Every finding on record at Sanford Care Center Vermillion

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, observation, and policy review, the provider failed to protect the safety of two of two sampled resident (1, and 2) identified as at risk for elopement (leaving the facility without staff knowledge) who had exited a secured door and crawled out of a room window and left the building without staff supervision. Findings include:1. Review of the 11/22/25 SD DOH FRI report regarding resident 1 revealed:*Resident 1 was admitted to the facility on [DATE].*On the night of 11/2/25:-Resident 1 was wandering around at his baseline looking for exits.-At approximately 12:40 a.m. the south door alarm goes off.-Resident 1 is in the south hall walking back toward the nurses station/central lobby.-Nurse [registered nurse (RN) B] heads down to the far south door to turn off the alarm.-Resident 1 turns to follow and immediately pushed open the south door and leaves the building at 12:42 a.m.[RN B] Unable to see resident [1] in the parking lot.-Due to [resident 1] history of aggression and it being dark outside, the nurse [RN B] contacted law enforcement for her [RN B] personal safety.-Camera's were viewed and resident 1 was in the car [police] at 12:48 a.m. being brought to the ambulance bay door.*[Resident 1] was wearing jeans, a T-shirt and shoes.*The temperature was 35 degrees outside.*[Resident 1] was found in our facility parking lot.*On return to the care center [resident 1] is noted to be anxious with tense body posture and clenched fists.*[Resident 1] refused skin assessment and vitals.*Call with voicemail was left for family, and information was faxed to physician. 2. Review of resident 1's electronic medical record (EMR) revealed:* He had pertinent diagnoses of:-Unspecified dementia with agitation.-Depression.-Alcohol abuse, in remission.-Anxiety disorder.-Attention-deficit hyperactivity disorder, combined type.-Insomnia.*He had a roam alert (a wearable door alerting device) on his ankle starting on 4/29/25.*He had a Brief Interview for Mental Status (BIMS) score of 0, which indicated severe cognitive impairment on 9/12/25.*He was assessed on 9/11/25 and was identified as at risk for elopement.*He was administered Tylenol pm extra strength (a pain medication used for sleeplessness) on 11/1/25 at 8:45 p.m. for anxiety.*He was administered lorazepam (an anxiety medication) on 11/1/25 at 8:45 p.m. for anxiety, agitation, or behavioral disturbances.*He had been administered olanzapine (an antipsychotic medication) 5mg IM (intramuscularly) on 11/2/25 at 1:20 a.m. upon his return for behavior issues [elopement].*He had been started on 15-minute visual checks on 11/10/25.*He was sent to the emergency department (ED) on 11/26/25 for suicidal ideation.*He was discharged from the ED and transferred to a higher level of care facility (HSC).*A telephone conference was held on 12/16/25 with HSC staff regarding discharge planning related to safety concerns.*Resident 1 was discharged from facility on 12/16/25 as facility could not meet the security needs. 3. Interview on 1/28/26 at 12:04 p.m. with certified nursing assistant (CNA) C revealed:*She had worked for the facility for four and a half years.*She worked the night shift from 11/1/25 at 10:00 p.m. to 6:30 a.m. on 11/2/25.*There is one nurse and three CNA's that typically work.*Resident 1 was having behaviors of agitation, exit seeking and threats against staff.*She was unsure if as needed (PRN) medications had been given to resident 1.*She was told by registered nurse (RN) B to stay in the building for resident and staff safety at the time of the elopement.*She had not completed any elopement drills since she started working for facility.*She completed education since the incident on the new elopement policy. 4. Interview on 1/28/26 at 3:30 p.m. with RN B revealed:*She had worked at the facility for almost four years.*She worked the overnight shift from 6:00 p.m. on 111/1/25 to 6:00 a.m. on 11/2/25.*Staff communicated with each other using a walkie talkie system.*Resident 1 wore a roam alert device.*On 11/2/25 resident 1 was setting off door alarms. She was going to reset the alarm (to the south door) when he pushed through the south end door. When she looked towards door, he could not be seen outside.*She immediately called 911 and gave them a description of resident 1.*She did not feel safe sending staff out to search for resident 1.*Resident 1 required a lot of one to one due to his exit seeking, aggressive behaviors towards staff, and scaring other residents. She stated that he even pushed a staff member into oncoming traffic once when he exited the building and staff followed him.*She had administered PRN medication for anxiety earlier that evening, but it was ineffective.*She had tried distraction, food, and redirection that shift due to his wandering behaviors.*She has never been trained by the facility to deal with that type of behavior.*She had completed education since the incident occurred. The education focused on assessment, not on what to do if an actual elopement incident occurred.*Resident 1 started on 15-minute visual checks after the elopement occurred.*She has not participated in any elopement drill since she has worked at the facility. 5. Review of the 1/21/26 SD DOH FRI report regarding resident 2 revealed:*Resident 2 admitted to facility on 1/13/26.*Resident 2's BIMS assessment score was 3, indicating severe impairment.*Resident 2 had a roam alert device placed on admission.*On 1/20/26 between 6:50 p.m. and 7:00 p.m. the charge nurse had been in resident 2's room to assist her.*At approximately 7:50 p.m. a call was received from the police department, resident 2 was located by them five blocks from the facility.*Resident 2 had removed the screen from her window and pried her window open enough to crawl out.*As a safety measure the facility does not leave cranks on our residents' windows.*Resident 2 was returned to the facility at approximately 8:00 p.m. by police and a family member.*The outside temperature was about 24 degrees.*Resident 2 was dressed in sweatpants, a flannel shirt/jacket, with 2 T-shirts under that and sandals with socks. Family also reported, resident 2 had a blanket with her.*Resident 2 was fully assessed upon her return and vitals were taken and were within normal limits, she had no injuries.*Family wanted to take resident 2 home for the night. He received education from the facility that resident 2 was not safe to be left to stay at home alone and he signed an acknowledgement of safety reasons she should not be left home alone. He ensured someone would remain with her.*Family returned to facility on 1/21/26 at 8:52 a.m. to sign discharge paperwork.*They plan to find placement closer to where they live that has a secure memory care unit.*Hospice would continue to see resident 2 at her home to ensure continuity of care.*Family, physician, director of nursing (DON) and hospice were notified at time of elopement and at time of discharge. 6. Review of resident 2's EMR revealed:*She was admitted to the facility on [DATE].*She was in hospice care when she admitted to the facility.*She had pertinent diagnoses of:-Anxiety disorder.-History of falling.-Unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances.-Diabetes (a condition involving disruptions in how the body regulates blood sugar).*Her BIMS assessment score was 3 on 1/15/26 indicating severe cognitive impairment.*Her elopement risk assessment dated [DATE] indicated she was at risk for elopement.*She had a doctor's order dated 1/15/26 for lorazepam (an antianxiety medication) 0.5 mg (milligram) tablet by mouth (PO) four times a day (QID).-She had taken all lorazepam doses on 1/20/26.*She had a doctor's order dated 1/13/26 for lorazepam 2 mg/mL (milliliter) to give 0.5 mg PO every two hours PRN.-She had not been given any PRN doses on 1/20/26.*She had a doctor's order dated 1/13/26 for lorazepam 2mg/mL to administer 0.5 mg by injection every four hours PRN.-She had not been given any PRN doses on 1/20/26. 7. Review of resident 2's baseline care plan completed on 1/13/26 revealed:-Roam alert was applied to her wrist on 1/13/26.-Roam alert was moved to her ankle on 1/14/26 as she had been trying to remove.-Behavioral concerns of elopement, confusion.-She was unable to recognize need for placement in nursing home due to dementia.-History of falls. 8. Interview on 1/27/26 at 1:05 p.m. with licensed practical nurse (LPN) D revealed:*She worked on 1/20/26 from 12:00 p.m. to 6:00 p.m.* LPN D and LPN E went to give resident 2's second tuberculin (TB) skin test that was due at 3:30 p.m.*Resident 2 was tearful, as her husband had recently passed away.*Approximately 45 minutes later, resident 2 was pacing the hallways then going back to her room.*She had noted that resident 2 had removed the inner screens to her windows.*She had notified clinical care leader (CCL) F of the removal of the screens.*CCL F told her to keep an eye on resident 2.*LPN D left the facility at the end of her shift at 6:00 p.m. that evening.*She had completed elopement education after resident 1 had left the building in November 2025. 9. Interview on 1/27/26 at 2:35 p.m. with CCL F revealed:*Staff were monitoring resident 2 on 1/20/26 as she was pacing and wandering the hallways.*Resident 2 had a roam alert device on.*There are no cranks on the window in her room, she was not aware of anything resident 2 could do other than remove the screens.*Resident 2 had an order for PRN anxiety medication; she was unsure if it had been given.*Floor staff can initiate 15-minute visual checks for closer monitoring, as they have done before for other residents. 10. Observation on 1/28/26 at 11:00 a.m. of resident 2's room revealed:*Door was shut.*Screens were in the windows.