policy review, the provider failed to promote the resident's right to quality of life to ensure:*Seven of eighteen sampled residents (1, 2, 3, 4, 5, 6, and 7) received staff assistance to have been bathed no less than weekly and per their individual preference. *There was an accurate and consistent process for documenting resident baths in each resident's electronic medical record (EMR). Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE]. * Her 5/13/25 Brief Interview for Mental Status (BIMS) assessment score was 11, which indicated she had a moderate cognitive impairment. *Her 5/10/25 care plan focus area and intervention for dressing/grooming/bathing indicated she required extensive assistance from one staff person with her bath. Review of resident 2's 5/5/25 through 6/3/25 bath book documentation and her EMR bathing documentation revealed:*Her baths were scheduled every Monday and Thursday on thelong-term care bath schedule a.m. lists. *There was no documentation that she had bathed from 5/12/25 through 5/22/25.*Scheduled baths that were not provided had not been rescheduled. *Resident 2 had not refused baths during that time.2. Review of resident 3's EMR revealed:*She was admitted to the facility on [DATE]. *Her 4/15/25 BIMS assessment score was 14, which indicated she was cognitively intact. *Her 5/26/25 care plan focus area and intervention for dressing/grooming/bathing indicated she required extensive assistance from one staff person with her bath. Review of resident 3's 5/5/25 through 6/3/25 bath book documentation and her EMR bathing documentation revealed:*The resident had been scheduled for one bath and was bathed on 5/14/25 during that period.*No other baths were scheduled or recorded in the EMR or on the bath sheets during that period. *Scheduled baths that were not provided had not been rescheduled. *Resident 3 had not refused baths during that time.Interview on 6/3/25 at 2:52 p.m. with resident 3 in her room revealed:*She stated she received one bath each week on Tuesdays. *She indicated she did not receive her scheduled Tuesday morning bath on 6/3/25.*Staff did not provide her with an explanation or reschedule the bath. *She expressed she preferred two baths a week and that she did not receive her baths consistently.3. Review of resident 4's EMR revealed: *She was admitted to the facility on [DATE]. *Her 4/15/25 BIMS assessment score was 9, which indicated she had a moderate cognitive impairment. *Her 4/25/25 care plan focus area and intervention for dressing/grooming/bathing indicated she required extensive assistance with her shower once a week. *She occasionally refused her showers. Review of resident 4's 5/5/25 through 6/3/25 bath book documentation and her EMR bathing documentation revealed:*Her shower was scheduled on the Saturday/Sunday long-term care bath schedule a.m. lists. *It was documented in her EMR and on the bath sheet that she refused her shower on 5/10/25.*There was no documentation that she had bathed after her refusal on 5/10/25 during that period. *Scheduled showers that were not provided had not been rescheduled. Interview on 6/3/25 at 3:05 p.m. with resident 4 in her room revealed:*She preferred a shower once a week during the daytime.*She was unable to recall if she received her shower from staff on a consistent basis.4. Review of resident 5's EMR revealed:*She was admitted to the facility on [DATE]. *Her 3/18/25 BIMS assessment score was 1, which indicated she had a severe cognitive impairment. *Her 3/15/25 are plan focus area and intervention for dressing/grooming/bathing indicated she required extensive assistance from one staff person with her bath. Review of resident 5's 5/5/25 through 6/3/25 bath book documentation and her EMR bathing documentation revealed:*Her bath was scheduled every Thursday on the long-term care bath schedule a.m. list. *She exhibited behaviors and refused bathing and other care occasionally. *There was no documentation that she had bathed from 5/8/25 through 5/22/25.*Scheduled baths that were not provided had not been rescheduled. 5. Review of resident 6's EMR revealed:*She was admitted to the facility on [DATE]. *Her 5/6/25 BIMS assessment score was 6, which indicated she had a severe cognitive impairment. *Her 5/6/25 care plan focus area and intervention for dressing/grooming/bathing indicated she required extensive assistance from one staff person with her bath. Review of resident 6's 5/5/25 through 6/3/25 bath book documentation and her EMR bathing documentation revealed:*Her bath was scheduled every Thursday and Sunday on the long-term care bath schedule p.m. list. *There was no documentation that she had bathed after 5/1/25.*Scheduled baths that were not provided had not been rescheduled. *Resident 6 had not refused baths during that time.6. Review of resident 7's EMR revealed: *She was admitted to the facility on [DATE]. *Her 6/3/25 BIMS assessment score was 8, which indicated she had moderate cognitive impairment. *Her 5/26/25 care plan focus area and intervention for dressing/grooming/bathing indicated she required extensive assistance from one staff person with bathing. Review of resident 7's 5/5/25 through 6/3/25 bath book documentation and her EMR bathing documentation revealed:*Her bath was scheduled every Wednesday and Sunday on the long-term care bath schedule p.m. list. *There was no documentation that she had bathed after 5/21/25.*Bathing information was not recorded in the EMR or on the bath sheets. *Scheduled baths that were not provided had not been rescheduled. *Resident 7 had not refused baths during that time.7. Interview on 6/3/25 at 10:40 a.m. with certified nursing assistant (CNA)/bath aide E revealed:*Each hall (200, 300, and 400) were staffed with one CNA and one bath aide during the day shift. *The day shift bathing tasks for residents in Hall 200 were shared between the scheduled bath aide and the CNA. *The bath aide was responsible for ensuring all baths for residents who resided in the 300 and 400 halls were completed. *The CNA assigned in the 200 hall was responsible for ensuring baths for those residents were completed. *The evening shift was staffed with three CNAs who shared the responsibility for completing the scheduled evening baths. *Resident bathing started at 6:00 a.m. and stopped at approximately 7:15 a.m. for staff to assist residents with getting to breakfast.*Resident bathing would then resume between 8:30 a.m. and 9:00 a.m. 8. Review of resident 1's EMR revealed:*He was admitted to the facility on [DATE].*His diagnoses included a traumatic brain injury, seizure disorder, and left side paralysis.*His 5/13/25 BIMS assessment score was six, which indicated he had severe cognitive impairment. *His 8/30/24 updated bathing/dressing/grooming care plan interventions indicated he required total assistance from one staff person with his bathing. Review of resident 1's 5/5/25 through 6/3/25 bath book documentation and EMR bathing documentation revealed:*He had been bathed one time, on 5/23/25 during that period.*Scheduled baths that were not provided had not been rescheduled. *Resident 1 had refused no baths during that time.9. Interview on 6/3/25 at 2:30 p.m. with ADON C regarding resident bathing documentation revealed:*Bathing documentation was written on bath forms that were kept in a bath binder. It was the responsibility of the designated bath aide to have completed those forms each day. -Resident names on the daily bath forms changed each day based on individual resident's scheduled bath days.*Daily bath form documentation from the bath binder was transferred to each applicable resident's EMR by the designated bath aide. Continued interview at 3:00 p.m. with ADON C and DON B regarding the resident bathing process revealed: *They expected all residents to have received the necessary assistance from the staff to have been bathed no less than once weekly.*One of two designated daytime bath aides was scheduled weekdays from 6:00 a.m. until 2:30 p.m. to complete resident baths. Those two bath aides had been in their positions for a consistent amount of time.-At times, the daytime bath aide was expected to fill a scheduled CNA work shift if a scheduled CNA could not work that day. Baths may not have been provided on those days.*ADON C was reviewing the daily bath book documentation to identify residents who had missed their scheduled baths. She had flagged those resident names in the bath book for the bath aide to have known their baths needed to be made up the following day. -There was no consistent process to ensure those missed baths that were flagged had been made up by the bath aide the following day.*DON B and ADON C thought the bathing documentation failed to account for bathing refusals and data entry mistakes that may have occurred when the bath book documentation was transferred to a resident's EMR. *Resident 1 was scheduled for evening baths to help him sleep and because his demeanor was better in the evening.-DON B stated evening and weekend baths were provided to accommodate resident preferences and support the completion of missed bathing opportunities. It was a newer process and she felt the staff who had assisted those residents with their baths were not as familiar with bath aide expectations like the daytime bath aides were. *DON B and ADON C confirmed resident 1's bathing documentation failed to support he had been bathed more than one time during the above 30 day period reviewed. That had not met their minimum expectation for him to have been bathed at least weekly.10. Interviews on 6/3/25 at 3:32 p.m. with ADON C and at 3:50 p.m. with DON B regarding residents 2, 3, 4, 5, 6, and 7's bathing documentation revealed they confirmed the bathing documentation failed to support those residents had been bathed more than one time weekly during the period reviewed or were offered bathing after refusing a bath during the period reviewed. That had not met their minimum expectation for resident bathing to have occurred.A Bath Aide job description was requested on 6/3/25 at 4:50 p.m. from administrator A. At 5:05 p.m. DON B stated the bath aide job description and the certified nurse aide job description were the same. Review of the provider's May 2019 revised Certified Nursing Assistant job description revealed: Summary: The primary purpose of the position is to ensure the highest quality of resident care available .Review of the provider's March 2018 revised Activities of Daily Living policy revealed:*2. Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with:a. Hygiene (bathing, dressing, grooming, and oral care);

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, record review, interview, and personnel file review, the provider failed to protect the resident's right to be free from physical abuse by one of one registered nurse (RN) (B) while providing evening cares for one of one sampled resident (1). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 1/15/25 SD DOH FRI revealed the provider had determined physical abuse had occurred when RN B slapped resident 1 while providing evening cares on 1/14/25. Observation on 1/28/25 at 10:00 a.m. in resident 1's room revealed: *She was sleeping in her recliner with a blanket over her lap. *A gray call light was on the bedside table to her right. *She had a fall mat on the floor next to her bed. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE] and her diagnoses included hemiplegia and hemiparesis (partial paralysis) following nontraumatic subarachnoid hemorrhage (bleeding between the brain and tissue covering the brain) affecting left non-dominate side, dementia, restlessness, agitation, anxiety, and dysphasia (condition that affects understanding and speech). *Her Brief Interview for Mental Status (BIMS) assessment score was an 8 which indicated she had moderate cognitive impairment. *Two skin assessments were completed as follows: -On 1/15/25 at 12:04 a.m. Bruising to R [right] side of forehead from previous fall, R [right] side of face and cheek-redness, R [right] skin tear has reopened-are cleansed and redressed -On 1/15/25 at 3:30 a.m. one red scratch mark-unopen, cleanse left open to air, three scratch marks that are re, superficial unopen, cleansed and left open to air, bruising to R [right] side of forehead from prior fall, skin tear to R [right] forearm-dressed *The resident's care plan was updated on 1/15/25 to reflect staff were to: -Monitor for increase/changes in mental anguish, fear, intimidation, and address accordingly. Changes in skin or pain. Notify POA [Power of Attorney], MD [Medical Director], LNHA [Licensed Nursing Home Administrator]. -Encourage to participate in activities outside of room, including meals and other social activities. -1:1 (one-to-one) validation of feelings and concerns, as needed. *The provider had multiple progress notes entered that showed her behavior was pleasant toward staff, they had not noticed any new behaviors since that incident had occurred *On 1/22/25 the facility entered and IDT (interdisciplinary team) note as follows: -*[Resident 1] has not displayed fear, intimidation, changes in mood, changes in daily routine, activities, meals, or interactions with staff and residents. [Resident 1] has been her normal self, and had not mentioned the incident. -*[Resident 1] has no changes with activities, she enjoyed pet visit per normal, joined art projects observations and people watching, enjoyed seeing the projects other residents completed, socializing with residents during other activities, no fear or intimidation, participating per her normal activity. -*Social Services has visited with [Resident 1] on numerous days since incident. [Resident 1] has no changes in mood, has not recalled the incident. She has had no changes in daily routine, does not show fear or intimidation. Has been enjoying increased visits. Interview on 1/28/25 at 1:06 p.m. with certified nursing assistant (CNA) C regarding the incident involving resident 1 and RN B revealed: *She stated resident 1 did not want to go to bed, and RN B had been forcing her. -CNA C stated RN B told her a skin assessment needed to be completed. *She felt uncomfortable with what RN B was doing and tried to leave, but RN B told her she had to stay. *RN B had been forceful with her handling of the resident, the resident hit her and RN B then slapped resident 1's face. *After RN B slapped resident 1, CNA C and CNA D told RN B she needed to leave and that they would finish getting resident 1 ready for bed. *CNA C stated RN B pulled her aside later and told her what happened had been her fault, CNA C should not snitch on her and RN B would call the administrator. *CNA C had worked with resident 1 since the incident and resident 1 had not shown any new behaviors or fear when she had assisted resident 1 for bedtime. Interview on 1/28/25 at 1:31 p.m. with CNA D regarding the incident involving resident 1 and RN B revealed: *She came in at 9:00 p.m. for her shift to relieve CNA C, and she could tell RN B was agitated when she arrived. *She stated RN B told both the CNA that resident 1 wanted to lie down, but CNA D stated that resident 1 did not want to lie down. *When resident 1 refused to lie down, RN B seemed upset and pushed her backward in her wheelchair, transferred her onto her bed, and started taking resident 1's clothes off of her. *She confirmed CNA C tried to leave but RN B would not let her. *Resident 1 was getting upset and was hitting and slapping RN B. *After RN B slapped resident 1 she said CNA C and herself told RN B to leave and they would get resident 1 ready for bed. *She stated RN B pulled her aside and told her not to snitch on her and that she would tell the administrator. *CNA D had worked with resident 1 since the incident and resident 1 had not shown any new behaviors or fear when she assisted resident 1 for bedtime. Review of RN B's personnel files revealed: *Her professional certification or licenses were current, and her pre-employment background checks identified no areas of concern. *Her mandatory resident rights and abuse/neglect training's were current. *She was terminated on 1/15/25. Interview on 1/28/25 at 2:00 p.m. with LNHA A revealed: *The incident was reported to the South Dakota Board of Nursing. *The incident was reported to the local law enforcement. *All residents were interviewed and the residents that were not able to be interviewed, had orders in their charts to monitor for psychological changes, signs and symptoms of mental anguish, fear, intimidation, behavioral changes, oral intake, withdrawal, isolation, sleep changes/nightmares, or depression. The provider's implemented systemic actions to ensure the deficient practice does not reoccur was confirmed on 1/28/25 after: *Education was provided to staff on abuse and neglect and how to deal with difficult residents. -Interviews with the two CNAs revealed they understand that education regarding those topics. *Handouts to all staff members regarding burnout including: -Reason for burnout. -What is burnout? -Preventing burnout. -Stages of burnout. -Symptoms of burnout. *Resident 1's care plan was revised to reflect any behavioral changes, and the interventions put into place for staff to notify the nurse. *Monthly nurse meetings included the topics of abuse and neglect. *All staff were interviewed and understood the education provided regarding expectations of abuse prevention including reporting, any observations of staff verbally, physically, or mentally abusing a resident. Based on the above information, non-compliance at F600 was determined on 1/14/25, and based on the provider's implemented corrective actions for the deficient practice confirmed on 1/28/25, the non-compliance is considered past non-compliance.