*There were no cranks on the windows for opening.*There was lock on the window. When released you could push the window open two to three inches until some resistance occurred.*The inner window frame has cracked wood in the lower right corner.*From the room floor to window ledge it is 28 inches. 11. Interview on 1/28/26 at 2:11 p.m. with LPN E revealed:*She started working at 2:00 p.m. on 1/20/26.*During shift report she was told by LPN D that resident 2 needed a second TB test.*Resident 2 was sad and tearful when she went into her room to assist LPN D with the TB test.*She was listening to music.*She would pack her things every day to leave.*She was verbalizing, wanting to leave and was visibly upset.*Resident 2 had been given two doses of lorazepam (an antianxiety medication) that day she thought.*She was aware that resident 2 was an elopement risk.*She wore a roam alert device.*At 4:00 p.m. on 1/20/26 she had observed resident 2 open her door and saw that her window screens were out of the frame, and resident 2 went to lie on her bed.*She had notified LPN D that the screens were removed.*CCL F had told staff after they noticed the screens were removed, that there were no cranks on the windows, and that resident 2 could not do anything.*She was notified by the police later that evening that resident 2 had left the building.*She notified the director of nursing (DON) A.*Resident 2 returned around 8:00 p.m. to the building, she was shivering and cold.*She sat her by the fireplace and gave her hot chocolate.*She completed vitals and skin assessment on resident 2 upon her return.*Resident 2 was wearing sandals and socks, a flannel shirt and two T-shirts.*DON A arrived shortly after resident 2 returned to the facility.*DON A talked with family, offered them support and arranged a therapeutic leave for overnight for resident 2.*Maintenance was notified to come and secure the window which he did.*She has not completed any elopement education following the incident. 12. Observation on 1/29/26 at 7:50 a.m. of resident 2's former room revealed that the doorknob was replaced and was completed by unidentified maintenance staff at the time of the observation. A lock was placed on the door, so no other residents have access to the room. The lock is on the door, and the room is secure as of 8:52 a.m. 13. Interview on 1/29/26 at 9:01 a.m. with DON A revealed:*She had arrived after resident 2 returned to the facility on 1/20/26, and resident 2 was sitting in the lobby with her suitcase and box packed. Resident 2 was wearing a flannel shirt and her family was with her.*She felt the staff should have been concerned when resident 2 removed her window screens.*A lock had been placed on resident 2's former room door to stop any further access by residents to the room and the window that was broken.*The facility had started 15-minute visual checks on resident 1 on 11/10/25 until he discharged to a higher level of care facility.*After resident 1's 11/2/25 elopement, only nurses were educated on the 10/22/25 elopement policy.*There has been no further education completed since resident 2's 1/20/26 elopement from the facility with any staff members.*She was unsure when the last elopement drill had been completed.*Elopement risk assessments were completed upon admission and quarterly depending on minimum data set (MDS) assessment.*Staff are notified of resident care needs through the Kardex (a quick reference guide for resident care) and shift change report, including if a resident has a roam alert device.*Staff were notified of an elopement over the walkie system by stating security alert, missing resident room number.*She expected to be notified immediately when a resident has an elopement.*If a resident was an elopement risk, the first consideration for resident placement was in the memory care unit.*If there was no availability in the memory care unit, then the preference for resident placement was in the north hall, which had no outdoor access. This was where resident 1 and 2 resided.*Floor staff were allowed to initiate 15-minute visual checks for residents if wandering or exit seeking behaviors were noted.*She expected staff to utilize PRN medication if available and residents were showing signs of anxiety and pain. 14. Interview on 1/29/26 at 10:09 a.m. with Improvement Advisor G revealed the elopement policy was revised on 10/25/25 and the nurses had completed education and policy review following resident 1's elopement on 11/2/25. 15. Review of the provider's 10/22/25 Missing Person-Elopement policy revealed:*It is the facility's responsibility to protect patients/residents from harm. If a patient or resident should wander from the facility grounds/property without notice, the following procedure will be followed:-Elopement will be defined as any resident leaving the grounds of the facilities without knowledge of staff, or any patient/resident unable to be located on the grounds/facilities.-When a resident is discovered as missing or door alarm is activated, the DON/Charge Nurse will immediately be notified. At the Care Center, a beeper system hooked up to the call light system is activated and lights at the end of the hallway in question will flash red.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, employee file review, and policy review, the provider failed to protect one of one sampled resident (3) from verbal abuse who had profanity verbalized toward her by certified nursing assistant (CNA) H.Findings include:1. Review of the 1/12/2026 SD DOH FRI report revealed:*A report was made on 1/12/26 involving [resident 4] who expressed concerns of verbal abuse by a staff member [CNA H] to another resident [resident 3].*CNA H was interviewed by director of nursing (DON) A and clinical care leader (CCL) F on 1/12/26 and then sent home and remained on suspension pending the investigation.*Resident 3's date of admission to the facility was on 12/2/25.*Resident 3's most recent Brief Interview for Mental Status (BIMS) assessment score was 3 indicating severe cognitive impairment.*Resident 3 had pertinent diagnoses of dementia, hearing loss, chronic kidney disease stage 3.*Resident 4's date of her admission to the facility was on 2/1/24.*Resident 4's most recent BIMS assessment score was 15 indicating she is cognitively intact.*Resident 4 had pertinent diagnoses of left leg above knee amputation, depression, and post-traumatic stress disorder.*It was reported, On the evening of 1/11/26 [Resident 4] heard [Resident 3] in the hallway saying I need it now repeating it a couple of times. [Resident 3] is known to be impatient and rude to staff.*[Resident 4] reports she overheard CNA H respond, [Resident 3] shut the [expletive] up.*[Resident 4] stated she then wheeled herself to the hallway and confirmed it was CNA H who had said this to resident 3.*When resident 3 was interviewed the next day by social worker (SW) I, she did not remember the incident and reported she was feeling okay.*CNA H was given education on disruptive conduct and behaviors and online education for customer service.*CNA H was allowed to return to work after completion of education and disciplinary action.*Audits were to be conducted weekly by director of nursing (DON) A or designee for three months which include interviews with three staff CNA H had worked with that week and three residents that he has cared for that week.*CNA K was interviewed on 1/13/26 at 3:00 p.m. by CCL F regarding the evening of 1/11/26 revealed:-When CNA K returned from her break at 5:00 p.m. CNA H was in a bad mood. She said CNA H seemed irritated and overwhelmed; she was unsure what had happened to put him in this mood.-She believed that was why he left early.-CNA H was being rude to her during that shift.-She had completed most of resident 3's cares that evening.-Resident 3 was no more demanding than usual that evening.-CNA K had seen CNA H get irritated before, but not swear at anyone. 2. Interview on 1/27/26 at 9:22 a.m. with resident 3 revealed:*She did not know the date or what day it was.*She said she was feeling fine.*When asked if staff had yelled at her she stated, I don't think so.*When asked how staff treat her, she stated okay. 3. Interview on 1/27/26 at 9:30 a.m. with resident 4 regarding the 1/11/26 incident revealed:*Resident 3 repeats things often and uses her call light often.*She had been sitting in her room on 1/11/26 across from resident 3's room.*She had overheard CNA H say to resident 3 to Shut the [expletive] up on 1/11/26 in the late afternoon.*She had pushed her wheelchair to the doorway and observed CNA H standing by resident 3 after she overheard the above statement.*She stated CNA H had always been nice to her.*She has no fear of CNA H following the above incident. 4. Interview on 1/27/26 at 12:40 p.m. with minimum data set (MDS) Coordinator J revealed:*Customer service education had been assigned to all staff and she thought they had until the end of the month to complete the education.*Audits on CNA H had not started, she believed they would start this week.*CNA H had given his notice and is quitting on 2/1/26. 5. Interview on 1/27/26 at 3:15 p.m. with CNA H revealed:*He started working for the facility on 9/8/25.*He worked on the evening shift until 7:00 p.m. on 1/11/26 in the south hallway with resident 3.*He had toileted resident 3 and transferred her that shift.*Resident 3 required toileting assistance, transfer assistance, and wheeling assistance to meals in the dining room.*Resident 3 had behaviors of forgetfulness, verbally repeating things, demanding at times, combativeness with staff and would kick out at staff while they perform cares.*He said on 1/11/26 resident 3 wanted her requests completed immediately, was demanding and impatient.*He denied when asked, if he had told [resident 3] to Shut the [expletive] up on 1/11/26 while caring for her.*He had been suspended pending the investigation of the incident.*He thought he returned to work on 1/16/26 and had completed the facility required re-education before returning to work.*He has not worked with resident 3 or resident 4 since his return to work on 1/16/26. 6. Interview on 1/28/26 at 11:40 a.m. with social worker (SW) I revealed:*She started working for the facility on 12/15/25.*She had interviewed resident 3 and resident 4 on 1/12/26 after the incident was reported to DON A by an unidentified CNA.*She had stated resident 3 did not remember anything that had happened the evening before.*Resident 4 stated to SW I that she had overheard resident 3 on her call light, as the buzzer sounds in the hallway and resident 3 was yelling Help me right now, right now.*Resident 4 stated, she heard a male voice state to resident 3 to shut the [expletive] up.*Resident 4 stated to her that she then wheeled herself to her doorway and observed CNA H standing outside her room.*She stated that resident 4 is a good source of information, she does not make up stories.*Resident 4 was even hesitant to tell her anything as she did not want to get anyone in trouble by talking with her.*Resident 4 has a BIMS assessment score of 15 out of 15 and is cognitively intact.*After completing the resident interviews, she forwarded the information onto DON A. 7. An interview with CNA K was requested by phone and email request, but she did not respond. 8. Interview on 1/28/26 at 2:11 p.m. with licensed practical nurse (LPN) E revealed:*She had worked with CNA H before.*She felt resident 4 was a reliable witness and truthful.*Resident 4 has reported observations before to her.*She had not yet completed the customer service education that had been assigned.*She had observed CNA H yell at a resident before that was exit seeking.*CNA H was still new and training and she used it as a teaching moment to tell him he could not talk to residents that way. This was on the night shift.*She had not notified anyone in management when that incident had occurred. 9. Interview on 1/28/26 4:47 p.m. with registered nurse (RN) L revealed:*She had worked on 1/11/26 with CNA H. He had left early around 6:30 p.m.*CNA H does not like to communicate with her.*CNA H had a sharp tone whenever he spoke to her that evening.*She had not had anything reported to her that evening regarding CNA H.*Resident 4 is a reliable witness, and if she told RN L something, she would believe it to be the truth.*She had completed the customer service training that had been assigned after the allegation was made. 10. Interview on 1/29/26 at 9:23 a.m. with DON A revealed:*She is unsure if resident 3 remembers the interaction.*Resident 3's cognition fluctuates, and she is hard of hearing.*She had completed some staff interviews for the investigation.*She considers resident 4 a reliable, trustworthy reporter for the most part; her cognition is intact.*She took what resident 4 had reported to be truthful.*CNA H was suspended pending the investigation; he missed 2-3 days of work.*CNA H received a written final warning.*CNA H was assigned and had completed staff education on professional communication in long term care and customer service before returning to work.*CNA H returned to work on 1/15/26.*No audits have been completed following the incident.*There had been no further follow-up with residents 3 or 4.*She expected staff to treat residents the way they wish to be treated, that this was their home, the staff were here to care for them. 11. Review of CNA H's employee file revealed:*He was hired on 9/8/25.*A background check had been completed on 8/19/25.*He completed Abuse, Neglect, and Exploitation education on 9/9/25.*He completed An Overview of Quality Dementia Care CNA education on 9/24/25.*There was a final warning written in file regarding the incident that occurred on 1/11/26. 12. Review of the provider's 4/11/25 revised Abuse and Neglect policy revealed:*Patients and residents have the right to be free from verbal, sexual, physical, mental abuse, neglect, misappropriation of property, corporal punishment, exploitation and involuntary seclusion.*Patients and residents must not be subjected to any kind of abuse by anyone, including, but not limited to, facility staff, other patients or residents, consultants, volunteer staff or other agencies serving the individual, family members, legal guardians or personal representatives, friends or other individuals.- Verbal abuse refers to any use of oral, written, or gestured language that includes disparaging and derogatory terms to the resident or their families, or within their hearing distance, to describe patients/residents, regardless of their age, ability to comprehend or disability.

Based on observation, interview, and policy review, the provider failed to follow industry accepted food safety standards to ensure proper glove use by cook (E) while preparing and serving residents' food during one observed meal service according to the provider's policy.Findings include:1. Observation on 9/30/25 at 11:40 a.m. of cook E while preparing residents' food in the dining room kitchenette revealed:*With her gloved hands she:-Touched the residents' menu slips.-Opened a bag of bread and pulled slices of bread out of the bread bag and placed them on top of the hot grill.*She then removed her gloves, washed her hands, and put on a new pair of gloves. With those gloved hands she:-Opened the refrigerator door, removed a bag of sliced cheese, and placed it on the counter beside the hot grill.-Touched the bread slices on the hot grill and slid them around.-Opened the bag of cheese and placed cheese slices on those slices of bread.-Opened the refrigerator door and removed a zip lock bag of two precooked burger patties.-Placed those burger patties on a plate.*She then removed her gloves, washed her hands, and put on a new pair of gloves. With those gloved hands she:-Removed a plate from a stack of clean plates and placed it on the counter by the hot grill. -Opened a bag of hamburger buns and removed two buns and placed them on plates. -Touched multiple resident menu slips.-Gathered a plate, bags of chips, and ketchup packets and placed them on the counter by the hot grill. -Touched both the grilled cheese sandwiches on the hot grill.-Touched the resident menu slips.-Removed frozen hamburger patties from the freezer and placed them on the hot grill.*She then removed her gloves, washed her hands, and put on a new pair of gloves. With those gloved hands she:-Touched several resident menu slips.-Opened a bag of bread, removed 4 slices of bread from that bag and placed them on the hot grill.-Handled a bag of chips.*She then removed her gloves, washed her hands, and put on a new pair of gloves. With those gloved hands she:-Handled a bag of chips.-Placed two slices of cheese on the bread slices on the hot grill.-Removed two hamburger buns from the plastic bag and placed them on plates.-Closed the bag of cheese and placed it back in the refrigerator. *She then removed her gloves, washed her hands, and put on a new pair of gloves. With those gloved hands she:-Touched resident menu slips.-Maintained the grilled cheese sandwiches in place on the hot grill while she removed the edges with a spatula.-Gathered two plates from the stack of clean plates and placed them on the counter next to the hot grill.-Placed the grilled cheese sandwiches on the plates.*She then removed her gloves and washed her hands.*She gathered a plate from the stack of clean plates, flipped the hamburgers on the hot grill, and then removed a bag of sliced cheese from the refrigerator.*She put on a new pair of gloves. With those gloved hands she:-Removed two slices of cheese from the bag and placed them on the hamburgers on the hot grill.-Placed the hamburger buns on top of the bag of cheese.-Gathered plates from the stack of clean plates and plated the hamburgers.*She removed her gloves and served the plated to the residents. Interview on 9/30/25 at 12:30pm with cook E revealed:*She thought she made a mistake when handing the residents' food items with her gloved hands but was unsure.*She felt her process of making the food was bad because she had to make multiple trips to the sink to wash her hands and put on new gloves.*She agreed that she should not have touched non-food items with her gloved hands and then touch the residents' food. Interview with dietary manager D immediately following the above interview with cook E revealed:*She had been worried about the staff's glove use practices in the kitchen.*Some staff chose to wear gloves in the kitchen while preparing and serving the residents' food but did not follow the best process.*She was aware cook E wore gloves and touched other items before touching the residents' food.*She expected staff to use proper glove use while preparing and serving residents' food. Review of the provider's revised 2/9/25 Sanitary Service of Food policy revealed:* To prevent foodborne illness by preventing cross-contamination of foods during service.* All foods will be served in a manner that reduces possible chemical, physical, or biological contamination.* Use proper hand washing procedures to wash hands and exposed arms up to elbows prior to handling or serving any food.* Do not use bare hands to directly touch or handle any foods during food preparation or service. Gloves are to be worn to handle any food with bare hand contact when prepping food, preparing a recipe, or serving food. Gloves are not worn when using utensils to mix or serve foods.* Wash hands before putting on gloves, each time gloves must be changed, when changing tasks, before beginning to serve food with utensils.* Handle plates by the edge or rim, cups by the bottom or handle, and utensils by the handles only.