Based on interview, observation, record review, and policy review, revealed the provider failed to ensure one of one sampled resident's (3) pressure injuries had been identified, assessed, documented, and her physician was notified. Findings include: 1. Interview on 10/16/24 at 8:05 a.m. with director of nursing (DON) B regarding resident 3's Stage III pressure ulcer that was listed on the facility provided Matrix revealed that pressure ulcer was healed at the beginning of September 2024. Interview on 10/17/24 at 10:09 a.m. with certified nursing assistant (CNA) N regarding resident 3's skin concern revealed: *She had sores on her buttock and on her inner thigh, one [is the] size of [a] quarter [the] other's [the] size of [a] dime. -She had sores on her heels in the past, but currently did not. *She had notified licensed practical nurse (LPN) M of the sores. Interview on 10/17/24 11:05 AM with CNA I regarding resident 3's skin revealed: *She had a little tiny one [sore] in between her thighs. -She thought a nurse was aware. Interview on 10/17/24 at 11:29 a.m. with DON B regarding resident 3's skin condition revealed: *She did not currently have any pressure injuries. -She had pressure injuries on both of her heels in the recent past that had healed. Review of resident 3's electronic medical record (EMR) revealed: *Nurse's progress notes that indicated: -On 9/6/24 area of breakdown to the back of Achilles heel. --The areas are not open and the L [left] heel at 1.5 cm [centimeters] long is worse that the R [right] at 1.0 cm long. Both measuring approximately 0.6 cm wide. Origin unknown. -On 9/11/24 Resident has two pressure areas to bilateral heels. R heel measurement (cm): 0.3 x 0.3 L heel measurement (cm) 0.4 x 1.4. Right heel is a small fully ruptured blister thathas [that has] a small open area where all fluid has drained out and epithelial tissue remains intact otherwise. -On 9/18/24 Resident had been on weekly wound rounds for a small blister to each heal [heel] and both are now healed. Observation and Interview on 10/17/24 at 3:00 p.m. with assistant director of nursing (ADON) C regarding resident 5's skin concern revealed: *Left proximal posterior upper leg with an open area that was an approximate size of 0.4 cm by 0.4 cm open area with 2 cm by 6 cm of raised nonblanchable skin surrounding the open area. *Left proximal posterior heel at approximately 0.2 cm x 0.5 cm that she identified as a suspected deep tissue pressure injury. *ADON C confirmed that she was not previously aware of resident 3's current skin issues, she wishes someone would have told me about it. Interview on 10/17/24 at 3:15 p.m. with registered nurse (RN) T regarding resident 3's skin condition revealed: *Her thighs were excoriated (skin was wearing off). *No staff member had asked for a silicone patch to be placed on her skin to assist in the prevention of a pressure injury. -She was not aware of resident 3 having pressure injury. Interview on 10/17/24 at 3:19 p.m. with RN J regarding resident 3's skin condition revealed: *She completed a skin assessment on 10/16/24. -She had looked at [her] bottom and looked at [her] heel she had not seen anything unusual. -After discussion of resident 3's pressure ulcer's on her posterior upper leg and posterior heel she stated, Those don't happen overnight. Interview on 10/17/24 at 3:30 p.m. with CNA N regarding resident 3's skin condition revealed: *She had notified nurse licensed practical nurse M a week previous that her bottom was open at that time and it wasn't big but open, right where [her] leg and butt cheek connect. *She stated she thought other nurses had been aware of the skin concern. Interview on 10/17/24 at 3:35 p.m. with DON B regarding resident 3's current pressure injuries revealed: *She confirmed the pressure injuries had not been assessed, documented, and her physician notified. *Her expectation for pressure injuries was that: -A professional nurse was to complete a full head-to-toe skin assessment. -The resident's physician was to be contacted with any concerns. -A risk management report was to be completed. Review of the provider's April 2018 Pressure Ulcers/Skin Breakdown-Clinical Protocol policy revealed: *The nursing staff and practitioner will assess and document an individual's significant risk factors for developing pressure ulcers; for example, immobility, recent weight loss, and a history of pressure ulcer(s). *In addition, the nurse shall describe and document/report the following: -a. Full assessment of pressure sore including location, stage, length, width, and depth, presence of exudates or necrotic tissue; Review of the provider's March 2020 Pressure Injuries Overview policy revealed: *Staging (National Pressure Injury Advisory Panel Classification System) *Deep Tissue Pressure Injury (DTPI): Persistent non-blanchable deep red, maroon or purple discoloration -Intact or non-intact skin with localized area of persistent non-blanchable deep red, maroon, purple discoloration or epidermal separation reveals a dark wound bed or blood-filled blister. -This injury results from intense and/or prolonged pressure and shear forces at the bone-muscle interface. *The wound mat [may] evolve rapidly to reveal the actual extent of tissue injury, or many [may] resolve without tissue loss.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Food plated for residents who received late, in-room mealtrays during one of one observed meal service were served at an appetizing temperature. *One of one resident's (43) room trays were delivered in a timely manner to ensure food temperatures were appetizing during two of two observed meal services. Findings include: 1. Observation on 10/16/24 from 5:05 p.m. through 6:10 p.m. of the evening meal service and interviews with cook F during that same time revealed: *Food for the evening meal was temped in the kitchen before placing it on the steam table in the main dining room (MDR) prior to serving. -Hot foods were all at an acceptable serving temperature. *Cook F plated the evening meals for residents in the following order: -Regular room trays (room trays for residents who regularly ate their meals in their rooms), the Bistro dining room, the MDR, and late trays (residents who usually ate in the Bistro or the MDR but had chosen to eat in their rooms for that meal). *At 5:05 p.m. cook F began plating the regular room trays using plates removed from a dual plate warmer. -Plates inside the two cylinders of the warmer rose six to eight inches above the lip of each cylindher cylinder opening that prevented those plates from being warmed. *A red light on the right side warmer was lit which indicated the warming cylinder was on but the light on the left side warmer was unlit. -Cook F thought the left side warmer may not have been working properly. *Instructions on top of the warmer read: Adjust thermometer inside tube. -Cook F had not known at what temperature the thermometer inside each tube was set at *Maintenance director D was responsible for making temperature adjustments to the warmer. -She had not discussed her concerns regarding the left side warmer with him. *Regular room trays and the portable steam table used to serve meals in the Bistro left the MDR for resident distribution at 5:15 p.m. *Residents sitting in the hall outside of the MDR were allowed into the MDR at 5:15 p.m. -MDR residents were scheduled to receive their meals at 5:30 p.m. *Between 5:15 p.m. and 5:30 p.m. cook F and dietary aide R had taken drink orders from the residents in the MDR and assisted them to complete their menus for the following days meals. -During that same time, the food containers on the steam table had been left uncovered. *Cook F stated the only food-related complaint she had heard from residents was lately their food had been cold. *At 5:40 p.m. plating and serving of the evening meal for residents in the MDR began. *At 6:00 p.m. the following temperatures were taken from the uncovered food containers on the steam table immediately before the late resident room trays were plated: -Mashed potatoes/122 degrees Fahrenheit (F), asparagus/102 degrees F, gravy/78 degrees F, and fish/80 degrees F. *Cook F indicated she had lowered the temperature on the steam table so the gravy would not burn. -That had likely affected the temperatures of all the other food held on that steam table. -The length of time it had taken to serve all the residents, the uncovered containers on the steam table, and the possibility the plate warmer may not have been functioning properly and may also have contributed to the low food temperatures. *Frozen ice cream cups were the dessert for that same evening meal. -A box of 48 stacked ice cream cups sat directly on top of a Blue Ice re-usable freezer pack in the MDR food serving station area. *Cook F confirmed the ice cream cups were soft and runny by the time they were served to residents who received late trays. 2. Observation and interview on 10/17/24 at 9:15 a.m. with maintenance director D of the dual plate warmer revealed: *The temperature gauge inside of both warmers was set between 1 and 2. -The plate warmer guide inside of the warmers regarding plate warmer temperatures indicated the following: Warm=1 and 5=Hot. Interview on 10/17/24 at 4:30 p.m. with administrator A regarding food holding temperatures revealed: *Hot food temperatures were not held and served at an expected temperature of at least 135 degrees F. *Frozen food was not kept at a temperature to prevent thawing from occurring. *There were opportunities to improve the food service delivery process to ensure food temperatures for all meal services were kept at an appetizing temperature. 42558 3. Observation and interview on 10/15/24 at 12:47 p.m. with resident 43 while in his room located in the 200-hallway revealed: *He was fully reclined in his recliner chair with oxygen being delivered by nasal cannula. *He stated he attended renal dialysis on Mondays, Wednesdays, and Fridays. *He had requested the noon meal to be delivered to his room. *He stated: -He hoped his food would arrive soon because he was hungry. -I never know when I will get it [this meal tray]. -It was his preference to eat his meals in his room so he could avoid sitting on a sore that was on his tailbone. -The hot food was always cold by the time the meal trays arrived. -He did not like most of the foods that were served to him. -He had quit filling out the meal preference sheets because he never received what he had ordered. -He sent his meal trays back to the kitchen in the past, but no alternatives were offered, and his food was never heated up and returned, so he had quit asking. Interview on 10/15/24 at 12:55 p.m. with dietary aide Q regarding meal tray service to the resident rooms revealed: *The noon meal service started at noon. *She stated the late room trays were normally delivered at 12:40 p.m. following the dining room meal service, but she was running a little bit late. -There were early meal trays that were delivered before the dining room service for those who always stayed in their rooms, and late meal trays were delivered following the dining room service for those residents who occasionally requested a tray for their room. Further interview on 10/15/24 at 1:04 p.m. with resident 43 in his room revealed he had not received his noon meal tray and he stated he was becoming angry because he was very hungry. Observation on 10/15/24 from 1:09 p.m. through 1:27 p.m. of the nurse's station adjacent to the 200-hallway revealed: *At 1:09 p.m. the plated and covered meal trays were delivered on a cart to the nurse's station, and staff were notified by walkie-talkie that the trays were ready to be delivered. *At 1:12 p.m. the tray cart remained sitting by the nurse's station while four unidentified staff members visited behind the nurse's desk. *At 1:19 p.m. an unidentified resident walked up to the covered meal tray cart and lifted the lid off a tray to view the food, removed a lid off a drink, took a sip, and then replaced those lids. -That tray was immediately removed from the cart by a staff member and taken back to the kitchen. -That meal cart was then taken down each hallway for delivery of the late room trays. -An unidentified aide walked the meal cart past resident 43's room twice without delivering any food to him nor explaining to the resident why his tray was late. Resident 43 continued to wait for his lunch meal. *At 1:27 p.m. resident 43 was delivered a noon meal tray to his room. -That was eighteen minutes after the meal cart had been delivered to the nurse's station and over forty-five minutes past the normal late tray delivery time. Observation and interview on 10/15/24 at 1:27 p.m. and at 3:47 p.m. with resident 43 following delivery of his noon meal tray revealed: *He stated his pulled-meat barbeque sandwich and his potato wedges were cold. -He had requested hot water and a green tea bag and was served a cup of slightly warm coffee along with a sealed green tea bag. He had no hot water for the tea bag. *He stated, I'll eat the coleslaw only. It's [the food] crap. It's always cold. *At 3:47 p.m., observation of resident 43's room revealed his noon meal tray remained sitting on his table next to his recliner with the uneaten barbeque sandwich and potato wedges. 4. Observation, interview, and food temperature monitoring on 10/16/24 from 5:28 p.m. through 6:25 p.m. with resident 43 and his former wife while he awaited a meal tray to be delivered to his room revealed: *His meal tray arrived at 5:29 p.m. and contained baked fish with an internal temperature of 100.4 degrees, mashed potatoes at 103.7 degrees, and asparagus at 90 degrees. -The resident stated he hated fish and that he would only eat the asparagus. -His ice cream cup dessert had melted and was mostly liquified. -He admitted he had not filled out a meal preference ticket for that meal and stated, It's a waste of time because they won't give me what I want. *At 5:30 p.m., he asked his former wife to order him some chicken noodle soup. She went to the adjacent nurse's station and placed a request for the soup. *At 6:25 p.m. he had not received his requested soup and no staff had come into his room to check on his meal or to remove his meal tray. Interview on 10/16/24 at 6:26 p.m. with assistant director of nursing (ADON) C who was at the adjacent nurse's station regarding the soup request for resident 43 revealed: *None of the four staff members who were at the nurse's station had been there when the resident's former wife requested the soup at 5:30 p.m. *ADON C stated, Whoever was at the desk should have called the kitchen on the phone. Interview on 10/16/24 at 6:27 p.m. with dietary aide (DA) R in front of the adjacent nurse's station while he was pushing the meal cart with used meal trays to the kitchen revealed: *He confirmed he had heard about resident 43's request for soup. -He stated, I think we forgot. I'm sorry. *He confirmed having to wait nearly an hour for an alternative meal of soup was unacceptable. -He stated he was not in charge of alternative meals and the person who oversaw fullfilling alternative meal requests was cook F. Interview on 10/16/24 at 6:29 p.m. with cook F regarding resident 43's soup request revealed: *She stated: -We didn't get it written down and it went out of our brains. -I can get it right away if the aides would come and wait for it. -We could use another person as we only have three people to serve two dining rooms. *She confirmed it was not acceptable to forget an alternative meal request made by a resident. Interview on 10/16/24 at 6:35 p.m. with resident 43 while in his room revealed he stated he was tired from attending dialysis that day and wanted to lay down in his bed. His soup was delivered at that time, and he stated it was not hot enough for his liking but he would eat it anyway. Record review of resident 43's electronic medical record (EMR) revealed: *He was admitted on [DATE] following a hospitalization . *He had a Brief Interview of Mental Status (BIMS) score of 15, indicating he was cognitively intact and could make his own decisions. *His relevant diagnoses included end-stage renal disease, dependence on renal dialysis, reduced mobility, weakness, renovascular hypertension, limitation of activities due to disability, atherosclerotic heart disease, hypertensive heart disease, pleural effusion, hypocalcemia, hyperlipidemia, hypomagnesemia, hyperuricemia, non-ST elevation myocardial infarction (NSTEMI), secondary hyperparathyroidism of renal origin, chronic pain, and a stage 4 pressure ulcer of the sacral region. *He was receiving comfort care services (a type of medical treatment that focuses on improving a patient's quality of life and comfort, rather than extending their life, and is often used for patients who are near the end of life). *He was admitted with a renal diet order, but the dietary order was changed to a regular diet on 7/24/24 because he was refusing most of his meals on the renal diet. *He had orders for an Ensure supplement drink once a day, along with Nepro and Prostat supplement drinks which he was refusing. He stated, They taste awful. *He was on a two gram low sodium diet and a 1,200 ml (milliliter) fluid restriction which was being monitored and documented every shift. *His weight would fluctuate daily depending on dialysis but he had remained stable, within five pounds, since his admission. Interview on 10/17/24 at 4:26 p.m. with administrator A regarding resident 43's meal service and food temperatures revealed: *She confirmed the holding temperatures of the foods could have been higher to maintain a more palatable temperature. *She was aware of what had occurred regarding his meal tray deliveries and his request for soup. She stated there needed to be a better way to deliver the meal trays to resident's rooms in a timelier manner. Review of the provider's 2019 Food Temperatures policy revealed: *1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 degrees F (fahrenheit). *3. Temperatures should be taken periodically to assure hot foods stay above 135 degrees F . Review of the provider's 2019 In-Room Dining (Room Service) policy revealed: *Procedure: -1. d. Insulated plate covers, coffee pots, mugs and bowls will help maintain food temperatures during delivery. All foods should be covered and delivered as soon as possible after plating to maintain food quality and temperature. -3. h. Hot food must be hot and cold food must be cold (as acceptable to the individual being served). Review of the provider's 2019 Early and Late Meals policy revealed: *Procedure: -3. Upon arrival on the nursing unit, it is the responsibility of the nursing staff to see that the meals are passed and individuals receive assistance as quickly as possible. *Late Trays: -2. After the meal is served, the cook/chef will reserve enough food for the meals that will be served later. Food should be held safely at the proper temperatures. -3.The nursing staff on the unit will prompt [promptly] serve the meal to assure proper food temperatures.

Based on interview, observation, record review, and policy review, the provider failed to ensure: *Residents maintained a sense of dignity by providing assistance to bathe once per week for 3 of 6 sampled residents (3, 6, and 26). *One of one sampled resident (18) had received staff assistance to change her clothes following one of two observed meal services in the Bistro dining room. *Staff had not stood over 2 of 2 observed residents (26 and 32) to assist them during 2 of 2 observed meal services in the Bistro and main dining rooms. *Two of two observed residents (5 and 29) were dressed in a dignified manner during one of one observed meal service in the main dining room. Findings include: 1. Interview and observation on 10/15/24 at 4:39 p.m. of resident 6 with certified nursing assistant (CNA) O in her room revealed: *She was lying in her bed, awake. -Her hair was shoulder-length and appeared to be greasy. *She stated she would like to receive one bath per week but did not always receive one. Review of resident 6's medical record revealed: *Her care plan indicated she preferred one bath per week and needed extensive assistance of one staff member to complete the bath. *Her bathing record indicated the following: -In August 2024 she received a bath on the 2nd, 16th, and 23rd. --In August 2024 she refused a bath on the 9th and 27th. -In September 2024 she received a bath on the 27th. -In October 2024 she received a bath on the 16th. Review of resident 3's medical record revealed: *Her care plan indicated she was to receive a bath once per week and she required the total assistance of a staff member to complete the bath. *Her bathing record indicated the following: -In August 2024 she received a bath on the 26th and the 28th. -In September 2024 she received a bath on the 4th, 13th, and 18th. -In October 2024 she received a bath on the 2nd and the 16th. Review of resident 26's medical record revealed: *His care plan indicated he required the total assistance of one staff member to complete a bath. *His bathing record indicated: -In August 2024 he received a bath on the 9th, 16th, and 19th. -In September 2024 he received a bath on the 16th, and 23rd. -In October 2024 he received a bath on the 4th. Interview on 10/17/24 at 10:09 a.m. with CNA N regarding resident bathing revealed: *She assisted residents with their bathing. *There was a bath schedule that listed when a resident was to receive a bath. -Most residents took a bath once a week. *Residents' bathing documentation was completed in their electronic medical record (EMR). -She confirmed no documentation of bathing was completed on paper. *When a resident refused a bath, she would notify a nurse. Interview on 10/17/24 at 11:05 a.m. with CNA I regarding resident's bathing revealed: *Residents received one or two baths per week. *When a resident refused a bath, she would notify a nurse and ask the resident later if they wanted to take a bath. *Residents' bathing documentation was completed in their EMR. Review of residents' bathing documentation and interview on 10/17/24 at 2:45 p.m. with director of nursing (DON) B and administrator A revealed: *Administrator A reviewed residents 3, 6, and 26 bathing documentation and confirmed the baths listed above for each resident was what had been recorded in their EMR. *The resident bath schedule was determined by their preferences identified during their admission process. -Those preferences can change weekly. *Each resident had a staff member advocate that reviewed: -That resident's appearance. -Their bathing documentation. *Visited with the resident at least one time each week and asked them if they had any concerns. -When a resident had a concern, their advocate would assist them in filling out a grievance form. *Documentation of a resident's bath was to be completed in their EMR. -They previously documented residents' baths on a paper form, this process was no longer be used. Review of the provider's February 2018 Bath, Shower/Tub policy revealed: * The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. *Documentation -1. The date and time the shower/tub bath was performed. -2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. -5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. -6. The signature and title of the person recording the data. *Reporting -1. Notify the supervisor if the resident refuses the shower/tub bath. -The policy did not indicate how often a resident would receive a bath or shower. 51472 2. Observation on 10/15/24 at 3:25 p.m. during initial tour of resident 18 in her room revealed: *She was lying in her bed with the head of the bed elevated. *A clothing protector was soiled and lying on the floor. *There was no food present at her bedside. *Her shirt was stained and soiled with food. *Her lips had dried food on them. *Her teeth had a layer of food residue on them. *Unknown CNA entered her room in response to her call light and did not address her appearance or clothing protector on the floor. Observation on 10/15/24 at 4:10 p.m. of resident 18 in her room revealed: *Unknown CNAs gowned and entered her room. -She changed her clothing. -She washed her face. -She cleaned her mouth. 42558 3. Observation on 10/15/24 at 12:10 p.m. during the noon meal service in the main dining room revealed: *Resident 32 was sitting in a wheelchair at a table and was not attempting to eat her meal independently. *She was being assisted with her meal by dietary aide (DA) Q. -DA Q stood next to the resident and spooned a pudding-like dessert into the resident's mouth. -She had not sat down next to the resident when she provided that assistance. -She left the dining room shortly following that observation. 47780 4. Observation on 10/16/24 at 8:30 a.m. in the Bistro dining room revealed: *Resident 26 was sitting in a wheelchair at a bedside table with a bowl with eggs, a plate with toast, and cups of liquids with straws in them, were placed in front of him. -Unlicensed medication aide/certified nurse aide (MA/CNA) H assisted the resident with eating his eggs while standing rather than sitting down next to the resident. -MA/CNA H walked away while resident 26 started eating his toast independently. -Resident 26 attempted to take a drink from a straw. MA/CNA H returned and stood in front of resident 26 and moved the straw to the resident's mouth. She then moved to his left and continued to stand while assisting him with his meal rather than sitting down next to the resident. -MA/CNA H walked away to talk to another staff member and assisted another resident out of the dining room. *CNA G stood up from assisting a different resident and walked over to an unidentified resident, stood to his left, and assisted him with his oatmeal rather than sitting down next to the resident. Interview on 10/16/24 at 8:47 a.m. with MA/CNA H regarding the above observation revealed: *She stated she had to stand rather than sit next to resident 26 because a chair and the bedside table were not at an equal height. *If she had sat, she was at fist level if he had swung at her. Interview on 10/16/24 at 9:00 a.m. with CNA G regarding the above observation of an unidentified resident revealed she: *Stated, We do what we can. *Stated sometimes he was able to. On the days he cannot feed himself they would have assisted him and that would have included them standing rather than sitting down next to him. Interview on 10/17/24 at 4:26 p.m. with administrator A regarding the above observations revealed: *She had been monitoring the staff for standing during mealtimes rather than sitting down next to the residents. *Staff had received disciplinary action for standing during mealtimes rather than sitting down next to the residents. *Agreed there had been a concern with staff standing during mealtimes rather than sitting down next to the residents. Review of the provider's 2019 The Dining Experience Policy revealed: *Policy: The dining experience will be person-centered with the purpose of enhancing each individual's quality of life and being supportive of each individual's needs during dining. Individuals will be provided with nourishing, palatable, attractive meals that meet daily nutritional, and/or special dietary needs and food preferences and are served at a safe and appetizing temperature. Individuals will be provided restorative dining services as needed to maintain or improve eating skills. -11. Staff will sit next to a person when assisting them with eating (rather than standing over them). 40788 5. Observation on 10/16/24 at 5:30 p.m. during the evening meal service in the main dining room revealed: *Resident 29 entered the dining room and then positioned himself in his wheelchair at an angle along the side of the dining table. *He wore a flannel shirt over the top of his t-shirt. -The center button of the flannel shirt was buttoned. *His bare stomach was exposed beneath the bottom edge of those shirts. Continued observation revealed: *Resident 5 entered the dining room and positioned himself in front of a dining table. *His bare stomach was exposed beneath the bottom edge of his green t-shirt. -He was unable to pull his shirt over his stomach to cover it because it appeared too small. Interview on 10/17/24 at 4:50 p.m. with administrator A regarding the above main dining room observations revealed residents 5 and 29 should have been verbally and or physically assisted with their clothing by staff to ensure their dignity had not been compromised. Review of the provider's February 2021 revised Dignity policy revealed: Each resident shall be cared for in a manner that promotes and enhances his or her sense of well-being, level of satisfaction with life, and feelings of self-worth and self-esteem.

Based on observation, interview, and policy review, the provider failed to ensure food items in one of one Bistro refrigerator/freezer and one of one walk-in refrigerator in the kitchen were properly labeled, dated, and/or covered. Findings include: 1. Observation on 10/15/24 at 4:50 p.m. in the Bistro kitchenette revealed: *A sign on the refrigerator: This fridge is for resident use only. Anything placed in this fridge for residents needs to be labeled with room number and the date it is placed. Anything in this fridge without a date or label will be thrown out. *Inside of the refrigerator were the following observed food items: -Two pieces of pizza in an undated and unlabeled plastic bag. -One unopened container of Yoplait peach yogurt marked with a resident room number and dated 8/9. The best by date on that container was 9/15/24. -Multiple pieces of sliced pepperoni in an undated and unlabeled plastic bag. -Half of a covered chocolate cream pie that was undated and unlabeled. -One unopened container of cottage cheese marked with a best by date of 10/7/24. -One piece of covered cherry pie in an undated and unlabeled plastic dish. -Two ham sandwiches in an undated and unlabeled plastic container. *In the freezer the following food items were observed: -A Lean Cuisine chicken parmesan dinner with a best by date of March 2024. -One carton of vanilla ice cream with a best by date of 9/7/24. -An uncovered chocolate Dairy Queen Blizzard cup with a spoon frozen inside of it. Observation on 10/16/24 at 4:45 p.m. of the walk-in refrigerator in the kitchen revealed: *Three undated cellophane-wrapped meat and cheese sandwiches. *One stainless steel container covered with torn aluminum foil labeled Beef for sandwich 10/14. Telephone interview on 10/17/24 at 2:00 p.m. with dietary manager E revealed: *The task of removing outdated food items was just added to kitchen staffs' weekly cleaning checklist. *No food items were to have been placed in any refrigerator or freezer without first properly covering, dating, and labeling that food item. Review of the provider's 2019 Food and Nutrition Services in Healthcare Policy and Procedure Manual revealed: *Food Production and Food Safety: -4.d. Leftovers must be dated, labeled, covered, cooled and stored in a refrigerator.

Based on observation, interview, and policy review the provider failed to ensure: *One of three public areas (300 wing) was free of urine odor, a chair did not have a urine odor, and carpet stains. *Two of three sampled residents rooms (12 and 18 ) were kept in a clean and homelike manner. *Two of three sampled residents rooms (6 and 18) were free of urine odor. 1. Observation on 10/15/24 from 9:30 a.m. through 9:45 a.m. of the public area located in the 300 wing revealed: *Lounge chairs in the common area that were made of cloth fabric. -A burgundy lounge chair smelled of urine. *A strong odor of urine was present throughout the area. *Brown stains were on the carpet in multiple locations. 2. Random observations on 10/15/24 from 12:45 a.m. through 4:34 p.m. of resident 18's room revealed: *There was a strong odor of urine in resident's 18's room. *A med cup with a dark yellow substance and an empty water glass was on the over-the-bed table. *Multiple creams, mouth swabs, and care items were on the top of the bedside table. *A pile of blankets and clothing was on the recliner. *An open closet door with resident belongings on the floor of the closet. *A gait belt was lying on the bare mattress of the bed. *A television (TV) table with two paper towels covering the TV table. -There was a butter knife and a soiled plastic cup cover on those paper towels. *Present on the floor were: -Black socks in front of the recliner. -A soiled clothing protector on the floor beside the bed. -An open package of incontinent briefs in the hallway just inside the door to the room, visible to anyone walking by. -Multiple wadded up tissues near the bed. -Dirt, dust, and food particles under the bed. Observation on 10/16/24 at 4:14 p.m. and on 10/17/24 at 9:30 a.m. of resident 18's room revealed: *The same observed items as 10/15/24. *Additional items that were observed included: *Present on the floor were: -A open, used, Betadine swab beside the head of the bed. -The wrapper for 4 x 4 gauze drain sponge on the floor in front of the bedside table. *Sit to stand sling was lying on the bare mattress of the bed. Interview on 10/16/24 at 4:44 p.m. with unlicensed medication aide/certified nurse aide (UMA/CNA) V regarding resident 18's room revealed: * When asked about the condition of the room he picked up some of the objects that were on the TV table and over the bed table. *Another CNA entered the room and made the bed. Interview on 10/17/24 at 4:32 p.m. with administrator A regarding resident 18's room revealed she stated, I'll have to check on it. Record review on 10/17/24 at 11:30 related to resident 18 revealed: *Her diagnoses included multiple communicable diseases that included hepatitis C and multi-drug resistant organisms. *She had a stroke affecting her dominant right side. -Her right hand was contracted. *She had an impaired immune system related to her chronic diseases. *Her care plan included she was at a high risk for infection. -She was on contact and enhanced barrier precautions (use of personal protective equipment such as gloves, gown, and/or eyewear). *She had a suprapubic catheter (tube surgically placed to drain urine) and required assistance from a staff member for suprapubic catheter care. 3. Interview on 10/15/24 at 11:37 a.m. with resident 12's daughter revealed: *She felt that the building and grounds were not cared for. *She stated that the facility smelled of urine and was dreary. *She stated that this was the fourth room that her mother had been in, since her admission on 8/16/23, and this room was cleaner than the previous rooms. *She reported that prior to the family having purchased sheets for her mother's bed, the bottom sheets often had holes in them and there was no top sheet on the bed. *She had witnessed that often the residents' beds were not made. *She stated that she had filed a grievance previously, but she did not feel that a change was made. 4. Observation on 10/17/24 at 11:45 a.m. of resident 6's room revealed a distinct odor of urine. 5. Interview on 10/17/24 at 2:45 p.m. with director of nursing B and administrator A revealed: *Each resident had a staff member advocate that reviewed: -That resident's appearance. -Cleanliness of their room and any non-cleanable surfaces. *Visited with the resident at least one time each week and asked them if they had any concerns. -When a resident had a concern, their advocate would assist them in filling out a grievance form. 47780 6. Interview on 10/17/24 at 2:35 p.m. with housekeeper U revealed: *She cleaned the hallway floors, both dining rooms and the residents' rooms daily. *Cleaning of the residents' rooms included she: -Removed trash bags from the trash cans and placed a clean trash bag in the trash can. -Swept the floors with a dry mop. -Cleaned the bathroom mirrors, cleaned the sink, cleaned and flushed the toilet. -Wiped the bedside tables and around the television stands. -Wiped all the handles in the residents' room. *She stated she would only dust if the residents were not in the room. *She stated she would get notified to clean up spills that happened during the day.

Based on interview, record review and policy review the provider failed to investigate one of one injury of unknown origin for one of one sampled resident (12) findings include: 1. Interview with resident 12's daughter on 10/15/24 at 11:37 a.m. revealed: *Resident 12 was sent to the emergency department on 9/24/24 due to an unresponsive episode. *Upon return to the facility, staff transferred resident 12 with a sit-to-stand lift. - One of resident 12's daughters noted her left leg was unstable and informed the staff member that was performing the transfer. *On 9/26/24 family of resident 12 demanded X-ray of resident 12's left leg. Review of resident 12's electronic medical record (EMR) revealed: *A 9/25/24 nurses note documented: c/o [complaints of] pain when moving the leg out or when the area above the knee is touched. No edema and no known injury. *On 9/26/24 she was seen by a Certified Nurse Practitioner. - On 9/26/24 an X-ray was ordered and an acute, displaced oblique fracture through the distal femoral diaphysis was diagnosed . Interview with director of nursing (DON) B on 10/16/24 at 3:45 p.m. regarding resident 12's fracture revealed: *On 9/25/24 she was notified of resident 12's left leg pain early in the a.m. * On 9/25/24 at 8:52 a.m. she notified the primary care provider of resident 12's left leg pain and her family was aware. -She received an order for an X-ray. -Family was present and aware of the X-ray order. *She stated that there was no known cause of resident 12's fracture and she had a history of pathological fractures. *She confirmed that she had not reached out to the emergency department to inquire about resident 12's pain or injury during her 9/24/24 visit. *She confirmed that she had not reported resident 12's fracture to any outside agency such as the South Dakota Department of Health (SD DOH). *She confirmed there was no documentation to support an investigation was completed. Review of the provider's September 2022 Abuse, Neglect, Exploitation or Misappropriation- Reporting and Investigating policy revealed All reports of resident abuse (including injuries of unknown origin), neglect, exploitation or theft/misappropriation of resident property are reported to local, state and federal agencies (as required by current regulation) and thoroughly investigated by facility management. Findings of all investigations are documented and reported.