Number of residents sampled: Number of residents cited: Based on observation, interview, record review, and policy review the provider failed to ensure a formalized dining assistance program was conducted with identified family member of resident (18) who assisted resident 11 with dining. The provider also had no documentation of training for any other resident family members or visitors who offered dining assistance. Findings include: 1. Observation on 9/30/25 at 12:15 p.m. of in the dining room revealed: *A visitor used resident 18's utensils in her right hand and assisted him with eating. She then turned to her right and picked up resident 11's utensils with her right hand, and assisted resident 18 with eating. *The visitor did not wash her hands after she assisted resident 18 with eating before she assisted resident 11 with eating. 2. Interview on 9/30/25 at 12:30 p.m. with certified nursing assistant (CNA) C revealed:*She and a medication aid assisted residents with eating their meals. Resident 18's wife came in to the facility everyday to help her husband with eating, and would help other residents. *She stated resident 18's wife had not been trained to assist residents to eat but should have been. 3. Interview on 10/2/25 at 11:50 a.m. with resident 18's wife revealed:*She had not been trained regarding assisting resident with eating. She helped her husband and their friend with eating when she visited. She helped her husband and their friend with eating when she visited. She stated resident 11 could feed himself at times, but needed a little help from time to time. She helped her parents with eating in the nursing home years ago and at that time, she did not think she had to have training on assisting them. *She stated she should not have helped her friend with eating, and did not want to get anyone in trouble. *She would have called a nurse if anyone had a choking episode. *She confirmed she had used the same hand to feed both residents and stated, I only touched the end of his fork. 4.Interview on 10/2/25 at 2:16 pm with Minimum Data Set (MDS) coordinator B revealed:*She did not have a list of visitors who were trained to provide feeding assistance to the residents.*She stated resident 18's wife had approached her yesterday and asked if she could be trained so she could assist her friend with eating. *She confirmed that resident 18's wife had not been trained on providing eating assistance. 5. Review of resident 11's electronic record (EMR) revealed:*He had impaired swallowing related to history of transient ischemic attack (TIA) (stoke) and dementia (a group of symptoms affecting memory), thinking and social abilities). *He used his left hand for eating due to a deformity of his right hand and used specialized silverware to accommodate that. *He had a Brief Interview for Mental Status (BIMS) assessment score of 12 which indicated his cognition was moderately impaired. 6. Interview on 10/2/25 at 3:01 p.m. director of nursing A regarding a visitor who assisted resident 11, who had impaired swallowing with eating revealed:*She was not aware that a visitor had assisted resident 11 with eating. *She expected anyone who had assisted a resident to eat would have been trained on how to safely provide that assistance but did not have a process for that training. 7. Review of Provider's 1/31/25 Dining Assistant policy revealed, The location must ensure that a dining assistant feeds only residents who have no complicated feeding problems. Complicated feeding problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations and tube or parenteral/IV feedings. The resident selection must be based on the interdisciplinary team's assessment and the resident's latest assessment and plan of care.

Based on observation, interview, and record review the provider failed to provide adequate supervision for 1 of 1 resident (20) to prevent actions of self-harm. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on [DATE] at 2:12 p.m. to administrator A for F689 and director of nursing B for F689 Accidents related to the prevention of his self-harm. *Observation on [DATE] of resident 20 in his room revealed he had multiple open areas, some of which were actively bleeding on his bilateral lower legs while holding a sharp instrument. *Multiple staff interviews revealed they were aware that he had various sharp tools in his possession and used these sharps to cut himself to remove bugs he believed were under his skin. *Record review of resident 20's care plan revealed he was allowed to have sharps he purchased in his possession to remove perceived bugs from his skin. On [DATE] at 4:23 p.m., administrator A provided the survey team with a written plan for removal of the immediate jeopardy. The removal plan, after revisions, with guidance from the long -term care advisor for the South Dakota Department of Health, was approved by the survey team on [DATE] at 5:06 p.m.: *All sharps have been removed from [Resident 20's] room. *Psychiatry, primary care provider and counselor have been notified of these changes for guidance in managing any adverse behavioral changes. *[Resident 20] has been re-educated on hand hygiene, sharps in his room, infection prevention to include covering wounds. *Updates to the care plan include removing sharps, offering tubi-grips for arms and lower legs for covering of wounds when leaving his room, handwashing education, wound assessment completed [DATE], one-hour check while in the facility for behaviors given resident psychiatric history for 48 hours then re-evaluate. *Center of Excellence for Behavioral Health in Nursing Facilities contacted with expected response within two business days. *[DATE] Addendum, in addition to the skin/wound assessment completed on [DATE]; on [DATE], director of nursing B spoke to [resident 20] about dressing changes. *Resident agreed to let nursing staff change dressing twice a day (BID). *Nursing staff will monitor for any signs of infection during BID dressing changes and notify the physician if any noticed. These will be documented on [resident 20's] treatment. *Nursing will remove soiled towels and washcloths when in his room providing dressing changes. This has been included in the treatment plan and added to the certified nursing assistant (CNA) flowsheet. *Resident was informed that he would not need to buy wound/dressing supplies. *Sharps removed from resident 20's room. *All other current resident rooms were checked for sharps and any of concern were removed. *[DATE] addendum, they had discussed with [resident 20] that his bags would be checked upon return from shopping. *Resident signed previous acknowledgment form that he agreed to staff removing sharps that he may bring back. *Staff will conduct random weekly room checks and will chart in [resident 20's] chart as a treatment. *This has been added to [resident 20's] treatment plan and CNA flowsheet. *They added a treatment order for nursing documentation for behavior/mood of resident 20 daily. *[Resident 20's] behavior documentation will be reviewed at weekly interdisciplinary team (IDT) meetings and as needed (PRN) with adjustments to care/treatment plan as warranted. *Admission packet updated regarding review of sharps for safety. *[Resident 20's] primary contacts have been re-educated on notifying staff prior to bringing/getting sharps items to resident via email. *[Resident 20] has been re-educated on proper hand hygiene for infection prevention and sharps. *Staff have been re-educated on sharps in rooms and planned review of infection prevention practices related to transmission through OnShift. *They receive this education annually at minimum. *A skills fair reviewing infection prevention is scheduled for [DATE]th and annually for staff. *Sharps restriction added to admissions packet. *Staff re-educated on infection prevention practices and safety of all residents related to sharps in resident rooms. *[DATE] addendum, staff were educated on [DATE] through onshift message about the removal of sharps for any resident. *Additional education provided to nursing staff on [DATE] related to resident 20 returning from shopping, the need to look in resident 20's bags for any sharp objects that staff would need to remove and secure in the medication room, staff will reiterate to resident that he is not able to have those items in his room *PRN treatment order added to check bags upon returning from shopping outings. *Staff will also be educated on the weekly random room checks that will be conducted on [resident 20's] room for sharps found, those items will be removed and secured in the medication room. *Treatment order added to document these random weekly room checks for [resident 20], also added to CNA flowsheet to check room BID. On [DATE] at 10:43 a.m., the survey team determined the immediacy was removed. After removal of the immediacy, the severity and scope was a level G. 2. Observation and interview on [DATE] at 9:29 a.m. with resident 20 revealed: *He was sitting on the edge of his bed scratching at his leg. *He had multiple open areas with some active bleeding on his bilateral lower legs and bandages on some of them. *He was dressed in only boxers holding and was holding a wooden handled tool with a flat top type screwdriver in his hand with his leg crossed, with his right ankle on his left knee. *There was a card table across from him that had two table lamps clamped to each side of it. *Pouches were hanging below each lamp contained various tools, scissors and glasses and a magnifying glass. *There was a white towel under his bare feet with dried blood on it and another lying to his left with dried blood on it. *Bandage wrappers were on the floor by his feet. *He stated his legs are better because he has been taking care of them. *He stated he kept his tools in alcohol. *He stated he had good medicine here but the nurse took it from him and said it was dangerous and he could not have it. *He stated he was doing okay for the shape he was in. *He stated he was sad when he first had to come here and when first came to live there but no it was not so bad. *His shower has two discolored towels on the floor that appeared to have been wet then dried multiple times and had what appeared to be dried blood on them. Interview on [DATE] at 4:00 PM CNA P in regards to resident 20 revealed: *He picked at his legs, and thought there was something under his skin. *Staff would take the tools he used to pick at his skin, but he would get them back. Interview on [DATE] at 4:15 p.m. with RN F in regards to resident 20 revealed he: *Had a picking disorder and could have sharps in his room. *Tried to cut bugs out of his skin. *Would not let any nurses take care of the open areas on his legs. *Had a brother or friend who was aware he cuts himself. *Was aware that staff had removed the sharp objects he used to cut himself. *Is independent and is allowed to leave the premises. *Would go to a store on public transit and buy what he wanted and would bring it back to his room. *He was aware that his sharps and cutting of himself were care planned. Telephone interview on [DATE] at 9:30 a.m. and 1:20 p.m. and with the regional long-term care ombudsman revealed. -She was not contacted by the provider and was not aware of resident 20's situation. -The Center of Excellence for behavioral health in nursing homes should have been contacted by the provider. Interview on [DATE] at 12:25 p.m. with the behavioral counselor for the provider revealed she: *Started seeing resident 20 in March of 2022. -Initially because he was having suicidal ideations. -He had lost his longtime girlfriend and had expressed if he had a gun he would end things. -His primary hallucination was bugs under his skin but then it changed to psoriatic arthritis in [DATE]. The psychiatrist adjusted his medications and his cutting had decreased. Then he