Based on observation, interview, record review, job description review, and policy review, the provider failed to: *Maintain the temperature of the water in the three-compartment wash sink in the kitchen at a minimum of 110 degrees Fahrenheit (F). *Maintain the temperature of the water in the three-compartment sanitizer sink in the kitchen at a minimum of 75 degrees F. Those failures increased the potential risk of foodborne illnesses for the entire resident population who received meals that were prepared in the kitchen. Findings include: 1. Observation on 9/3/24 at 12:15 p.m. in the kitchen near the three-compartment sink revealed: *On the wall above the sink posted signage read: Dishwashing By Hand: The Basics. -Wash: 110 degrees F with detergent. -Sanitize: 75 degrees F with sanitizer. *A September 2024 Three-Compartment Sink Log that kitchen staff documented the temperature of the wash water used in the wash sink. -Wash Temp [temperature]: 110 degrees F was type-written at the bottom left corner of the log. -Five of five documented wash water temperatures were 90 degrees F or lower. Interview on 9/3/24 at 12:20 p.m. with cook C at the three-compartment sink revealed she: *Was hand washing cookware she used to prepare the noon meal. *Thought the water temperature in the wash sink should have been 104 degrees F and the water temperature in the sanitizer sink should have been 70 degrees F. *Documented the wash water temperatures for the morning meal services on 9/1/24, 9/2/24, and 9/3/24 as 90 degrees F or less. -Agreed based on the signage by the three-compartment sink, the wash water temperature should have been 110 degrees F and the sink sanitizer water temperature should have been 75 degrees F. Interview on 9/3/24 at 1:05 p.m. with dietary supervisor B revealed she: *Had not known the expectation for the wash water temperature in the three-compartment sink. -Stated it should be warmer than 90 degrees F. *Reviewed the Three-Compartment Sink Logs monthly only to ensure documentation was completed and not to ensure data was within the expected parameters. Continued interview with dietary supervisor B and cook C and review of the August 2024 Three-Compartment Sink Log revealed: *Under the wash temperature column, the wash water temperatures were either exceedingly high (up to 210 degrees F) or exceedingly low (70 degrees F). *Dietary supervisor B and cook C concluded: -Either the sanitizer water temperature or the PPM (parts per million-a measurement of the concentration of sanitizer) number was documented in the wash water temperature column for the entire month. --No wash water temperatures were documented in August 2024. *Under the PPM column of the log, 23 of 77 recorded PPMs were less than the expected 150-200 PPM range. *Dietary supervisor B and [NAME] C concluded: -The sanitizer water temperature was documented in the PPM column for most of the month. *53 of 77 recorded sanitizer water temperatures documented in the PPM column were not maintained at a temperature of 75 degrees F per the FDA's recommendation and the provider's policy. Notice: On 9/3/24 at 3:45 p.m., notice of immediate jeopardy (IJ) was given verbally and in writing to administrator A related to the provider's failure to ensure: *The wash water temperature in the three-compartment sink in the kitchen was maintained a temperature of 110 degrees Fahrenheit (F) per the Food and Drug Administration's (FDA) recommendation and the provider's policy. *The sanitizer temperature in the three-compartment sink in the kitchen was maintained at a temperature of 75 degrees F per the FDA's recommendation and the provider's policy. She was asked at that time for an IJ removal plan for the F812 deficient practice. On 9/4/24: *At 12:50 p.m. an IJ removal plan was received from administrator A. *At 1:12 p.m. the IJ removal plan was accepted. *At 1:30 p.m. while on-site the survey team verified the immediacy was removed. After the removal of the immediate jeopardy, the scope and severity of the citation level was F Plan: 1. DM [dietary supervisor] educated all dietary staff on the 3 sink [three-compartment sink] method, 3 compartment sink order, 3 compartment sink steps, water temperature in a 3 compartment sink, sanitizer temp [temperature], and when it is essential to clean and sanitize a utensil, sanitizer per manufacturer recommendations that include submerging for at least 1 minute. 2. Education to dietary staff on compartment sink log requirements of testing temps and sanitizer ppm, including action required if temps are not within the requirements. Education completed on 9/3/24. Those not educated on 9/3/24 will be educated prior to working next shift. 3. DM, primary dayshift cook, primary evening cook, are enrolled in ServSafe Certification to be completed on 9/3/24 by evening cook, 9/4/24 prior to working shift for dayshift cook, by end of day 9/4/24 for DM. 4. All new dietary staff will receive ServSafe certification and complete by 9/30/24. 5. A new log was created by DM to record wash, rinse, sanitizer water temperatures, and sanitizer ppm with each use, including what to do if temps or ppm are outside of parameters. 6. LNHA [administrator] provided education to DM on 9/3/24 on the policy and procedure manual, including 3 compartment sink method regulations, job description of the dietary manager including adherence to policies and ensure that sanitary regulations are followed by the entire department. 7. Education provided on supervisory roles including ensuring the department adheres to State and Federal regulations, and assuming the authority, responsibility and accountability to carry out the duties of the dietary department, monitor use of equipment and chemicals, and ensuring required documentation is competed and appropriate per regulations. 8. Education included reporting to LNHA any areas of concern within the dietary department, equipment, and chemicals. 9. Dietary manager will complete ServSafe certification by end of day 9/4/24. Review of the provider's undated Dietary Supervisor job description revealed the essential duties and responsibilities of the position included: Must ensure that safety precautions, sanitary regulations, infection control and universal precautions are followed by the entire department during daily work assignments. Review of the provider's 2019 Cleaning Dishes-Manual Dishwashing policy revealed: *Sink 1: Wash -3. Water should be at 110 degrees F. *Sink 3: Sanitize -1. Water should be 75 to 100 degrees F.

Based on observation, interview, record review, and policy review, the provider failed to identify and implement individualized interventions to prevent: *Facility acquired pressure ulcers from developing for five of five sampled residents (9, 32, 45, 56, and 73). *A blister from worsening and becoming a pressure ulcer for one of one sampled resident (62). Findings include: 1. Review of resident 9's medical record revealed: *She had been admitted on [DATE]. *Her Brief Interview of Mental Status (BIMS) score was three indicating she had severe cognitive impairment. *She had been admitted with a right wrist splint and right knee immobilizer. Review of resident 9's skin assessments between 1/15/19 and 5/21/19 revealed on: *1/15/19 she was admitted with a stage three pressure ulcer on her right buttock and a blister on her right rear thigh. *1/29/19 both were healed. *1/30/19 three wounds had been identified: -Unstageable pressure ulcer between right thumb and fore finger. -Stage two blister to the right upper thumb area. -Suspected deep tissue injury to the right lower thumb. *2/5/19 two additional pressure ulcers were identified on her right hand: -Outside of the right little finger. -Back of the right hand. *2/12/19 two additional pressure ulcers were identified on her right outer ankle. -One stage one. -One stage two. *2/19/19 a stage two pressure ulcer was identified on her right inner heel. *2/26/19 all the above pressure injuries were healed. *4/30/19 a stage two pressure ulcer was identified on her left buttock. *5/7/19 Area to left buttock is bigger. Resident has cushion to w/c (wheelchair). Is working with therapy so doesn't always get laid down. *5/14/19 she had completed wound care and an unstagable wound was found on her coccyx. *5/21/19 two new suspected deep tissue injuries were identified. -Left lower heel. -Left upper heel. Review of resident 9's 5/22/19 care plan revealed: *There were no focus, goals, or interventions related to the brace/splint she had been admitted with on her right hand. *She was identified to be at risk for skin breakdown on 1/15/19 and the interventions included: -Pressure reducing cushion to wheelchair (w/c) initiated on 1/18/19. -Weekly skin observations by a nurse initiated on 1/18/19. -Heel protector boots on both feet while in bed initiated on 5/21/19. -Pressure redistributing mattress on her bed initiated on 1/18/19. -Staff to monitor for potential skin breakdown imitated on 1/18/19. -Staff to lay her down between meals and reposition at least every two hours imitated on 5/6/19. Multiple observations of resident 9 on 5/21/19 from 7:51 a.m through 2:04 p.m. revealed: *Resident wearing no heel boots while in bed. *Resident wearing a heel boot only on her right foot in wheelchair and in bed. Observation and interview on 5/21/19 at 04:23 p.m. with licensed practical nurse (LPN) J of resident 9 revealed: *She had identified a circle about the size of a quarter on the inside of her left heel that was hard and unblanchable. *She was unable to locate two heel boots in the resident's room when finished with her assessment. *She had verified the one heel boot on the right foot had been put on incorrectly. Multiple observations on 5/22/19 and 5/23/19 from 8:15 am through 6:00 p.m. resident 9 had been wearing two heel boots correctly. Interview on 5/23/19 at 8:16 a.m. with the medical director regarding her role in wound management revealed: *She assisted with identifying people at risk, their risk factors, and implementing preventative measures. *Sometimes it was hard to determine if a wound was preventable. -Sometimes they knew they should have been more on top of the risk factors. *How to manage wounds after they had developed. *Utilized the wound care clinic, physical therapy, occupational therapy, speech therapy and dietary. *Resident 9's hand wounds were related to the wrist splint. -Nursing was to notify the physician when the splint had been moved or was ill fitting. -She had never observed her messing with the sling. Interview on 5/23/19 at 9:08 AM with the director of nursing (DON) and administrator regarding resident 9's pressure ulcers revealed: -There was no documentation for evaluating her for a low air loss mattress. -All mattress's in the facility were pressure redistributing and were evaluated by the manufacture annually. -The expectation would be for her to have both heel boots on at all times. 2. Review of resident 45's medical record revealed: *She was admitted on [DATE]. *Her BIMS score was zero indicating her cognition was severely impaired. *She required the extensive assistance of one staff member for bed mobility. *She required the extensive assistance of two staff members for transferring. Review of resident 45's weekly Pressure wound assessments from 4/21/19 through 5/21/19 revealed on: *4/21/19 four stage two pressure ulcers were identified. -Right buttock. -Left buttock. -Lower coccyx. -Upper coccyx. *4/23/19 right buttock pressure ulcer was healed. *4/30/19 all pressure ulcers were healed. *5/7/19 two pressure ulcers were identified. -Stage one on left outer ankle. -Stage two on right inner ankle. *5/14/19 she was seen by wound care and the pressure ulcers on her ankles were verified. Observation and interview on 5/21/19 at 1:45 p.m. of resident 45's pressure ulcers revealed: *Certified nursing assistant (CNA) O pointed out a spot on her left outer ankle that was painted with [MEDICATION NAME]. *She verified the resident had a pressure injury on her right inner ankle that was covered with a bandage. *She placed the resident's heel boots on after she was laid down in bed. Interview on 5/21/19 at 2:25 p.m. with resident 45's representative revealed: *She did not know about the pressure ulcers on her heels. *She did have a pressure ulcer on her buttock at one time. -She had been told they had healed the one on her buttock. Review of resident 45's 5/22/19 care plan revealed: *She was identified to be at risk of skin breakdown on 8/3/15. *On 8/3/15 she required frequent reminders to shift her weight when she was sitting in her w/c. -Revised on 4/29/19. *On 5/17/19 she needed to have a pillow between her knees and ankles to to prevent her skin from rubbing on itself. -She also needed heel boots to off load her feet. *On 4/24/19 a gel cushion was implemented for her w/c. *On 10/24/16 she needed assistance to change positions every two hours. Interview on 5/22/19 at 6:16 p.m. with the DON and administrator revealed: *Roho cushion (pressure relieving) was put into place on 4/23/19, prior to gel cushion, initiated on 4/24/19. -Verified interventions were put into place after she had developed four pressure ulcers on her buttock. *She would need to be assessed to know if she could off load herself. -She had needed less assistance when her care plan was developed. *The administrator personally educated staff to put pillows between her knees and ankles prior to the wound development. -She did that education on the day she was assessed to require a total body lift. (Date unknown) 3. Review of resident 73's medical record revealed: *She was admitted on [DATE]. *Her BIMS score was thirteen indicating her cognition was intact. *She was totally dependent on two or more staff members for: -Transfers. -Bed mobility. Her weekly pressure wound assessments from 5/2/19-5/21/19 revealed on: *5/2/19 a stage two pressure ulcer was identified on her left buttock. -Will try off loading from buttocks when in bed. *5/14/19 the area was healed. *5/21/19 stage two pressure ulcer was identified on her coccyx. Interview on 5/21/19 at 9:46 a.m. with Resident 73 revealed she had developed a sore on her buttock since her admission. Observation on 5/22/19 at 10:40 a.m. of resident 73 revealed she was her in w/c in her room with the Hoyer sling under her. Observation and interview on 5/22/19 at 2:07 PM with resident 73 revealed: *She was still sitting in her w/c. *She denied that she had been laid down, since getting up for therapy, after breakfast. *She was tearful and stated I am still in my damn chair when asked about repositioning. Observation and Interview on 5/22/19 at 2:10 p.m. with resident 73 revealed: *Two staff taking a total lift into her her room. *She was transferred into her recliner and staff left. *She indicated that at first her buttock hurt because of her pressure injuries. *When they began treatment for [REDACTED]. *She tried to move around in her chair when her bottom would hurt. *She would lay in bed for long periods of time without assistance to reposition prior to her pressure injuries. *She started to get assistance with repositioning after her pressure injury developed. Interview on 5/22/19 at 4:51 p.m. with the DON and administrator regarding resident 73 revealed: *Everyone who lives in the facility is to be repositioned every two hours unless specified otherwise. *It is standard for the resident to be repositioned every 2 hours even if she was in a w/c. Review of resident 73's 5/22/19 care plan revealed on 1/29/19: *She was identified to be at risk for skin breakdown. *She had a pressure redistributing pad on her chair and mattress on her bed. *She was to have a skin assessment by a nurse weekly and staff were to monitor for potential skin breakdown. *There was no indication to assist resident with repositioning. 4. Observation on 5/21/19 at 1:40 p.m. of LPN J while she completed wound care for resident 56 revealed: *The resident had a pressure relieving mattress on her bed and in her wheelchair. *There had been a white terry cloth hand towel underneath the resident's buttocks. -LPN J: --Asked the resident what it was for and she did not know. --Left that wrinkled, terry cloth towel was left in place. *LPN J assisted the resident to position on her left side. She: -Removed the [MEDICATION NAME] gentle and looked at her buttocks. -Stated: --There was a dark red area on her buttocks. --It was slightly elevated and irritated. --It extended upward from the resident's tailbone approximately four inches. -Completed the resident's treatment and had her onto her back. -Provided no care or additional interventions for the newly identified reddened skin area on the resident's tailbone. Review of resident 56's care plan with a print date of 5/22/19 revealed: *A focus area for a pressure wound. *The newly identified skin area of 5/21/19 had not been identified on the current care plan. *There had been no nonpharmacological interventions in place for the resident to assist her in repositioning and off loading her tailbone area. *There had been one intervention that stated the resident refused pillows and staff assistance. -Observations on 5/21/19 from 9:00 a.m. through 12:00 p.m. and again from 1:15 p.m. through 5:00 p.m. revealed no staff had been observed asking her if she wanted help to reposition. -Observation on 5/22/19 from 9:30 a.m. through 12:30 a.m. and again from 2:00 p.m. through 4:30 p.m. revealed no staff had been observed asking her if she wanted help to reposition. Interview on 5/23/19 at 10:45 a.m. with the DON regarding resident 56's revealed she agreed: *The wrinkled terry cloth towel should not have been left under her. *The reddened area on her buttocks had required follow-up by LPN J. 5. Observation on 5/21/19 at 1:20 p.m. of LPN J while she completed a dressing change to resident 62's right heel revealed: *The resident was sitting in her recliner. *No pressure relieving device on or under her right heel. *She removed the dressing from the resident's right heel. *Used a compact mirror to view the wound on her heel. *She stated Oh, the blister has opened. *Did not ask the resident or assist her to off load her right heel after the dressing change had been completed. Review of the weekly wound and pressure assessments for resident 62 revealed LPN J documented: *4/2/19 there had been a blister to the resident's right heel. *4/9/19 the fluid filled blister had been unchanged. * Area to right heel the blister had now popped. Area has separated at the upper edge flap intact. had moderate amount of drainage noted. will cover with [MEDICATION NAME] no [MEDICATION NAME] to area if more drainage may start to use calcium alginate. *4/23/19 a note by LPN J stated Resident blister broke open last week. Is dry no drainage noted. *5/21/19 LPN J recorded This presented as a fluid filled blister when admitted from hospital. Has been dry no fluid. Top of wound came off today with wound care. Area is bloody with serous sangious () drainage to area. Lower part of wound still has slough/eschar to wound bed. Are covering with foam border dressing over area. Review of resident 62's current care plan printed on 5/22/19 revealed: *A focus area for skin breakdown. *The interventions for the above areas had been I am refusing foam boots, staff will continue to offer these. offer pillows to offload heels when in bed. *Observations on 5/21/19 from 9:00 a.m. through 12:00 p.m. and again from 1:15 p.m. through 5:00 p.m. revealed no staff had been observed asking her if she wanted help to reposition. *Observation on 5/22/19 from 9:30 a.m. through 12:30 a.m. and again from 2:00 p.m. through 4:30 p.m. revealed no staff had been observed asking her if she wanted help to reposition. *there had been no area of intervention that had been nonpharmacological on resident 62's care plan. Interview on 5/22/19 at 10:30 a.m. with resident 62 revealed no staff ask her if she would like to off load her right heel while she is sitting in her recliner. She stated I don't always want to but they don't ask. I should have asked them. 6. Review of resident 32's 9/19/18 admission assessment Minimum Data Set (MDS) revealed: *Her admitted was 9/12/18. *Her 9/12/18 Braden scale assessment for predicting pressure sores was 13 indicating she was at moderate risk. *There was no Brief Interview for Mental Status (BIMS) assessment score due to significant cognitive impairment. *She required extensive assistance with a physical assist of one for: -Bed mobility. -Transfers. -Dressing. -Eating. -Toilet use. -Personal hygiene. *She was frequently incontinent of urine and bowel movements. *She was at risk for pressure ulcers (PU). *She had no unhealed PU's. *She had interventions in place for a: -Pressure reducing device for her chair. -Pressure reducing device for her bed. * There was no hospice or respite care. Review of resident 32's 12/18/18 quarterly MDS assessment revealed: *There was no Brief Interview for Mental Status (BIMS) assessment score due to significant cognitive impairment. *She was rarely understood. *She had a mechanically altered diet. *She required extensive assistance with a physical assist of two for: -Bed mobility. -Transfers. *She required extensive assistance with a physical assist of one for: -Dressing. -Eating. -Toilet use. -Personal hygiene. *She was always incontinent of urine. *She was frequently incontinent of bowel movements. *She was on a mechanically altered diet. *She was at risk of PUs. *She had one unstageable PU due to non-removable dressing/device. *She had two unstageable PU with suspected deep tissue injury's. *She had interventions in place for a: -Pressure reducing device for her chair. -Pressure reducing device for her bed. -Nutrition or hydration intervention. -PU care. *There was no: -Turning or repositioning schedule. -No hospice or respite care. Review of resident 32's 3/18/19 quarterly MDS assessment revealed: *There was no Brief Interview for Mental Status (BIMS) assessment score due to significant cognitive impairment. *She was rarely understood. *She had a mechanically altered diet. *She required extensive assistance with a physical assist of two for: -Bed mobility. -Transfers. -Dressing. -Eating. -Toilet use. -Personal hygiene. *She was frequently incontinent of urine and bowel movements. *She had no swallowing disorder. *She was on a mechanically altered diet. *She was at risk of PUs. *She had one stage two PU. *She had one stage four PU. *She had interventions in place for a: -Pressure reducing device for her chair. -Pressure reducing device for her bed. -Turning and repositioning schedule. -Nutrition or hydration intervention. -PU care. *There was no hospice or respite care. Interview on 5/23/19 at 9:08 a.m. concerning resident 32 with the director of nursing and administrator revealed: *The administrator meets with staff providing care. *She made sure interventions were in place and being provided to residents. *She stated resident 32 was on a repositioning schedule. -She expected everyone to reposition themselves if capable. *If unable to reposition themselves: -They would have contacted physical therapy (PT) and occupational therapy (OT). -Assessed for grab bars. -Put nutritional interventions into place. *She agreed there were no repositioning or foam boot interventions. -Stated even though there was no documentation, those interventions were done for everyone. *She agreed those interventions were not documented until after she developed PUs. Interview on 5/23/19 09:48 a.m. with the Medical Director, her nurse, and the administrator concerning resident 32 revealed: *She had dysphagia. *She had spoken with the daughter and established goals of care. -She was not to go to the hospital because of advancing: -Dementia. -Dysphagia. *She was to have no feeding tube. *She was not eating. *PT and OT were involved for: -A wheelchair cushion. -The safest way to transfer her. *Dietary was involved. *There was a swallowing evaluation performed. *The medical director stated with all the above in place she still developed a PU. *The medical director believed the PU was unavoidable. *She did agree there were other interventions that could have been in place proactively related to: -Foam boots. -Turning and repositioning schedule. -Nutrition and hydration interventions. *She agreed she did not have PUs when she was admitted . *She agreed she was at moderate risk of developing PUs when admitted . *The MD stated the resident's daughter agreed to sending her to wound care. *The facility did what they could to keep her comfortable and get her better. *If you would have asked me I would have thought that she would be in hospice. *Any PU on paper is unpreventable but you have to look at the person. *She took a dip and now she is functioning better. Review of resident 32's weekly wound care documentation for a right heel wound revealed: *Date of onset was 10/10/18. *It was facility acquired (FA). *A suspected deep tissue injury from 11/6/18 through 12/11/18. *A stage one PU on 12/11/18. *A stage one PU on 12/18/18. *Not staged on 12/24/18. *A stage three PU on 12/28/18 and 2/5/19. Review of resident 32's weekly wound care documentation for a left heel wound revealed: *Date of onset was 12/11/18. *It was FA. *A PU on 11/6/18 was not staged. *A stage three PU from 12/18/18 through 1/8/19. *A suspected deep tissue injury on 1/15/19. *A stage three PU from 1/22/19 through 1/29/19. *A stage three PU from 2/12/19 through 2/19/19. *A stage four PU from 2/26/19 through 3/5/19. *A stage three PU on 3/5/19. *A stage two PU from 3/12/19 through 4/02/19. Review of resident 32's weekly wound care documentation for a right buttock wound revealed: *Date of onset was 11/13/18. *It was FA. *A blister on 11/13/18. *A stage one PU on 11/20/18. *A suspected deep tissue injury from 11/27/18 through 12/4/18. *An unstageable PU on 12/11/18. *A stage four PU from 12/24/18 through 1/29/19. *A stage four PU from 2/12/19 through 2/19/19. *A stage three PU on 2/26/19. *A stage four PU on 3/5/19 through 4/30/19. *Progress note on 5/22/19 indicates weekly wound care has been completed. Review of resident 32's weekly wound care documentation for a left buttock wound revealed: *Date of onset was 11/3/18. *It was FA. *Not stageable on 11/13/18. *A stage two PU on 11/20/18. *A stage four PU on 12/18/18, 12/28/18, and 2/5/19. Review of resident 32's weekly wound care documentation for a sacrum wound revealed:*It was FA. *A stage two PU on 11/20/18. Review of resident 32's weekly wound care documentation for a coccyx wound revealed: *A stage two on 11/27/18. *It was FA. *Healed on 12/4/18. *There was no other documentation given to this surveyor concerning this residents wound care during the survey.

Based on observation, interview, and record review, the provider failed to ensure three of six residents (52, 73, and 125) who required a full body sling with lift transfers were given an option to use a commode or toilet. Findings include: 1. Review of resident 52's medical record revealed:*An admission date of [DATE].*She had a Brief Interview for Mental Status (BIMS) score of two indicating she was severely cognitively impaired.*Her 4/16/19 quarterly Minimum Data Set assessment (MDS) revealed:-She was an extensive assist with a two plus person physical assist for:--Bed mobility.--Transfers.--Dressing.--Toilet use.--Personal hygiene.--Bathing.Interview on 5/21/19 at 8:06 a.m. after resident 52's brief change with certified nurse aides (CNAs) O and P revealed:*She was a Hoyer lift resident.*Residents that are a Hoyer lift and wear a brief are not brought into the bathroom.-It is to hard to get the Hoyer sling off of the resident so they could use the toilet or commode.*They stated residents urinate and have bowel movements (BM) in their brief.-Residents are then changed.*Residents can have a bedpan if they choose.*They are not given the choice to use the toilet.Interview on 5/22/19 at 1:18 p.m. with CNA M concerning resident 52 revealed:*If a resident is a Hoyer lift, their choice is to use a bedpan or urinate or have a BM in their brief.*We check her brief when we lay her down.*She won't use a bedpan.*She uses a Hoyer lift.*We do not toilet her.*I don't know what else we're suppose to do if she will not use a bedpan. She is a Hoyer lift. Interview on 5/22/19 at 1:34 p.m. during resident 52's brief change with CNAs H and N revealed:*They both state they check on her every two hours.*She urinates and has BM's in her brief.*She is a Hoyer lift.*There is no way to toilet her or put her on the commode.-They do not have the correct Hoyer sling to do that. 2. Review of resident 73's 3/29/19 MDS assessment revealed: *She had been admitted on [DATE]. *Her BIMS score had been thirteen indicating her cognition was intact. *She required the extensive assistance of one staff member for personal hygiene. *She was totally dependent on two or more staff members for: -Dressing. -Transfers. -Toilet use. -Bed mobility. *She had an indwelling catheter and had been frequently incontinent of bowel. Interview on 5/21/19 at 7:40 a.m. with resident 73 revealed: *She could not walk or stand and required a total lift for transfer. *She could not use the toilet for bowel elimination due to needing the total body lift. *She stated it would be too hard for the staff to get her into the bathroom and onto a toilet. *She did not know what a commode was and had never been offered one for bowel elimination. Interview on 5/21/19 at 8:00 a.m. with CNA Q revealed, residents who use a total body lift must use the bed pan. Interview on 5/21/19 at 9:23 a.m. with CNA A revealed, residents using a total lift had to use the bed pan due to not being able to access the toilet with the lifts. Interview on 5/21/19 at 9:26 a.m. with physical therapy assistant (PTA) B revealed: *He did the nursing assistant training for lift use. *Residents cannot be toileted with a total lift due the full body slings. Interview on 5/22/19 at 11:01 a.m. with unlicensed assistive personnel (UAP) C revealed, residents who required a total lift had to use the bed pan. Interview on 5/22/19 at 11:02 a.m. with UAP D revealed: *The provider did have mesh slings that would allow for toileting with a total lift. *She was not aware of this until a few days prior. -She was informed of these slings due to another resident who currently used the toilet being evaluated for a total lift. *There were no bathrooms big enough to get into with a resident in a total lift. Interview on 5/22/19 at 11:04 a.m. with CNA E revealed, she did not believe residents who required a total lift could use a toilet or commode. Interview of 5/22/19 at 2:10 p.m. with resident 73 revealed: *She was unable to get onto a bed pan and had to eliminate her bowels in her incontinent products. *When asked if she felt embarrassed about having to use her incontinent product for bowel elimination she stated, I have to go in my diaper and that is it. *She then changed the topic to her upcoming birthday party and the weather. 3. Review of resident 125's medical record revealed: *An admission date of [DATE]. *A BIMs of thirteen that indicated she had been cognitively intact. *Her admission MDS assessment revealed: -She required extensive assistance with two person physical assistance for: --Bed mobility. --Transfers. --Dressing. --Personal hygiene. --Bathing. -She had an indwelling urinary catheter. -She had been frequently incontinent of bowel. Interview on 5/22/19 at 11:02 a.m. with resident 125 revealed she: *Had to use the bedpan for bowel elimination. *Stated she: -Did not like using the bedpan. -It had been embarrassing for her to ask to use the bedpan. -Had been told by staff she had to use the bedpan for bowel elimination. Interview on 5/22/19 at 8:30 a.m. with CNA U revealed she stated: *Resident 125 used the bedpan for bowel movements. *That was how she had been told to assist her by the nurses and therapy. *She thought the resident could probably use a commode but could not do that unless therapy told them they could. Observation on 5/22/19 at 2:00 p.m. of resident 125 while she had been in the therapy room revealed: *She was sitting in a chair with her right leg extended and elevated on a therapy ball. *The certified occupation therapy assistant W and CNA U were looking for a commode. -It took fifteen minutes to find a commode. *That commode was to have been used to do a dry run transfer for the resident to use a commode for bowel elimination. Observation on 5/22/19 at 2:35 p.m. of resident 125 in her room revealed a stand aid transfer done by CNA U and PTA B. They assisted the resident onto the commode. The resident had a continent bowel movement. Interview on 5/23/19 at 9:45 a.m. with resident 125 in the therapy room revealed she stated It is a good thing I don't have to use that bedpan anymore. I could do it but really did not like it. It is much better now when I can use a commode. Easier too. Interview 5/23/19 at 10:45 a.m. with the DON confirmed resident 125 should not have had to use the bedpan for bowel elimination. She stated There are alternate ways. Review of providers Qtr 3, (YEAR) Quality of Life-Dignity policy revealed: *Each resident shall be cared for in a manner that promotes and enhances quality of life, dignity, respect and individuality. *Treated with dignity meant the residents will be assisted in maintaining and enhancing his or her self-esteem and and self-worth. *Demeaning practices and standards of care that compromise dignity are prohibited. Staff shall promote dignity and assist residents as needed by: promptly responding to resident's request for toileting.

Based on observation, record review, interview, and policy review, the provider failed to have adequate supervision and interventions in place for one of one sampled resident (41) with multiple falls occurring in the facility and resulting in two major injuries. Findings include: 1. Review of resident 41's medical record revealed: *She had been admitted on [DATE]. *She had been admitted for weakness from the hospital. *She had been at home prior to that with a care giver. *She had been identified at risk for falls during her admission assessment. *The 12/19/17 fall risk assessment score was twenty-one. -A score of ten or above indicated a risk of falling. -They were to implement the fall prevention protocol and place approaches in the plan of care. --The fall prevention protocol initiated had been: Resident is very confused. She was orientated to call light but does not appear to know how to use this. She will be working with therapy. Will initiate low bed/mat. *She had twenty-four falls since her admission on 12/19/17. -Two of those falls had resulted in major injury, a [MEDICAL CONDITION] on 1/14/18 and a head injury on 2/22/18. Review of resident 41's 12/26/17 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was zero indicating she had severe cognitive impairment. *She had verbal behaviors that had occurred one-to-three days during the assessment period. *She had not rejected care during the assessment period. *She required assistance of one staff member for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Locomotion off the unit. -Toilet use. -Dressing. -Personal hygiene. *Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -Diabetes. -[MEDICAL CONDITION]. *She had a fall prior to admission. *She had one fall with no injury since admission. Review of resident 41's 1/26/18 MDS assessment revealed: *Her BIMS score was zero indicating she had severe cognitive impairment. *She had no behaviors. *She had rejected care one-to-three days during the assessment period. *She required extensive assistance of two staff members for the following: -Bed mobility. -Transferring from one location to another. -Locomotion on the unit. -Toilet use. *She required assistance of one staff member for the following: -Locomotion off the unit. -Dressing. -Personal hygiene. *Her [DIAGNOSES REDACTED].>-Cancer. -Hypertension. -[MEDICAL CONDITIONS]. -Diabetes. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. *They had documented no falls since admission or prior assessment. Review of resident 41's fall scene investigation reports from 12/19/17 through 2/28/18 revealed she had eight unwitnessed falls. Refer to F610, finding 1. Review of resident 41's fall scene investigation reports revealed the following witnessed falls: *On 12/29/17 she had a witnessed fall at 2:30 p.m. that stated resident lost balance. -She had been alone and unattended. -The last time toileted had a question mark in the box. -Conclusion had been Is working with therapy cont (continue) with hourly checks. Ensure call light is within reach. -There had been no additional care plan updates documented. *On 12/31/17 she had a fall in the open court area at 9:30 a.m. -She had been sitting in her wheelchair. -She stated her butt keeps sliding to edge of wheelchair. -Root cause: Cushion in wheelchair slick. Resident keeps sliding to edge of wheelchair seat. -Initial interventions to prevent future falls had been Staff to monitor positioning. -Additional care plan updates had been Ensure cushion has cover and is hooked to wheelchair. Therapy looking to adjust w/c (wheelchair). Review of resident 41's interdisciplinary notes from 12/19/17 through 2/27/18 revealed: *She had also fallen on the following dates: -1/2/18. -1/3/18 a third time. -1/4/18. -1/5/18 two times. -1/6/17. -1/27/18. -1/28/18. -2/1/18. -2/2/18 two times. -2/5/18. -2/6/18. -2/7/18. *There had been no fall scene investigation reports for the above falls. Review of resident 41's current undated care plan revealed: *There had been no intervention to check on her hourly per the above 1/10/18 intervention. *Her toileting plan had been to toilet every two hours. *There had been no interventions regarding an individualized toileting plan. *Interventions in place were initiated after the falls had occurred and not prior. Observation and interview on 2/27/18 at 11:20 a.m. of resident 41 revealed: *She had been sitting in her recliner in her room with the TV on. *She had a green/yellow bruise under her right eye and a two-inch bandage on her forehead. *Her left leg was stuck in-between the recliner seat and the foot rest. *The gap between the two areas had been approximately four inches. *She asked to have her slipper put on. -She seemed unaware her leg was stuck. *She was told her leg needed to be unstuck from the chair. *She stated Oh no can you put on my slipper. *She attempted to pull her leg out from between the gap but was not successful. *She could not put her call light on when asked to, and she just looked at it. -The surveyor put her call light on. *The resident grimaced when she attempted to move her leg. *No one had come to her room. -An unidentified activities staff member was doing an activity in the common area and was asked if there were staff around who could assist the resident. *She stated she was not sure and looked around the area. *She then pointed out a certified nursing assistant (CNA) on the south end of the common area. *The staff member was asked if she had gotten a page for room [ROOM NUMBER]. *She stated she was not wearing a pager. *She came to assist resident 41, and when she saw the residents leg stuck stated Oh wow! *She then used her walkie talkie to call another CNA as her partner on that hall had been on break. -The CNA she called stated she would be down after she helped another resident. *The CNA in resident 41's room assisted the resident by herself and pulled her leg out of the gap. *She then left the room. Observation and interview on 2/27/18 at 11:45 a.m. with registered nurse (RN) I regarding resident 41 revealed: *The resident was lying in her bed. *RN I stated she was told about the resident getting her leg stuck in the recliner. *They were going to remove the recliner from her room due to the incident. *At that time the maintenance director came over to take the recliner out of her room. *RN I stated the resident can not be left alone in her wheelchair without supervision, as she had fallen out of the wheelchair. -She had hit her head as a result of falling out of her wheelchair. Observation on 2/27/18 at 12:30 p.m. of resident 41 in the dining room revealed: *She had been pushed up to the table. *Her foot pedals had been angled up. *She had not been able to get up to the table due to the foot pedals being angled up. *The foot pedals hit the tablemate to her right when she was pushed closer to the table. Interview on 2/27/18 at 12:40 p.m. with CNA P revealed: *They had tried to put the foot pedals down in her w/c, but she was not sure why they left them up. *She went over and took the pedals off and pushed her closer to the table. *Recreation services aide Q stated she had not known the foot pedals were to come off. Observation on 2/27/18 at 2:10 p.m. and again at 4:50 p.m. of resident 41 revealed she was lying in bed. The recliner had been taken out of her room and not replaced. Observation on 2/27/18 at 6:25 p.m. of resident 41 revealed: *She had been lying in bed. *She was attempting to get out of bed. *Both her legs were over the scooped mattress. *She was trying to lift her body up to get out of bed. *She was wide awake. *There were no CNAs in the area. -The director of nursing (DON) was found and the above situation was explained to her. Observation on 2/28/18 at 7:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. There were no staff in the common area. Observation on 2/28/18 at 8:29 a.m. of resident 41 revealed she was up in her wheelchair in the living room/common area. She was slouched over. The leg pedals were angled up. Observation on 2/28/18 at 8:49 a.m. regarding resident 41 revealed: *She was slouched over in her wheelchair sleeping. *There had been no staff in the area supervising her. *The leg pedals were angled up. Observation on 2/28/18 at 9:02 a.m. of resident 41 revealed she was taken into her room and laid down. Observation on 2/28/18 at 9:27 a.m. of resident 41 revealed she was attempting to get up out of bed. There had been no staff around to witness her attempt at getting up. Interview on 2/28/18 at 9:31 a.m. with CNA N revealed: *They checked on resident 41 every two hours to see if she needed to go to the bathroom. *They usually laid her down in between meals. *She is the first one they lay down after breakfast, and the last one to get up before lunch. *She had been the only CNA on the 300 hall at that time due to her partner being on break. Observation on 2/28/18 at 10:00 a.m. of resident 41 revealed RN I had been in her room changing her dressings to her heels. She was in a sitting position with her feet hanging over the bed. She was lying back against wall. Observation on 3/01/18 at 9:59 a.m. of resident 41 revealed she was lying in bed with both feet hanging off the bed and heel protectors on. There were no staff around to observe her. Observation on 3/01/18 at 10:41 a.m. of resident 41 revealed she had been lying in bed. Both legs were hanging off the side of the bed. The lights were off. She was awake. Interview on 3/01/18 at 2:03 p.m. with the DON regarding resident 41 revealed: *They were putting her in bed between meals, because she had to be supervised if she was up in her chair. *They had not attempted an individualized bathrooming schedule for her. *The CNAs only documented one time per shift that they toileted the resident. *The fall interventions had been implemented after falls had occurred and not before for her. Review of the provider's March 2017 Fall Prevention policy revealed: *A fall risk assessment will be completed at the following times: -Upon admission/readmission to the facility. -Quarterly - can complete a quarterly review instead of full assessment if no change since previous assessment. -Prior to the annual MDS. -Change of condition. *Fall precautions will be reviewed and appropriate precautions will be implemented after a fall occurs and as needed. *Incident report and a fall scene investigation form will be completed after fall. *Falls will automatically be logged through completion of Incident Report in PCC (point click care).