had some issues when applying for Medicaid and was questioned about his finances, which she felt caused him anxiety and increased his behavior of cutting. -When his partner or his own health would decline he would have increased anxiety and cutting of himself. the issue of cutting gets worse. -His vision is getting worse. She wasn't sure if that would increase his safety risk. -He does not cause self-harm other than his belief of bugs in his body. -He had denied having a plan of self-harm. -She was aware of an instance of him having believed he had seen his long-term friend in his room after she had passed. -He had acted angry or snippy with staff but was not aggressive with them. -His cutting was not as regular when his friend was still alive. -She stated some of his wounds such as the ones under the large bandages were from his leg having been caught on the edge of his bed. There was no incident report to support this. -She would see him every ,d+[DATE] weeks. -He had expressed in [DATE] that he felt more like living. Interview on [DATE] at 1:30 p.m. with RN K in regards to resident 20 revealed: *He had concerns regarding resident 20 and stated, I can't believe he isn't septic with his cutting. *Resident 20 had all kinds of sharps from a Hobby knife kit he had bought from at a local store. -Nurses do not provide his wound care, he did his own. -RN K did not work resident 20's hall but was aware of his cutting behavior. -He said all of resident 20's wounds on his legs were from his cutting himself and he had no injuries from falls or scraping on his bed frame that he knew of. -He does not believe resident 20 would hurt anyone or himself intentionally, he is just trying to get the bugs out of his skin, which there aren't any. -He was not aware of a list of what tools he had or a way to track what he brought back from outings. -He has had fewer visitors but RN K why. Interview on [DATE] at 1:45 p.m. and again at 2:05 p.m. with LPN L revealed: *She did not do wound care for resident 20 and she had concerns about him cutting himself. *She was not sure how many open areas he had. *There had been no pictures for documentation of his wounds. *There was no sharps inventory or count of how many sharps resident 20 had in his possession. *She had concerns about his history of falls and the potential he could fall and be injured by a sharp object. *She would organize his room due to her concerns, he would allow that, but he would tell her to not take anything. *She stated the previous social worker was aware him cutting himself with the sharps he had. *She stated that she does not participate in care conferences but has reported her concerns and all the management were aware of his cutting himself with the sharps he had in his room. *He was not on any antibiotics but had an order for Neosporin to self-administer in his room. *He has not been tested for infectious diseases. *Certified nurse aides (CNA's) should report any new wounds or concerns. Interview and observation on [DATE] at 1:40 p.m. with resident 20 revealed: *He has eleven open areas on his inner lower left leg with four small bandages and his right lower inner leg had eight open areas with three large bandages. *He stated the bandages are because those I made bleed, so I put band-aids on them. *He said he cleaned them himself but had not been educated by the facility staff on how to clean tools or his open areas. - I have a bottle of alcohol I clean my legs first, then use hot water, and then put Neosporin on them. -A bottle of 91% alcohol was under his bed and was approximately a third full. -He stated he used the alcohol to clean his scalpels a couple of times a day. -There was no redness observed to the surrounding tissue of his visible open areas. Interview and observation on [DATE] at 9:05 a.m. with resident 20 revealed: *He had tubi-grip (elastic tubular bandage) on his bilateral lower legs and stated, his wounds were better and he hoped they stayed that way. His mood was pleasant. *There was a hand washing reminder sign in his room and bathroom. Record review of resident 20's care plan dated [DATE] revealed. *Behavioral symptoms included cutting and or picking off warts and scabs on his skin. He utilizes scalpels he gets at the hardware store. -He declines to follow physician recommended advice of no cutting warts off his skin, and will decline skin-care and other treatments at times needed to properly address his self-inflicted wounds (see delirium). He will regularly create or manipulate his own or facility items to fix them or create things (i.e. Using a belt for a strap on his wheelchair). He was encouraged not to create restraints for himself and to seek staff input before fixing facility property. - Long-term goal date of [DATE] noted, he would decrease his use of sharps. He was able to keep sharps in his room, per his refusal to comply with [NAME] policies and concerns for safety without sharps to pick at his skin (as he relies on dull/other unsanitary means to pick at his skin). -He will not utilize scalpels in a way that puts his well-being or life into question. -He will not harm himself outside of cutting off his warts/scabs. -He will not harm or threaten others with his scalpels. *Approach date [DATE] noted, allow [resident 20] to have sharps in his room. -Remove sharps with conversations regarding self-harm with these sharps. -Offer education in regard to safety/infection control as needed. -Notify the physician/registered nurse (RN) if statements of self-harm manifest. -Assess for pain and offer pain medications, as able, with thoughts of death-statements. As needed PRN1, PRN 2, PRN 3. -Discipline noted, all staff and social services. *Long-term goal target dated [DATE] noted, that [resident 20] will have fewer episodes of refusing care. -Resident will consider physician-recommended interventions to treat what is causing ailments. -Resident will be more open to allowing RN's to treat open areas on his skin related to infection prevention. *Approach start dated [DATE] noted, redirect resident as needed. -Ask for help or re-approach if resident becomes abusive or resistive. -Keep environment calm and relaxed. -Remove from public area when behavior is unacceptable. -Document refusal of care when it occurs. -Assist in applying antibacterial creams and appropriate dressings for open area to the skin, PRN. -Ask RN's to assist in evaluating and treating wounds. As needed PRN 1, PRN 2, PRN 2. -Discipline noted, all staff, nursing and social services. *Problem start date [DATE], environment noted, -[Resident 20] keeps sharps in is room related to behavioral concerns/delusions of bugs in his skin. -As long as there is no self-harm ideation/intent, he is able to have these in his room due to resident rights and continued non-compliance with having them removed. (similar care plan noted under behavioral symptoms) -[Resident 20] is sensitive to others touching items in his room, even for infection control reasons. He sternly requests that he is consulted before environmental services (ES) deep-cleans his room, as he is not compliant with this task and has had verbal interactions with ES and others before over items in his room being tidied /moved. -He likes to be in charge of where his dirty clothes go and often keeps paints on tables that are still clean and has his wallet and things in it. It has been care planned that he will have a laundry basket in his room to put his dirty clothes in and staff will take the clothes from the basket only to wash. -He will independently buy items at Walmart related to his delusions of bugs. He has no cognitive impairment and is self-sufficient enough to go out and about to purchase his own things. Education has been provided to to him on the safety of certain pesticides and those items have been removed but it causes more agitation for him. *Long term goal target date [DATE] noted, [resident 20] will be able to keep sharps in his room, per his refusal to comply with [NAME] policies and concerns for safety without sharps to pick at his skin (as he relies on dull/other unsanitary means to pick at his skin when sharps are not available). -He will not utilize scalpels in a way that puts his well-being or life into question. -He will not harm himself outside of cutting off his warts/scabs. -He will not harm or threaten others with his scalpels. -He will be accepting of the removal of sharps from his room if there is question of self-harm or harm to other with these utensils. *[Resident 20] will work with ES and certified nursing assistants (CNA's) to keep his room somewhat tidied and disinfected. -He will refrain from verbal interactions with other over his room cleanliness. _he will be understanding of the basic infection control measures that have to be taken with is room, in reference to bloodied or dirty cloth items and other unsanitary items on the floor of his room. -He will put his dirty clothes in the laundry basket provide for ES to know what is dirty and what is clean. -He will be aware of certain pesticides that he brings into his private room and sue them with caution. *Approach start date [DATE] noted, allow [resident 20] to have sharps in his room. -Remove sharps with conversations regarding self-harm with these sharps. -Offer education in regard to safety/infection control as needed. -Notify physician/RN if statements of self-harm manifest. -Assess for pain and offer pain medications, as able, with thoughts of death-statements. -Consult with resident prior to deep-cleaning his room. -Help mediate infection control needs and resident rights between resident ES staff. -Help to remove unsanitary cloth items as they are seen, and replace them with unsullied linens/washcloths/towels. -Staff will be respectful to only grabbing the dirty clothes out of his laundry basket to clean. -Staff will be respectful and continue to educate [resident 20] on the dangers of some of the pesticides that he purchases and has in his room. -As needed, PRN 1, PRN 2, PRN 3. -Disciplines, all staff and social services. *Problem start date [DATE] noted, delirium, [resident 20] believes there are microscopic bugs under his skin. -He believes this is why his skin itches and, possibly why he gets warts -He cuts off his warts and scabs to stop the itching from the bugs under his skin. (see behavioral symptoms). *Long term goal target date of [DATE] noted, [resident 20} will utilize other methods of itch-control outside of cutting off his warts. He will speak with his physician about the bugs under his skin and/or the itching of his skin. *Approach start date [DATE] noted, Help communicate [resident 20's] concerns about itchiness and bugs to his physician as needed. -Help to apply anti-itch lotion as prescribed. -Encourage scratching/patting his skin as a way of itch-control as needed. -Utilize frequent checks if he is utilizing his scalpel to cut off warts or scabs. *Discipline noted, all staff and social services. *Problem start date [DATE] noted visual function. -[Resident 20] has impaired vision and utilizes corrective lenses for reading activities. -Per [resident 20], an optometrist visit in 2020 relays that he is slowly losing his eyesight, and may be absent of useful vision in the future. *Long term goal target date of [DATE] noted, resident will have optimal ability. -He will utilize glasses/corrective lenses as preferred. -He will be accepting of staff assistance in managing glasses, as able and as needed. *Approach start date [DATE] noted, visual aides. -Keep glasses clean and encourage use. -Keep glasses readily available. -Adequate lighting in room. -Encourage activities appropriate for visual acuity. -Optometrist visits as needed. -Monitor for appropriate navigation of small objects related to possibly losing vision in his eyes. -As needed, PRN 1, PRN 1, PRN 3. *Discipline noted, all staff and social services.