Based on observation, record review, interview, resident group interview, and policy review, the provider failed to ensure one of one sampled resident (11) who wandered and had behavioral symptoms was effectively monitored and had behavioral interventions put in place to ensure no physical or emotional harm occurred to thirteen of thirteen residents (8, 17, 18, 19, 20, 22, 26, 27, 28, 29, 30, 31, and 32). NOTICE: Notice of immediate jeopardy was given verbally to the administrator, the interim administrator, the interim director of nursing, and the director of clinical services on 8/12/14 at 4:25 p.m. They were asked for an immediate plan of correction (POC) at that time. That included: *Monitoring and management of residents with behaviors who wandered. *Assurance of safety and no harm to other residents. PLAN: An immediate POC for resident-to-resident abuse was accepted on 8/12/14 at 7:00 p.m., and the immediate jeopardy was abated (removed). A comprehensive plan of action was accepted on 8/13/14 at 4:10 p.m. That included the following: *"Resident 11 would not be readmitted to the provider's care on 8/12/14. Resident 11 was identified on 8/12/14 as a potential safety risk to others. Resident 11 was transferred to the emergency department (ED) on 8/12/14 at 1:20 p.m. The ED physician's nurse was notified at 4:45 p.m. by the interim administrator of resident 11's not being able to be readmitted to this nursing facility because of resident to resident inappropriate behaviors of a sexual nature. The interim administrator instructed the ED to fax communication of admittance to hospital as soon as possible. A call was placed at 5:15 p.m. by the ED and confirmation was received that resident 11 would be admitted to the hospital at that time." *"All residents would be reassessed by the interim administrator, administrator, director of clinical services, interim DON, and social services designee on 8/12/14 and 8/13/14 to ensure their placement was appropriate. That assessment would include review of wandering, behaviors affecting others, and danger to self or others. The facility interim DON or designee would complete interdisciplinary progress note reviews on all progress notes in Point Click Care (electronic medical record) five times weekly to identify any potential issues or concerns with resident safety and wellbeing. Any issues with residents currently residing at facility would be addressed on the date identified. The resident's physician would be involved and the ombudsman notified as well. The administrator would report findings to the facility quality assurance performance improvement (QAPI) committee monthly for review and recommendations." *"Resident safety, abuse and neglect policy. All staff prior to their next shift worked from 8/13/14 at 9:00 a.m. and ongoing would be educated on the healthcare abuse and neglect policy and reporting procedures. Any issues identified on the education of staff would be taken to the facility QAPI committee monthly by the interim DON or designee for review and recommendations." *"Admission process. The administrator and/or interim administrator and the interim DON or DON would be involved and approve all admissions/readmissions. Any resident admission issues would be compiled and then brought forward by the administrator, interim administrator, and the interim DON to the facility QAPI committee monthly for review and recommendations." During the extended survey on 8/12/14 at 7:00 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Review of resident 11's medical record revealed he had been admitted on [DATE] from home. He had [DIAGNOSES REDACTED]. Review of resident 11's following interdisciplinary progress notes revealed:*A 5/30/14 12:15 p.m. admission note included: -He was admitted from his home. -He had lived with his wife. -His wife stated he had his days and nights mixed up, was very active at night, and he had to use the restroom frequently at night. -A Wanderguard (tracking bracelet) was put on his left wrist as his wife stated he did get up at night and wander. He would not know where he was going. *A late entry on 5/31/14 at 3:01 p.m. "Resident was found outside of the front door sitting in a person's car. The day was about 65-70 degrees Fahrenheit outside. When returning inside he showed no signs of dehydration or injuries. Normal behavior was observed for an individual with dementia and wandering." *A late entry on 5/31/14 at 6:45 p.m. "Resident was sexually inappropriate with CNAs (certified nursing assistant)." *A 6/1/14 at 6:47 p.m. note "Resident was being sexually inappropriate with CNAs." *A 6/2/14 note at 9:11 p.m. "Resident was up wandering and headed outside but was stopped before he made out the doors." *A 6/2/14 at 9:13 p.m. note "Resident was being sexually inappropriate with the CNAs." *A 6/10/14 at 3:46 p.m. Care area assessment (CAA) for resident behaviors "Resident has Alzheimer's and has behavior d/t (due to) this. He wanders around is not aware of his surroundings. He also has been making sexually inappropriate comments to staff. He did wander at home but not sure if he had other behaviors. His behaviors are easily controlled at this time." *A 6/11/14 at 4:19 a.m. note "Resident has been awake most all of shift wandering around building going into other resident's rooms turning on water in bath rooms or lights sitting in chairs in rooms several female residents reported being scared by him." *A 6/24/14 at 5:42 a.m. note "Resident at 2:30 a.m. was found in bed in ______ (room and bed number) with female resident 32. He was removed from the room and directed back to his room where he stayed for most of the night." *A 7/2/14 at 12:30 a.m. note "Resident in room ____. _______(Resident 30) is yelling @ (at) him to get out and using her walker to direct him out and ________(resident 27))is attempting to hit him with her pillow and telling him to get away from her, both women very upset, they report they wake up with him standing over them telling them to get up. _____ (resident 11) escord (escorted) out of their room and taken back to his to use the BR (bathroom)." *A 7/13/14 at 4:54 a.m. note "Resident becoming more combative with staff when trying to redirect him out of other's rooms or put clothes on him after he takes them off. Did attempt to leave building 1 time, got as far as between the front doors before staff turned him around." *A 7/16/14 at 2:14 p.m. activities aide note "I spent a lot of 1 on 1 times with _____ (resident 11) today. He is confused and tends to wander in other residents' rooms which is very upsetting to many of them. He was able to work with wooden blocks and dominoes but needed constant cueing d/t dementia. He did read several items in the newspaper. When he became restless, we offered him the restroom and something to eat/drink, which did calm him down. Did take a short nap in recliner in the activity room before lunch. Visited with the CRAs (certified resident assistant) on 300 wing (where most of our wandering residents are located) and told them to bring these residents to us and we would (provide) activities/supervision as needed." *A 7/27/14 at 5:23 a.m. note "On 7/26/14 at 2145 (9:45 p.m.) resident reached down inside of female CNA's top and tried to fondle her breasts resident was told that this was not allowed and was redirected back to his room and toileted by CNA and male nurse, when done resident then made comment that he would make it all right if she came to bed with him. At 2330 (11:30 p.m. on the same evening resident was found groping female resident's (rm ___) (resident 29) breasts and was informed that this was not allowed at which time he just chuckled and hit the CNA several times. Resident was redirected to a recliner in the open court where he stayed most of the shift." *A 7/30/14 at 5:00 a.m. note "Resident walked up to a female resident (resident not identified in note) and dropped his pants, CNA intervene promptly and escort resident after helping to pull up pants out of the area." *A 8/3/14 at 8:50 p.m. note "Resident in room _____, shaking ______ (resident 22), turning buttons on resident C-PAP (continuous positive air pressure) machine. Resident 22 was yelling and I went in and attempted to redirect." *A 8/7/14 at 1:30 a.m. note "Was asked to remove resident out of another residents room, when attempt to escort him out he told me to shut up, hit my hand away and slaped (slapped) my mouth. While leaving the area he cont (continued) to tell me to shut up and attempt to hit my mouth and hand several times. Did get to his room and sat on bed, would not lay down and told me to leave. Report off to CRA that were caring for him, they would F/U (follow up) on him." *A 8/8/14 at 2:31 p.m. physician's orders [REDACTED]." There was no mention of resident 11's behaviors or wandering in those physician's note. *A 8/9/14 at 9:30 a.m. note a facsimile had been sent to his physician that included a possible request for some [MEDICATION NAME] to assist with his sleep. *A 8/10/14 at 10:45 p.m. note "Resident found in another residents room, attempting to get her up and take him to BR, cursing @ her and tugging on her leg to get up. Resident 22 becoming upset and little scared. Appologis (apologies) as he was being removed from her room. Resident 11 hitting @ staff and telling her to shut up." *A 8/10/14 at 11:00 p.m. note "Resident from room ___ (resident 19) out @ the nurse's station asking for staff to come and remove ______ (resident 11) from her room, he is telling _____ (resident 28) to get up and come with him, he needs to use the toilet and needs 'Mamma's help', resident escorted out and taken to his BR, he is little aggressive tonite and telling staff to leave him alone, shut up and attempting to hit the staff." *A 8/10/14 at 11:30 p.m. note "Resident was in room _____ (resident 22) attempting to get into bed with that resident who was screaming for help. ______ (resident 11) was removed but he was also attempting to hurt staff and call her names." *A 8/11/14 at 12:00 a.m. note "Resident again back into Rm (room) _____ (resident 22), telling her to get up and pulling @ her feet. Her room is dark and he is able to get to her bedside by the window and wake her up. She has request to some how keep him out, she has agree (agreed) to shut her door to see if that will stop him, cont to monitor and appologis for the incident." Review of a 8/11/14 physician's orders [REDACTED]. Review of resident 11's care plan revealed:*A revision on 7/29/14 by the MDS coordinator that included: -A focus area for wandering and sexually inappropriate comments and behaviors. -A goal his behaviors would have been addressed as they occurred. -Interventions that included: "I wander and often wander into other resident rooms. Monitor for this and redirect me. Monitor for behaviors and assess for any physical, emotional or social cause and correct if possible." *A 6/17/14 entry by the activity director that included: -A focus area that "Staff must anticipate and provide all of my social needs D/T (due to) [MEDICAL CONDITION]." -A goal that "I will attend and participate in planned activities that I enjoy with assistance from staff as needed. I will show acceptance and enjoyment in attending these activities through positive verbalizations and expression each review." -Interventions that included "Staff provide me with 1:1 (one-to-one) visits PRN (as needed). Activity staff provide me with 1:1 time/activities when I am wandering." *A 5/30/14 entry by the social services director (SSD) that included:-A focus area on cognition (memory). "I am alert and quiet, I am able to converse minimally and make limited decisions. My wife will be my major decision maker and will attend my care conference." -A goal of "I want to maintain my alert cognitive status. I would like to participate in the decision making I am able to do such as leaving my room, going to the bathroom etc. with staff assistance for guidance." -Intervention of "I want staff to monitor for changs (changes) in my cognition, such as worsening, or inability to determine what I want. Staff will anticipate decision making and report any noticeable changes to nursing." Review of the behavior charting for resident 11 from 6/8/14 through 6/16/14 by the CRAs revealed: *He had wandering on 6/8/14 at 1:02 a.m. and 8:49 a.m., and on 6/11/14 at 10:52 p.m. that did not impact other residents. *He had wandering on 6/8/14 at 3:15 p.m. and 11:40 p.m., 6/9/14 at 10:51 p.m., 6/10/14 at 5:28 a.m. and 2:19 p.m., 6/11/14 at 3:06 a.m., 6/14/14 at 5:37 a.m., 12:18 p.m., and 9:29 p.m., 6/15/14 at 5:54 a.m., 10:18 a.m., 3:12 p.m., and 11:54 p.m., and 6/16/14 at 9:31 a.m. that significantly intruded on other residents' privacy or activities. *On 6/12/14 at 5:35 a.m. he had repetitive verbalizations that caused a disruption of the care or living environment and significantly intruded on other residents' privacy or activities. *On 6/13/14 at 10:25 a.m. he had repetitive verbalizations that interfered with his care. Review of resident 11's 6/8/14 admission MDS, section E (behaviors), revealed: *He had no indications of hallucinations or delusions that would have indicated [MEDICAL CONDITION] (altered state of mind). *He had behavioral symptoms that included verbal behavioral symptoms directed toward others (for example threatening others, screaming at others, and cursing at others). Behaviors of that type had occurred one to three days during the seven day assessment reference period. *That behavioral symptom impacted the resident for physical illness or injury, significantly interfered with his care, or significantly interfered with his participation in activities or social interactions. *That behavioral symptom did not put other residents' at a significant risk for physical injury, significantly intrude on the privacy or activity of other residents', or significantly disrupt care or the living environment. *He had no rejection of care behaviors. *He had wandered one to three days during the seven day assessment reference period. *His wandering did place the resident at a significant risk of getting to a potentially dangerous place (for example outside of the building.) *His wandering did significantly intrude on the privacy or activities of other residents'. Surveyor: Resident group interview on 7/29/14 at 3:05 p.m. revealed five of eleven residents (8, 17, 18, 19, and 26) voiced concerns about incidents at the facility. They were in agreement about two residents (1 and 11) who would wandered throughout the facility and enter other residents' rooms without permission. They stated they were not concerned about resident 1 as she was confused and did not cause any harm. They did express concerns about resident 11, as he would not leave the female resident's rooms. Residents 18 and 19 revealed they had asked the staff to place a barrier on their doors to try and prevent resident 11 from entering their rooms. They stated they would call for staff and they would come and take him out of the room, but he would come right back. Surveyor: . Observation on 8/12/14 at 9:20 a.m. revealed wide yellow plastic banners had been placed across the entrances to residents 18, 19, 20, 22, 28, 29, 31, and 32's rooms. Interview on 8/12/14 at 9:22 a.m. with resident 20 revealed he was not sure when the yellow banner had been placed across the entrance to his door. He stated there was another resident who frequently entered his room. He also stated he fell a lot. By having the banner across his door, his door could stay open, and he would not fall as much. He wanted his door closed due to another resident that wandered frequently into his room. Interview on 8/12/14 at 9:30 a.m. with the interim DON/MDS coordinator revealed residents would ask her or the social services designee (SSD) for a barrier to be put up across the entrance to their doors if needed. Interview on 8/12/14 at 9:45 a.m. and at 1:20 p.m. with resident 19 revealed the yellow plastic banner had been put up across the entrance to her and her roommates (resident 28) door the previous evening (8/11/14). She stated she had requested that as resident 11 had been coming into their room. She stated she was not afraid of him. But she was worried about her roommate, as she was very "vulnerable" and he had "messed" with her (resident 28) before. Interview on 8/12/14 at 10:25 a.m. with the SSD regarding resident 11 revealed:*They had placed yellow banners across the entrances to rooms he frequently entered. *She agreed four of the seven yellow banners had just been placed on 8/11/14 and the morning of 8/12/14. *She had visited with resident 11's wife approximately ten days ago regarding his behaviors. *She stated resident 11's wife had told her he had the same behaviors when he was at home. *She had not documented that conversation. Review of resident's 18, 19, 20, 28, 29, 31, and 32's interdisciplinary progress notes revealed no documentation of when the yellow plastic banners had been placed across the entrances to their rooms. Resident 22 had documentation she had asked for a room banner on 8/12/14 at 9:30 a.m. Interview on 8/12/14 at 12:55 p.m. with the interim DON/MDS coordinator regarding resident 11 revealed:*No behavioral interventions had been put in place in regards to his wandering and inappropriate sexual behaviors. *Redirection did not work anymore for his behaviors. *She had not known until 8/10/14 he had been putting his hands down the CNAs shirts. Staff had told her while she was the charge nurse he had been doing that for awhile. *She agreed there was no documentation of resident 11's physician or wife having been contacted regarding his behaviors. Surveyor: Interview on 8/12/14 at 1:20 p.m. with resident 27 confirmed she had been slapped on the face by a male resident when trying to assist him out of her room. She was unable to tell this surveyor the name of that resident. She stated "He calls out for Mama." She confirmed she was afraid of him because of that physical abuse. The majority of his wandering occurred at night. Interview on 8/12/14 at 1:37 p.m. with resident 22 confirmed she had been "bothered" by a male resident who wandered into her room since she had been a resident within the facility. She was able to tell this surveyor that this specific male resident had a [DIAGNOSES REDACTED]. That male resident had hit her, and she had reported the physical abuse to a staff member. She was unable to tell this surveyor who the staff member was. That wandering resident had caused disruption in her sleep patterns. She gave an example of the prior night, when that resident had awakened her at 10:00 p.m., 11:30 p.m., and midnight. She had turned her call light on and had staff remove him from her room. Surveyor: Review of an 8/12/14 unsigned, untimed facsimile to resident 11's physician revealed: *"Resident has behaviors, wandering, sexually assaulting residents & (and) staff & physically abusing staff. *The physician's response was "Send to _______ (hospital name) ER (emergency room ) for evaluation & possible admission to behavior management due to behaviors." Review of the 7/1/14 physician's progress notes for resident 11 revealed the staff had reported there were no behavioral changes. Review of the South Dakota Department of Health required nursing facility event reports regarding resident 11 included: *On 7/26/14 he had been reported to have groped a female resident's breasts. -The plan was to have been "Will visit with resident's physician and wife about possible interventions and it will become part of his care plan that he needs to be monitored and away from female resident's." *On 8/10/14 and 8/11/14 he had been reported to have cursed and attempted to get in bed with a female resident. -On 8/11/14 "Yellow banners across the doors are now on 309, 310, as well as 320 and 313 and 318 and this has turned _____ (resident 11's name) from those rooms." -His care plan had not been updated after the 7/26/14 incident to include the monitoring. -There was no documentation resident 11's physician or wife had been consulted regarding his behavior. Review of the provider's revised February 2014 Behavior Assessment and Monitoring policy revealed: *Problematic behavior would be identified and managed appropriately. *The nursing staff would identify, document, and inform the physician about an individual's mental status, behavior, and cognition including the onset, duration, and frequency of problematic behaviors or changes in behavior. Review of the provider's June 2013 Behavioral and Mental Health Treatment policy included: *All residents with behaviors against other residents would have an in person assessment to ensure those behaviors were able to be managed. *Any resident who displayed an outburst of unmanageable behavior which places other residents at risk would have been sent by ambulance to the ER.

Based on observation, record review, interview, policy review, and professional standards review, the provider failed to ensure six of eight sampled residents (1, 3, 4, 6, 10, and 13) with acquired (developed at the facility) pressure ulcers (a wound that form whenever prolonged pressure occurs) had appropriate interventions and treatments that would have made those acquired pressure ulcers avoidable. Findings include: NOTICE: Notice of immediate jeopardy was given verbally to the interim administrator, director of nursing services (DNS), and the director of clinical services (DCS) on 7/30/14 at 5:28 p.m. They were asked for an immediate plan of correction to ensure all residents at risk of harm from pressure ulcers were effectively assessed and appropriate treatment was put in place. PLAN: An immediate plan of correction for pressure ulcers was accepted on 7/30/14 at 6:30 p.m. from the interim administrator. The plan was as follows: *"Task: Wound care nurse and job description. -Person(s) accountable: DCS/DNS. -Root cause analysis: Issues noted w/(with) wound assessment and dressing change. -Goal/plan: Change associate (staff) duties effective 7/30/14. -Action steps: Effective immediately (7/30/14 at 6:30 p.m.) the process owner for wound care (licensed practical nurse (LPN) C) is being replaced by (registered nurse (RN) I.) -Process owner: Interim administrator will report to the facility quality assurance performance improvement (QAPI) monthly on the process for further review and recommendation. -Follow-up: Nurse has reviewed and signed the job description as of 7/30/14. *Task: Wound care nurse assessment and physician orders. -Person(s) accountable: Wound care nurse. -Root cause analysis: Issues noted with competency -Goal/plan: 7/30/14 and ongoing. -Action steps: RN I and RN/wound care certified (WCC) I will assess every acquired and admitted pressure ulcer to ensure the staging and length/width/depth is appropriately documented. --They will review the physician orders [REDACTED]. --If the order needs to be modified, they will obtain an order from the physician. --The treatment will correspond with the physician orders. --They will ensure the interventions are appropriate. -Process owner: Facility wound care nurse. Wound care assessments and Dr. (doctor) orders will be reported to the facility QAPI meeting by the facility DON (director of nursing) or designee monthly for further review and recommendation. *Task: Communication to medical director. -Person(s) accountable: DNS and interim ED (executive director). -Root cause analysis: Update with survey issues. -Goal/plan: 7/31/14 and ongoing. -Action steps: Interim administrator and DON contacted the medical director at 6:15 p.m. on 7/30/14. --Discussed pressure ulcer IJ (immediate jeopardy) and actions steps and QA process. --She will be at the facility at 9:00 a.m. on 7/31/14 to meet w/ the survey team and facility DNS, director of clinical services, and interim administrator. -Process owner: Interim administrator will report any facility skin issues to the facility QAPI meeting monthly PRN (as needed). *Task: Education. -Person(s) accountable: ED/ DNS. -Root cause analysis: Issues noted during survey process with associates and their knowledge of who has skin breakdown. -Goal/plan: Ongoing starting 7/30/14. -Action steps: All staff will be educated by the DON or designee on which residents currently have a pressure ulcer and what care and treatments are in place for that resident. --Also presented includes a presentation on "Skin and the elderly" which includes risk factors, prevention and staging of pressure ulcers. --All on-coming staff will receive the education prior to working their shift. -Process owner: DON or designee will report to the facility QAPI meeting monthly on the education process r/t (related to) pressure ulcers for further review and recommendation. *Task: Identification of skin concerns. -Person(s) accountable: Wound care nurse, charge nurse, and unit manager. -Goal/plan: 8/8/14. -Action steps: All residents will receive a comprehensive skin assessment within the next week by a licensed nurse. Audit will include review of the skin assessment process. -Process owner: DON or designee will report weekly skin assessments to the facility QAPI meeting monthly for review and recommendations. *Task: Audit of pressure ulcers. -Person(s) accountable: Nurse manager. -Root cause analysis: Issues identified with PU (pressure ulcer) systems. -Goal/plan: Daily. -Action steps: All residents with acquired and/or admitted pressure ulcers will be audited daily by the DON or designee to ensure proper interventions are in place. --Audit will include questioning of staff to ensure knowledge of wound and interventions, and hands-on observations of cares. --Audit will include turning and repositioning and observation of cushions and mattresses. --Pain management with PU will also be included in the audit. --Weekly skin assessments will also be audited and documented. -Process owner: DON. Results of the written audits will be reported weekly by the DON to the interim administrator. Further review will occur monthly at the facility QAPI meeting for further review and recommendations. *Task: Prevention of pressure ulcers. -Person(s) accountable: DNS or designee. -Root cause analysis: Noted increase in # (number) of acquired pressure ulcers. -Goal/plan: Ongoing. -Action steps: All residents with current skin breakdown or identified at risk (per Braden scale (score given for risk factors for pressure ulcers)) will have interventions in place to prevent further breakdown and healing of current skin issues. i.e. (for example) mattress, cushion, turning and repositioning schedule, dietary considerations, etc. --Licensed associates (staff) will be responsible to assure cushion placement is appropriate at time of placement. -Process owner: Director of nursing or designee will report monthly to the facility QAPI meeting on issues noted with prevention of pressure ulcers. *Task: Family notification. -Person(s) accountable: Wound care nurse/unit manager. -Root cause analysis: Potential issues identified by the state survey team. -Goal/plan: 8/7/14. -Action steps: All families or responsible party will be notified of current status of PU. --Initial notification, with significant change or at least monthly. -Process owner: DON or designee will report monthly to the facility QAPI meeting any issue with family notification. *Task: Care plans. -Person(s) accountable: Wound care nurse, Minimum Data Set (MDS) coordinator, DON, charge nurse. -Goal/plan: 8/8/14. -Action steps: All pressure ulcer care plans will be reviewed and updated per progress or decline, change in treatments, & (and) new or changed orders. -Process owner: MDS coordinator or designee will report monthly to the facility QAPI meeting any issues noted with PU care plans. *Task: Pain. -Person(s) accountable: Wound care nurse/unit manager. -Goal/plan: 7/31/14 -Action steps: All residents with an acquired or admitted PU will have pain assessed r/t wound. --Current tx (treatment) interventions will be reviewed and Dr. notified as needed for new interventions. --See weekly wound care assessment in PCC (point click care electronic medical record). -Process owner: DON or designee will report pain concerns to the facility QAPI meeting monthly for review and recommendations. *Task: Weekly skin assessment. -Person(s) accountable: Charge nurse. -Root cause analysis: Issue was previously identified by the facility and a plan was implemented. -Goal/plan: Ongoing. -Action steps: All residents will have a weekly skin assessment completed by a licensed nurse and documented on the treatment record. --If the resident refuses their bath, the assessment will still be completed on a weekly basis (no more than every 7 days) -Process owner: DON or designee will report the results of the skin assessments monthly to the facility QAPI committee for further review and recommendations." During the standard survey on 7/31/14 at 1:45 p.m. the surveyors confirmed the immediate jeopardy situation had been abated (removed). Findings include: 1. Observation of resident 4 on 7/29/14 at 8:30 a.m., 12:30 p.m., 2:45 p.m., 4:00 p.m., from 4:59 p.m. through 5:29 p.m., and at 6:20 p.m. revealed: *At 8:30 a.m. he was seated in his recliner. There was no pressure reducing cushion in that recliner. *At 12:30 p.m. he was still seated in his recliner with no cushion under him. *At 2:45 p.m. he was still seated in his recliner with no cushion under him. *At 4:00 p.m. he was still seated in his recliner with no cushion under him. *From 4:59 p.m. through 5:29 p.m. he had been assisted from his recliner and was seated in a wheelchair. There was no pressure reducing cushion in that wheelchair. He remained in the wheelchair until 6:20 p.m. He was then assisted to sit back in the recliner that had no cushion. *During the above observations it was noted resident 4 leaned towards his left side. Interview with resident 4 on 7/29/14 at 12:40 p.m., 2:45 p.m., and again at 4:59 p.m. revealed: *He usually waited a long time for someone to help him after he had turned on his call light. *He had been up before breakfast, and he would stay up until they helped him to bed around 8:00 p.m. *His bottom was "Really sore" and "It hurt like hell." *He leaned to his left, because his right buttock hurt so bad. *He did not feel "Like anybody cared much." Review of a 7/28/14 facsimile (fax) request sent by LPN C to resident 4's physician revealed:*The fax included: "Has 2 open areas to buttock open one is .5 X (by) .5 stage 2 (partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum (fluid)-filled blister) the other is .3 x .2 in coccyx (tailbone) area is open is stage 3 (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure (hide) the depth of tissue loss. May include undermining (wound is wider at its base than on the surface) and tunneling (extends farther under the skin like a tunnel). Can we use Hydrogel dressing covered with foam dressing to area daily." *The physician had replied "OK." Review of resident 4's July 2014 treatment administration record (TAR) revealed:*From 7/24/14 through the a.m. of 7/28/14 the treatment of [REDACTED]." *That treatment was also documented as having been done the a.m. of 7/29/14. *The treatment had not been documented as having been done in the p.m. of 7/28/14 or the p.m. of 7/29/14. *The treatment to apply INZO barrier cream to the right buttock pressure area BID until healed had been ordered by the physician on 7/23/14. *The treatment of [REDACTED]. Observation of a wound care treatment for [REDACTED]. *He had two open areas. One was on his right buttock, and the other was on his coccyx. *There was no dressing present to either open area. *LPN C cleansed both areas with a wound cleanser and placed a piece of Hydrogel wound dressing on the two open areas. She then covered the Hydrogel with a secondary dressing of gauze and tape. Review of the interdisciplinary progress notes for resident 4 revealed: *He had been admitted on [DATE] from an acute care hospital. *He had a stage 1 pressure ulcer to his right buttock that measured 0.5 centimeters (cm) by 0.5 cm. *On 7/25/14 at 1:15 p.m. "Noted the top skin is off of red area on right buttock 0.5cm x 0.5cm. [MEDICATION NAME] (barrier cream) applied and reposition off of right buttock and pills (pillows) in place." Review of the 7/24/14 hospice interdisciplinary care plan revealed: *"Stage 1 0.2 cm x 0.2 cm." That note did not state where the stage one was located or if it was a pressure ulcer or not. *"Low air loss mattress was delivered by ________ (durable medical equipment provider) during admission." *Under integumentary (skin) status section a pressure ulcer was listed as stage 1. *Remedy repair cream to have been applied BID. Review of resident 4's 7/23/14 initial wound sheet included:*His physician had been notified on 7/23/14 of the stage 1 pressure ulcer. *That pressure ulcer was measured at 0.5 cm x 0.5 cm with no depth and staged at a 1. *The wound treatment plan was to apply INZO barrier cream to the area BID. *It was to have been managed with off loading (taking pressure off of the affected area), a gel cushion, and a low loss air mattress. Review of resident 4's 7/28/14 wound assessment revealed: *"Resident has a pressure area to right buttock 0.5cm x 0.5 cm will get order for hydrogel and cover with foam border dressing. has open area to coccyx which measures .0. 0.3 cm x .2 cm will use hydrogel to this area also." *No staging had been done for those pressure areas. Interview on 7/30/14 at 1:30 p.m. with the interim administrator, the DON, and the director of clinical services revealed:*There were a "ton" of air overlays on beds in the facility for the prevention of pressure ulcers. *Pressure ulcer training was to have been done that day (7/30/14). *Therapy did the wheelchair cushions and positioning evaluations. *They had no licensed nurse that was interested in wound care. *Documentation was not done on turning or repositioning. *They were aware there had been an increase in pressure ulcers. *Redevelopment of the wound care process had been planned. *There would be CNA (certified nursing assistant), licensed nurse (LPN or RN) training on pressure ulcer treatment. *Review of specific residents during the interview included: -Resident 1: Had been ill in January 2014, and she had heel protectors. -Resident 3: treatment of [REDACTED]. -Resident 4: They were not aware he had no pressure relieving cushions in his recliner or wheelchair. They were not aware the CNAs were not aware of his pressure ulcers. -Resident 10: He was not to have had shoes placed on his feet. They were not aware his shoes had been put on after his wound care treatment. *A pressure ulcer meeting had taken place on 7/15/14 with LPN C and the MDS (Minimum Data Set) assessment coordinator. They had physically visited all residents with pressure ulcers. Resident 4 had been missed for pressure relieving cushions. They had reviewed three residents daily to assess for pressure relieving cushions. *A weekly skin assessment for the nurses to complete had been started on 7/21/14. Before that time the bath aides should have notified the nurse if a skin problem had been noted. Interview on 7/31/14 at 11:30 a.m. with the medical director revealed: *She had not been aware of the increased number of acquired pressure ulcers. *She stated the increase of pressure ulcers could have been attributed to the increase in acuity (level of the severity of a disease process) of residents that had been admitted . *She had been contacted by staff in regards to treatment options for pressure ulcers. *She stated she had relied on the provider's clinical resource specialist to give guidance on what were the best wound care interventions. *She had not been involved in the development of the provider's pressure ulcer policies. *She would consult a hospital's wound care clinic also for treatment options. *She only observed a resident's pressure ulcer if it was a large size pressure ulcer. 