Based on observation, interview, and record review the provider failed to deliver appropriate wound care, assessment and monitoring for one of one (20) sampled residents observed with wounds. Findings include: 1. Observation and interview on [DATE] at 9:29 a.m. with resident 20 revealed: *He was sitting on the edge of his bed scratching at his leg. *He had multiple open areas with some active bleeding on his bilateral lower legs and bandages on some of them. *There was a white towel under his bare feet with dried blood on it and another lying to his left with dried blood on it. *Bandage wrappers were on the floor by his feet. *He stated his legs are better because he has been taking care of them. *He stated he kept his tools in alcohol. *He stated he had good medicine here but the nurse took it from him and said it was dangerous and he could not have it. *He stated he was doing okay for the shape he was in. *His shower has two discolored towels on the floor that appeared to have been wet then dried multiple times and had what appeared to be dried blood on them. Interview on [DATE] at 4:15 p.m. with RN F in regards to resident 20 revealed he: *Had a picking disorder and could have sharps in his room. *Tried to cut bugs out of his skin. *Would not let any nurses take care of the open areas on his legs. *Is independent and is allowed to leave the premises. *Would go to a store on public transit and buy what he wanted and would bring it back to his room. *He was aware that his sharps and cutting of himself were care planned. Interview on [DATE] at 1:30 p.m. with RN K in regards to resident 20 revealed: *He had concerns regarding resident 20 and stated, I can't believe he isn't septic with his cutting. *Resident 20 had all kinds of sharps from a Hobby knife kit he had bought from at a local store. -Nurses do not provide his wound care, he did his own. -RN K did not work resident 20's hall but was aware of his cutting behavior. -He said all of resident 20's wounds on his legs were from his cutting himself and he had no injuries from falls or scraping on his bed frame that he knew of. Interview on [DATE] at 1:45 p.m. and again at 2:05 p.m. with LPN L revealed: *She did not do wound care for resident 20 and she had concerns about him cutting himself. *She was not sure how many open areas he had. *There had been no pictures for documentation of his wounds. *There was no sharps inventory or count of how many sharps resident 20 had in his possession. *She had concerns about his history of falls and the potential he could fall and be injured by a sharp object. *She would organize his room due to her concerns, he would allow that, but he would tell her to not take anything. *She stated the previous social worker was aware of him cutting himself with the sharps he had. *She stated that she does not participate in care conferences but has reported her concerns and all the staff management were aware of his cutting himself with the sharps he had in his room. *He was not on any antibiotics but had an order for Neosporin to self-administer in his room. *He has not been tested for infectious diseases. *Certified nurse aides (CNA's) should report any new wounds or concerns. Interview and observation on [DATE] at 1:40 p.m. with resident 20 revealed: *He has eleven open areas on his inner lower left leg with four small bandages and his right lower inner leg had eight open areas with three large bandages. *He stated the bandages are because those I made bleed, so I put band-aids on them. *He said he cleaned them himself but had not been educated by the facility staff on how to clean tools or his open areas. - I have a bottle of alcohol I clean my legs first, then use hot water, and then put Neosporin on them. -A bottle of 91% alcohol was under his bed and was approximately a third full. -He stated he used the alcohol to clean his scalpels a couple of times a day. -There was no redness observed to the surrounding tissue of his visible open areas. Record review of resident 20's care plan dated [DATE] revealed. *Behavioral symptoms included cutting and or picking off warts and scabs on his skin. He utilizes scalpels he gets at the hardware store. -He declines to follow physician recommended advice of no cutting warts off his skin, and will decline skin-care and other treatments at times needed to properly address his self-inflicted wounds (see delirium). He will regularly create or manipulate his own or facility items to fix them or create things (ie. Using a belt for a strap on his wheelchair). He was encouraged not to create restraints for himself and to seek staff input before fixing facility property. -He will not utilize scalpels in a way that puts his well-being or life into question. -He will not harm himself outside of cutting off his warts/scabs. *Approach date [DATE] noted, allow [resident 20] to have sharps in his room. -Remove sharps with conversations regarding self-harm with these sharps. -Offer education in regard to safety/infection control as needed. -Assess for pain and offer pain medications, as able, with thoughts of death-statements. As needed PRN1, PRN 2, PRN 3. -Discipline noted, all staff and social services. *Long-term goal target dated [DATE] noted, that [resident 20] will have fewer episodes of refusing care. -Resident will consider physician-recommended interventions to treat what is causing ailments. -Resident will be more open to allowing RN's to treat open areas on his skin related to infection prevention. *Approach start dated [DATE] noted, redirect resident as needed. -Document refusal of care when it occurs. -Assist in applying antibacterial creams and appropriate dressings for open area to the skin, PRN. -Ask RN's to assist in evaluating and treating wounds. As needed PRN 1, PRN 2, PRN 2. -Discipline noted, all staff, nursing and social services. *Problem start date [DATE], environment noted, -[Resident 20] keeps sharps in is room related to behavioral concerns/delusions of bugs in his skin. -As long as there is no self-harm ideation/intent, he is able to have these in his room due to resident rights and continued non-compliance with having them removed. (Similar care plan noted under behavioral symptoms) -[Resident 20] is sensitive to others touching items in his room, even for infection control reasons. He sternly requests that he is consulted before environmental services (ES) deep-cleans his room, as he is not compliant with this task and has had verbal interactions with ES and others before over items in his room being tidied /moved. -He likes to be in charge of where his dirty clothes go and often keeps paints on tables that are still clean and has his wallet and things in it. It has been care planned that he will have a laundry basket in his room to put his dirty clothes in and staff will take the clothes from the basket only to wash. -He will independently buy items at Walmart related to his delusions of bugs. He has no cognitive impairment and is self-sufficient enough to go out and about to purchase his own things. Education has been provided to him on the safety of certain pesticides and those items have been removed but it causes more agitation for him. *Long term goal target date [DATE] noted, [resident 20] will be able to keep sharps in his room, per his refusal to comply with [NAME] policies and concerns for safety without sharps to pick at his skin (as he relies on dull/other unsanitary means to pick at his skin when sharps are not available). -He will not utilize scalpels in a way that puts his well-being or life into question. -He will not harm himself outside of cutting off his warts/scabs. *[Resident 20] will work with ES and certified nursing assistants (CNA's) to keep his room somewhat tidied and disinfected. -He will refrain from verbal interactions with others over his room cleanliness. -He will be understanding of the basic infection control measures that have to be taken with is room, in reference to bloodied or dirty cloth items and other unsanitary items on the floor of his room. -He will put his dirty clothes in the laundry basket provide for ES to know what is dirty and what is clean. -He will be aware of certain pesticides that he brings into his private room and sue them with caution. *Approach start date [DATE] noted, allow [resident 20] to have sharps in his room. -Offer education in regard to safety/infection control as needed. -Assess for pain and offer pain medications, as able, with thoughts of death-statements. -Consult with resident prior to deep-cleaning his room. -Help mediate infection control needs and resident rights between resident ES staff. -Help to remove unsanitary cloth items as they are seen, and replace them with unsullied linens/washcloths/towels. -Staff will be respectful to only grabbing the dirty clothes out of his laundry basket to clean. -Staff will be respectful and continue to educate [resident 20] on the dangers of some of the pesticides that he purchases and has in his room. -As needed, PRN 1, PRN 2, PRN 3. -Disciplines, all staff and social services. *Problem start date [DATE] noted, delirium, [resident 20] believes there are microscopic bugs under his skin. -He believes this is why his skin itches and, possibly why he gets warts -He cuts off his warts and scabs to stop the itching from the bugs under his skin. (see behavioral symptoms). *Long-term goal target date of [DATE] noted, [resident 20} will utilize other methods of itch-control outside of cutting off his warts. He will speak with his physician about the bugs under his skin and/or the itching of his skin.

Based on record review and interview, the provider failed to ensure the facility assessment had addressed the staffing resources needed to ensure appropriate care and services were available to the residents. Findings include: 1. Review of the provider's undated facility assessment revealed: *The assessment did not address their resources for staffing needs. *The assessment was an eleven-page excel spreadsheet that included: -An overall monthly trending analysis of census that indicated it was a 64-bed nursing facility that had. --One dementia care unit of 12 beds. --General units of 52 beds combined. --A January through May overall census average of 58. -A Physical Function and Care Needs analysis of residents including: --Assistance needed with bathing, dressing, transferring, toilet use, eating, and mobility. --Bowel and bladder status. --Cognitive disabilities. --Skin integrity. --Cultural sensitivity, religious and ethnicity care recognition. --Communication. --Conditions. --Medication use. --It had not specified how many staff were needed to care for the residents or how they would have been scheduled/assigned. -A Medical Diseases and Conditions analysis of residents including those with diagnoses of: --Cancer. --Heart/Circulation. --Gastrointestinal. --Genitourinary. --Infections. --Metabolic. --Musculoskeletal. --Neurological. --Nutritional. --Psychiatric/Mood Disorder. --Pulmonary. --Vision. --It had not specified how those diagnoses would have impacted their care needs such as how much assistance the residents would have potentially required from the staff. *There had been no mention of: -The usual amount of assistance required by the residents based on their medical and mental health diagnoses. -How the facility would have been staffed to ensure the residents' care needs were met. Interview and facility assessment review on 7/1/24 at 4:27 p.m. with director of nursing (DON) B and Minimum Data Set (MDS) nurse C revealed: *The eleven-page excel spreadsheet was their facility assessment. *They agreed the assessment had not included or addressed their staffing needs. Interview and facility assessment review on 7/1/24 at 4:46 p.m. with administrator A revealed: *She confirmed the eleven-page excel spreadsheet was their facility assessment. *She stated they did not have a connecting piece between the spreadsheet and the staffing needed to ensure appropriate care and services were available to the residents, including the competencies (knowledge and skills) needed of staff to meet the needs of the residents. *There was no specific policy on the process for the facility assessment.

Based on observation, interview, record review, policy review, and manufacturer's instructions review, the provider failed to clean and disinfect one of one community shared blood glucose meter for two of two sampled residents (44 and 48) that resulted in a potential increased risk for bloodborne pathogen infections. Findings include: 1. Observation and interview on 06/25/24 at 4:02 p.m. and 4:18 p.m. with registered nurse (RN) F revealed: *RN F completed a blood glucose check for resident 44. *She then wiped the blood glucose meter with a gray top Sani-cloth (germicidal) wipe and placed the blood glucose meter on the medication cart. *RN F stated that glucose meter was to be first wiped off with a wipe to clean visible blood or fluids off the glucose meter and then with another one to wet it and let it dry for two minutes. *She did not know if there was a policy on how to clean a glucose meter. *She used that same blood glucose meter to check resident 48's blood glucose and again wiped it with a gray top Sani-cloth wipe and placed it on the medication cart. 2. Interview on 6/27/23 at 8:40 a.m. with RN/ clinical learning and development specialist D regarding the blood glucose meter cleaning and disinfecting procedure revealed: * She stated the glucose meter cleaning process involved wiping off any visible blood/fluid with a wipe and then another wipe to wet it and let it dry. *She stated that the dry time was different. If staff used a purple top Sani-cloth the dry time was two minuets or the gray top Sani-cloth dry time was three minutes. *She admitted that the glucose meter should have been cleaned per the directions on the gray top Sani-cloth wipe container. *She admitted that the glucose meter could not stay wet for either the two or three minute contact time by just wiping it and placing it on the medication cart as observed above. 3. Interview on 07/01/24 at 11:38 a.m. with director of nursing (DON) B revealed, she would have expected staff to follow the proper process to clean the glucose meter and use the correct contact time for the wipe used. 4. Review of the provider's 1/31/24 Blood Glucose Monitoring Disinfecting and Cleaning-R/S (Rehabilitation/Skilled Care), LTC (Long-term Care) policy revealed: *The policy referred to CMS requirements and best practices, that indicated blood glucose meters should have been cleaned and disinfected after each resident use whether the meter was assigned to a resident or shared among residents. *The policy referred to the user manual for specific instructions for each meter. *Cleaning procedure: -2. Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant or germicide wipe. -4. Remove the wipe from container and follow the label instructions to disinfect the meter. 5. Record review of the provider's StatStrip Glucose Hospital Meter user's manual revealed: *Dilute Bleach. A 10% solution of household bleach (Sodium Hydrochloride) may be used. *70% Isopropyl (rubbing) alcohol may be used. *Commercial surface decontamination preparations that are approved for use by your facility can be used. Apply to a small test area first to ensure surface finish integrity. *Avoid harsh solvents such as benzene and strong acids. 6. Review of the Sani-Cloth container lable regarding directions for use revealed: *To clean, disinfect and deodorized hard, nonporous surfaces: -Surface to remain wet for three (3) minutes. *Contact time: -Allow surface to remain wet for three (3) minutes.

Based on observation, interview, record review, and policy review, the provider failed to maintain the temperature of the memory care unit (MCU)'s pantry refrigerator below 41 degrees Fahrenheit (F). Findings include: 1. Observation on 6/25/24 at 3:33 p.m. of the MCU's pantry refrigerator revealed: *The thermometer inside the refrigerator read 46 degrees Fahrenheit (F). *The Refrigeration Temperature Log located on a clipboard hanging on the wall next to the refrigerator had no documented refrigerator temperatures for December 2023 and no other monthly logs were found. *Contents of the MCU's pantry refrigerator included: -Numerous eight fluid-ounce soda cans. -Six opened 48-ounce containers of juice labeled Refrigerate after opening. -Three four-ounce Mighty Shakes labeled Thaw at or below 40 degrees F. Use thawed product within 14 days. Keep Refrigerated. 2. Interview on 6/25/24 at 3:40 p.m. with certified nursing assistant (CNA) I revealed she: *Had not normally worked on the MCU. *Was not sure whose responsibility it was to record the fridge's temperature. *Was not sure how long the mighty shakes had been in the fridge. 3. Observation on 6/26/24 at 9:18 a.m. revealed: *The thermometer inside the MCU's pantry refrigerator read 50 degrees F. *The Refrigeration Temperature Log located on a clipboard hanging on the wall next to the refrigerator had no documented refrigerator temperatures for June 2024. 4. Interview on 6/26/24 at 10:30 a.m. with director of nursing (DON) B revealed: *The night nurses' responsibilities included to check the refrigerator temperatures on the nursing units which included the MCU's pantry refrigerator. *She would have expected the refrigerator temperatures to be between 32 and 41 degrees F. *She agreed the 6/25/24 refrigerator temperature of 46 degrees F and the 6/26/24 refrigerator temperature of 50 degrees F was too warm to adequately refrigerate food items. 5. Interview on 6/26/24 at 12:28 p.m. with DON B revealed: *A new thermometer was placed in the MCU's pantry refrigerator. *She provided and explained she had updated the Night Nurse Tasks sheet that day with directions to Check North Fridge Temp (record on form). *She clarified the North nursing unit was the MCU. *She agreed refrigerator temperature checks had not been completed for the months of December 2023 through May 2024 as she had no completed Refrigeration Temperature Logs in her office and was not sure where else the completed logs could have been. 6. Observation and interview on 6/26/24 at 2:16 p.m. with certified nursing assistant (CNA) I revealed the MCU's pantry refrigerator had a new thermometer that read 44 degrees F. CNA G adjusted the dial inside the refrigerator to make it colder and stated she would recheck the temperature later that day. 7. Observation on 6/26/24 at 3:28 p.m. revealed the thermometer inside the MCU's pantry refrigerator read 40 degrees F. 8. Observation on 6/27/24 at 7:35 a.m. of the MCU's pantry refrigerator revealed: *The thermometer inside the refrigerator read 32 degrees F. *The documented temperature on the Refrigeration Temperature Log form for 6/26/24 was 38 degrees F. 9. Observation on 7/1/24 at 11:05 a.m. of the MCU revealed: *The thermometer inside the pantry refrigerator read 40 degrees F. *The posted June 2024 Refrigeration Temperature Log form had documented temperatures for that pantry refrigerator: -For 6/26/24: 38 degrees F. -For 6/27/24: 34 degrees F. -For 6/28/24: 33 degrees F. -For 6/29/24: 32 degrees F. -For 6/30/24: 33 degrees F. *A new Refrigeration Temperature Log form had been started for July 2024. 10. Interview on 7/1/24 at 3:58 p.m. with DON B revealed she had discussed the task of monitoring the MCU's pantry refrigerator temperatures in person with the night nurse the morning of 6/27/24 and had emailed the nurses on staff educating them that the nurses' night shift duties included monitoring the MCU's pantry refrigerator temperatures. 11. Review of the provider's 12/25/23 Refrigerator for Patient Food, Use Care and Monitoring-[NAME] policy revealed: *Purpose: To ensure clean, proper and safe storage of refrigerated and frozen food in clinical areas .To establish temperature ranges for the safe storage of refrigerated food items. *Policy: Refrigerator and freezer temperatures will be monitored and logged. *Procedure: -Monitor and log food refrigerator temperatures at least daily, maintaining temperatures at or below 41 degrees Fahrenheit or 4 degrees Celsius. -If refrigerator/freezer temperature exceeds the upper or lower range limits take the following action: --Staff should adjust refrigerator/freezer thermostat. Document adjustment under comments section on log. --Check and document temperature again in approximately 1 hour. If temperature is still out of range, contact Maintenance. Maintenance determines if the refrigerator can be repaired or replaced.