2. Review of resident 1's medical record revealed: *The "Skin/Wound notes" stated: -On 1/22/14 there had been a blister to her left heel that had not been open. It measured 5.4 cm by 5.4 cm. The order was to "Paint with [MEDICATION NAME] until it gets healed?" -On 2/3/14 the blister to the left heel had opened. "Will continue with [MEDICATION NAME] paint." -On 2/6/14 the blister remained. Total blister measured 6.0 cm. by 6.0 cm. The wound edges had been rolled and macerated (skin is softened and turns white from moisture). No drainage. Open area measured 2.0 cm by 4.0 cm. "Continue with [MEDICATION NAME] paint. -2/10/14 "Continue with [MEDICATION NAME] paint." -2/17/14 Skin note stated "Resident continues to have blister to left heel. Area measures 3.0 by 5.0 centimeters." -2/24/14 the notation stated, "Continues to have blister 3.0 cm. by 5.0 cm. Treating area on inner heel with Thera honey. No eschar (tan, brown, black scab). Apply [MEDICATION NAME] to peri wound (area around wound), apply therahoney to wound and cover with [MEDICATION NAME] (type of dressing). Change every 3 days." -3/3/14 Blister continues to left heel. Area measured 2.8 cm by 3.0 cm. No eschar. Periwound was macerated and measured 6.0 cm. by 5.0 cm. Changed treatment to [MEDICATION NAME] daily with foam border dressing for protection. -3/10/14 Blister was soft and open whitish-yellow color to edges. Outside was pink in color. Had foam dressing on area that was saturated with drainage. Cleansed with [MEDICATION NAME] and covered with [MEDICATION NAME]. Measurements were 1.5 cm by .8 cm. -3/17/14 Heel ulcer measured 2 cm by 1.7 cm. [MEDICAL CONDITION] to lower legs. Note to physician to change dressing to paint area with [MEDICATION NAME] and cover with calcium alginate foam dressing. *Per fax to physician: -3/25/14 Apply skin sealant to periwound and apply calcium alginate to wound bed. Cover with bordered foam. Change daily. -3/31/14 Will start therahoney to area and cover with foam dressing. Area measures 2 by 1 cm. -4/28/14 A referral with a wound care clinic for debridement was requested. -Further skin/wound notes and wound measurements had been done weekly at the wound care clinic. They were received back at the facility per fax. *The wound care clinic (wound care nurse): -First visit had been on 5/6/14. -Had not ordered [MEDICATION NAME] for a treatment. -Determined the wound had undermining (wound being open underneath the lip of the border). -Stated per fax on 7/8/14 the wound had not been treated according to orders. "The previous dressing applied did not appear to have any packing. If you change the dressing-please fill dead space with order dressings." -Stated per fax on 7/8/14, "Please date dressing when changing so I can more accurately assess drainage." *Weekly wound assessments from 1/22/14 through 4/28/14 revealed: -The wound always had an odor. That odor had not been addressed. -The wound had declined in status for three different weeks. -The wound had not shown regular improvement until assistance from the wound care clinic for debridement (cleaning wound of dead tissue) and treatment had been requested. That time frame had been from 1/22/14 through 4/28/14. 3. Review of resident 3's medical record revealed: *On 7/18/14 a progress note by LPN K stated, "Noted 1 cm. abrasion (scraped off area of skin) on the bottom of left big toe. Rubbed bottom of foot on head board." -No treatment had been started. -A nursing order for health maintenance had been entered on the MAR indicated [REDACTED] *On 7/22/14 an initial wound assessment for the resident's left outer foot had been completed by LPN K. It had been recorded as a pressure ulcer and had been 100% eschar and unstageable (full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed). . -The nursing order entered on the MAR indicated [REDACTED]. -That had not followed this policy and procedure for pressure ulcers. *On 7/31/14 the resident had been seen by the wound care nurse, and a new treatment had been ordered. The order had been for "Collagen to open area and then cover with foam dressing." 4. Review of resident 13's medical record revealed: *The resident had been readmitted on [DATE]. *A skin assessment had been completed at the time of admission, on 9/9/13, and on 9/16/13. *There had not been a weekly skin assessment completed on 9/23/13 and on 9/30/13 by a licensed nurse. *The next skin assessment completed by a licensed nurse had been on 10/11/13 when a pressure ulcer had been identified to the sacral (bottom) area. Review of the bath aide skin checks on 9/5/13, 9/16/13, and 9/26/23 revealed no documentation under the heading "Skin assessment and outcome." Interview on 8/12/14 at 10:45 a.m. with the interim director of nurses regarding resident 13 revealed: *A skin assessment was to have been completed at the time of admission and then weekly for four weeks. *She stated after that time the bath aides did a skin check weekly. *She agreed that only the admission and first two weekly skin assessments had been completed by a professional nurse. *She agreed a professional nurse had not completed the last two skin assessments. A skin problem could have occurred during that time and not have been identified. 5. Review of resident 6's medical record revealed she had been admitted on [DATE]. Review of the 1/22/14 revised care plan stated she was at risk for skin breakdown with that problem area initiated on 3/6/13. Review of resident 6's Braden scores (determines risk for pressure ulcers) from the electronic medical record (EMR) on the following dates revealed: *Moderate risk with a score of 13 on 8/06/13. *Moderate risk with a score of 13 on 10/30/13. *High risk with a score of 12 on 12/22/13. *High risk with a score of 11 on 4/2/14. Those scores showed an increased trending for risk of skin breakdown. Review of resident 6's wound documentation from the EMR revealed the right heel pressure ulcer measurements had no depth measurements and were indicated on all of the entries as length X (by) width: *The initial wound notation had been on 10/2/13 as 5 cm X 3.5 cm and staged as suspected deep tissue injury (injury or damage to underlying tissue). That form had no indication the family had been notified of the pressure ulcer. *10/7/13, 4.5 cm X 3.5 cm; staged as suspected deep tissue injury. *11/4/13, 4.5 cm X 3.2 cm; staged as suspected deep tissue injury. The ulcer had 100 percent (%) eschar (scab). *12/02/13, 3.6 cm X 3.1 cm; staged as unstageable with 100% eschar. *1/13/14, 3.5 cm X 2.4 cm; staged as unstageable with 100% eschar. *2/03/14, 3.6 cm X 3.2 cm staged as unstageable with 100% eschar. No change was noted in the plan of care with the increase in wound size. *3/03/14, 3.5 cm X 3.2 cm; staged as unstageable with 100% eschar. *4/07/14, 3.0 cm X 3.0 cm; staged as unstageable with 100% eschar. *5/05/14, 1.8 cm X 2.8 cm; staged as unstageable with 100% eschar. *6/02/14, 1.8 cm X 2.8 cm; staged as unstageable with 20% granulation (healing tissue), 30% slough (dead tissue), and 50% eschar. No change was noted in the plan of care. *7/28/14, 1.4 cm X 1.4 cm; stated as unstageable with 100% eschar. No change was noted in the plan of care. *All of the above assessments indicated there had been pain associated with that pressure ulcer. *When changes in wound measurements occurred there had not been any documentation the family had been notified. Review of the wound care for the right heel ulcer had been initiated on 10/2/13 and included the following treatment: *[MEDICATION NAME] (iodine) applied to the affected area twice a day. *On 10/7/13 heel protectors were applied and were to have been worn at all times. An air mattress overlay had been applied to the bed. [MEDICATION NAME] was to have continued to be applied. *On 3/02/14 the wound care had been decreased to [MEDICATION NAME] applications once a day. No alternative treatment had been investigated to promote wound healing when either no changes or an increase in the size of the wound had been noted. Review of the 8/2/13, 10/25/13, 1/17/14, 4/11/14, and 5/19/14 Minimum Data Set (MDS) assessments revealed the resident's overall status remained about the same: *Her bed mobility (help moving in bed) had been extensive (majority of staff assistance) to total (staff complete the task with no resident help) assistance needed. *She had required extensive to total assistance from staff with transfers. *She required extensive to total assistance from staff with putting on and taking off her clothing. *She had required extensive to total assistance from the staff to eat. *She had been on a therapeutic (medically indicated diet) mechanical (ground) soft diet. Observation on 7/29/14 at 3:50 p.m. with the DON of the right heel ulcer revealed a stage 3 (deep tissue that formed a crater) ulcer with slough present in the wound bed. No eschar was present. At that time the DON indicated the resident had obtained the ulcer in 2013 from moving her feet back and forth while in bed. 6. Review of resident 10's medical record revealed he had been re-admitted on [DATE]. Review of the 5/23/12 revised care plan from a previous admission revealed the problem area had been initiated on 3/8/11 and was being used as the current care plan. The focus area for skin breakdown had not been revised when pressure ulcer care had been initiated. Review of the 7/12/13, 10/2/13, 1/2/14, 3/27/14, and 6/16/14 Braden scores from the EMR revealed he had remained at moderate risk for skin problems. Review of the wound care documentation in the EMR revealed: *On 7/14/14 a pressure ulcer was noted on the right inner ankle that measured 0.4 cm X 0.4 cm X 0.2 cm. It had been a stage 3; with 10% slough. The family had not been notified. *The 7/21/14 assessment measured it at .6 cm X .6 cm X .2 cm stage 3 with 80% granulation and 20% slough. The assessment stated the wound had been stable. The physician or family had not been notified of the wound size changes. *The 7/28/14 assessment measured at 0.5 cm X 0.5 cm X 0.2 cm stage 3 with 80% granulation and 20% slough. Review of the wound care in the EMR for the right inner ankle pressure ulcer revealed: *On 7/14/14 wound care had been initiated to paint the area with [MEDICATION NAME] and cover with [MEDICATION NAME] (name brand dressing). Heel protectors were to have been worn when in bed. *Wound care treatment had not changed when the pressure ulcer had increased in size. Review of the 7/5/13, 9/27/13, 12/20/13, 3/14/14, and 6/6/14 MDS assessments since this admission on 2/9/12 in the EMR revealed he had remained the same: *His bed mobility had been extensive assistance from staff. *He had required extensive assistance from staff with transfers. *He had required extensive assistance from staff for putting on and taking off clothing. *He had been independent with feeding himself. *He had been on a mechanically altered diet with no weight loss noted. Random observations from 7/29/14 through 7/31/14 revealed resident 10 was wearing a compression (snug fitting) stocking on the right leg. He was wearing white cotton anklet stockings and white high top tennis shoes on both feet. Observation and assessment of resident 10 on 7/30/14 at 9:35 a.m. with the DON revealed an ulcer on the inside of the ankle on the right foot without a dressing present. When the anklet and compression stocking had been removed by an unidentified nurse there had been redness in the surrounding skin. The high top tennis shoe and compression stocking had applied pressure to the surrounding area when worn. Interview at the above time with the DON confirmed resident 10 wore compression stockings, anklets, and tennis shoes each day. He had obtained the pressure ulcer after the family had purchased new tennis shoes (white high top shoes) for him. Staff were not to be putting the white tennis shoes on him, and he was to be wearing the old black tennis shoes. The DON could not confirm if the family had been told about the tennis shoes that had caused the skin problems. Interview on 7/30/14 at 10:10 a.m. with LPN C, the wound care nurse, confirmed the resident was to have been wearing his black tennis shoes. She continued to stage it at 3, because it had "Slough and it is deep." Surveyor: 7. Interview on 7/31/14 at 11:30 a.m. with the medical director revealed: *She had not been aware of the increased number of acquired pressure ulcers. *She stated the increase of pressure ulcers could have been attributed to the increase in acuity (level of the severity of a disease process) of residents that had been admitted . *She had been contacted by staff in regards to treatment options for pressure ulcers. *She stated she had relied on the provider's clinical resource specialist to give guidance on what were the best wound care interventions. *She had not been involved in the development of the provider's pressure ulcer policies. *She would consult a hospital's wound care clinic also for treatment options. *She only observed a resident's pressure ulcer if it was a large size pressure ulcer. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St. Louis, MO., 2005, p.1484, revealed "Pressure is the major element in the cause of pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: *Pressure intensity (amount of pressure required to close a capillary (blood vessel)). *Pressure duration (how long the pressure remains). *Tissue tolerance (the ability to handle pressure). Review of the National Pressure Ulcer Advisory Panel, revised 2007 Pressure Ulcer Prevention Points talksheet revealed: "Implementation of pressure ulcer prevention program are structured, organized, comprehensive, and directed at all levels of health care providers, patients, family, and caregivers." Included information on: *"Etiology (cause) of and risk factors for pressure ulcers." *"Risk assessment tools and their application." *"Skin assessment." *"Selection and use of support surfaces (gel cushions)." *"Nutritional support (supplements)." *"Program for bowel and bladder (incontinence) management." *"Development and implement individualized programs of skin care." *"Demonstration of positioning to decrease risk of tissue breakdown." *"Accurate documentation of pertinent data." Review of the provider's February 2014 Pressure Ulcers/Skin Breakdown policy revealed: *The nursing staff and attending physician would assess and document an individual's significant risk factors for development of a pressure ulcer. *The nurse should assess and document/report the following including: -Full assessment of pressure ulcer including location, stage, length, width, and depth. -Pain assessment. -Current treatments, including support surfaces. *The physician would authorize orders related to wound treatments including pressure reduction surfaces, wound cleansing and debridement (removal of dead tissue) approaches, dressings, and the application of topical (to the skin) agents. Review of the provider's February 2014 Pressure Ulcer Treatment policy revealed: *"The pressure ulcer treatment program should focus on the following strategies: -Assessing the resident's pressure ulcer(s). -Managing tissue loads. -Pressure ulcer care. -Managing infection. -Education and quality improvement. *When eschar (scab) is present, a pressure ulcer cannot be accurately staged until the eschar is removed. *Stage one pressure ulcer: Intact skin with non-blanchable (does not become pale when pressed) redness of a localized area usually over a bony prominence. *Stage two pressure ulcer: Partial thickness loss of dermis (skin) presenting as a shallow open ulcer with a red pink wound bed, without slough (dead tissue). May also present as an intact or open/ruptured serum (fluid)-filled blister. *Stage three pressure ulcer: Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon, or muscle are not exposed. Slough may be present but does not obscure (hide) the depth of tissue loss. May include undermining (wound is wider at its base than on the surface) and tunneling (extends farther under the skin like a tunnel). *Stage four pressure ulcer: Full thickness tissue loss with exposed bone, tendon, or muscle. Slough or eschar may be present on some parts of the wound bed. Often includes undermining and tunneling. *Unstageable: Full thickness tissue loss in which the base of the ulcer is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, black) in the wound bed. *Pressure ulcer treatment requires a comprehensive approach, including: -Debridement, managing infections, maximizing

Based on record review and interview, the provider failed to ensure one of ten sampled residents (13) who required transfer and toileting assistance was assisted in a timely manner and remained free from skin injury. Findings include: 1. Review of resident 13's 8/1/14 at 10:23 a.m. progress notes revealed the following: *"Resident was left in the restroom unattended for approx. (approximately) 45 minutes. upon assessment on RT (right) upper thigh next to the RT gluteal (bottom) fold a open area has appeared approx. 1 inch long 1/2 cm (centimeter) wide." *Review of resident 13's medical record revealed no prior open area to her right gluteal fold. Interview on 8/12/14 at 10:50 a.m. with the interim director of nurses confirmed and revealed: *The above resident used a lift to transfer. *There had been no reason she should have been left on the toilet that long. *The above resident had been harmed by the skin injury from the above incident. A policy had been requested from the interim director of nursing regarding resident toileting. That policy had not been received by the time of exit on 8/13/14.