A. Based on observation, interview and record review the provider failed to properly store eye drops, lotions, gels, creams, lotions, and ointments for 2 of 20 residents (1 and 16). Findings include: 1. Observation and interview on 6/25/24 at 10:16 a.m. with resident 16 in his room revealed: *He had 2 boxes of eye drop medication on his bedside table. One was latanoprost (for pressure inside the eye) and one was Carboxmethylcell. *He stated they were left in his last night by the nurse who didn't come back to pick them up. 2. Observation on 6/25/24 at 10:34 a.m. of resident 2's room revealed: *A container that had anti itch lotion, Vicks vaporub, vaseline, Aquaphor, aloe gel, simple saline wound wash and Metholatum in it, on a stand next to his recliner. 3. Interview on 6/25/24 at 10:23 a.m. with licensed practical (LPN) L revealed: *She stated maybe resident 16's eye drops were left in his room due to his positive coronavirus disease (COVID-19) test but was unsure. *He was cognitively intact, which was demonstrated by his score of 14 for brief interview for mental status (BIMS). 4. Interview on 6/25/24 at 3:45 p.m. with director of nursing (DON) B and minimum data set nurse C revealed: *There are no orders for medications left at bedside due to COVID unless for cough drops. *There should not be any medications left at a residents bedside without an order. *MDS nurse C confirmed resident 2 had a bedside order for cough drops, -She confirmed resident 16 did not have an order for anti itch lotion, vicks vaporub, vasoline, aquaphor, aloe gel, simple saline wound wash and metholatum left in his room. Record review of residents 2 and 16's electronic medical record revealed. *Resident 2 had an order for cough drops at bedside and self administration. *Resident 16 did not have an order for bedside medications nor for self administration. 50015 B. Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview and policy review, the provider failed to ensure one of one resident (37) was transferred as directed in his care plan and then fell from a mechanical lift. Findings include: 1. Review of SD DOH FRI report received 6/10/24 at 11:26 a.m. revealed: *On the evening of 6/3/24 at 7:50 p.m. resident 37 slipped out of the sit-to-stand lift, after lifting his arms while in the EZ stand lift. *Two staff were assisting the resident at the time certified nursing assistant (CNA) H and CNA I. *The waist belt was on resident 37 and secured properly. *The leg belt was not used. *An EZ total mechanical lift was then used to place him in his bed. 2. Review of resident 37's electronic medical record (EMR) and paper medical record revealed: *He admitted to the facility on [DATE]. *His current Brief Interview for Mental Status (BIMS) score was 03, which indicated he had severe cognitive impairment. *His active diagnosis was: -Chronic kidney disease, stage 4 (severe). -Unspecified dementia, unspecified severity, with other behavioral disturbance. -Depression. -History of falling. -Essential hypertension. -Weakness. *Review of the resident's fall history for last six months revealed: -On 2/13/24 at 6:00 a.m. he fell with no injuries while he was ambulating. -On 2/22/24 at 11:44 p.m. he fell with a skin tear after being observed on the floor by staff. -On 5/23/24 at 1:31 a.m. he fell and was observed on floor in another resident's room, no injuries were noted. -On 6/3/24 at 7:50 p.m. he slipped out of an EZ sit-to-stand lift, landing on a garbage can, EZ total mechanical lift was used to get him off floor and transferred into his bed, no injuries noted. *His care plan with a start date of 1/10/23, regarding activities of daily living (ADL) functional status/rehabilitation potential problem revealed: -Partial/moderate to substantial/max assist of one with transfers, fluctuates (hoyer lift if a lift is needed). -Independent/supervision with ambulation. -Independent/supervision with locomotion. -Supervision to partial/moderate assist of one with toileting. -Last revised 6/4/24 at 10:34 a.m. *His current care plan revealed: -Partial/moderate to substantial/max assist of one with transfers, fluctuates (hoyer lift if a lift is needed). -Independent/supervision with ambulation. -Independent/supervision with locomotion. -Supervision to partial/moderate assist of one with toileting. -Last revised 6/4/24 at 10:34 a.m. *Identified problem falls: -Total mechanical lift for all transfers with two assist, approach start date 6/4/24. -Keep bed in lowest position with brakes locked. -Last revised 6/4/24 at 12:52 p.m. *A kardex (staff pocket care plan) type dated 2/13/24 on the special care unit (SCU) revealed: -Transfers partial/moderate to substantial/max fluctuates EZ lift-prn. -Ambulation independent to supervision with walker-fluctuates at times not walking utilizing w/c. -Supportive devices: walker, glasses, bariatric bed, gripper socks (as allows), motion sensor, tubigrips and Hoyer [total mechanical lift] (Do not utilize EZ lift), w/c with pressure relieving cushion-PRN (as needed). *A kardex type dated 2/13/24, pen dated 6/4/24 on the SCU revealed: -Transfers partial/moderate to substantial/max fluctuates EZ lift-prn. -Ambulation independent to supervision with walker-fluctuates at times not walking utilizing w/c. -Supportive devices: walker, glasses, bariatric bed, gripper socks (as allows), motion sensor, tubigrips and Hoyer (Do not utilize EZ lift), w/c with pressure relieving cushion-PRN (as needed). 3. Observation on 6/25/24 at 2:10 p.m. of resident 37 revealed a posted note not to use the sit-to-stand lift, and to use the total mechanical lift. 4. Interview on 6/26/24 at 10:12 a.m. by phone with CNA I revealed: *Resident 37 was transferred with the EZ stand lift. *No total lift sling was under the resident in his wheelchair prior to the transfer. *Resident was having a bowel movement, and the staff were cleaning him in the sit-to-stand lift. *Resident 37 let go of the hand bars on the lift and slid out of the sit-to-stand lift. *The waist belt of the sling was secured. *The leg strap was not secured. *Staff placed feet on the footplate of the lift. *She had not read his care plan to see how he was to be transferred, she followed what the prior shift had used to transfer the resident. 5. Interview on 7/1/24 at 10:45 a.m. with director of nursing (DON) B revealed: *There are no lift assessments. *There is no lift assessment policy. *The nurse would determine based on observation what type of lift device would be used. 6. Interview on 7/1/24 at 10:55 a.m. with CNA G revealed: *She was unsure when the no sit-to-stand lift note was placed in resident room. *She followed the Kardex in the resident binder. *The Minimum Data Set nurse (MDS) C or DON B determined what lift to use on residents. *Resident 37 had been having fainting-like spells when he used the sit-to-stand lift. *One person can use the sit-to-stand lift with residents and two staff were to use the total mechanical lift with residents. *She found out resident 37 was no longer to use the sit-to-stand lift during verbal report but could not recall the date that had occurred. *She provided the staff kardex dated 6/4/24 that indicated staff were to no longer use the stand lift for resident 37. 7. Interview on 7/1/24 at 11:25 a.m. by phone with registered nurse (RN) E revealed: *EZ sit-to-stand lift had been used PRN for resident 37 for a couple weeks prior to the fall on 6/3/24. *He had not had any fainting-like episodes before the one on 6/3/24 that she was aware of. *Report from shift to shift is recorded, she stated she did not always have time to listen to that report and would get a verbal report from the previous nurse instead. *CNA's were to read the care plans, she was unaware if they do read them. *Nurses would determine the amount of assistance needed and any devices that need to be used with residents. *Care plans were updated by DON B or MDS nurse C. *She had given CNA H and CNA I education on the proper use of the lifts on the night of 6/3/24. *She had emailed MDS nurse C and senior social worker J and informed them of everything that was done and that she felt the CNA's needed more education. -She never heard back about the email she sent. 8. Interview on 7/1/24 at 11:52 a.m. by phone with CNA H revealed: *She is a PRN (as needed) staff member. *The sit-to-stand lift harness was in resident 37's room on 6/3/24, and they had used that. *She stated the waist buckle and leg buckle were used during the transfer. *Resident 37 slid through the harness, and landed on the garbage can. *They had asked for assistance over the call system. *They had used the total mechanical lift to get him off the garbage can and placed him into his bed. *She had not worked on the North wing for nine months. *Resident 37 had been ambulating with a walker the last time she had worked prior to that incident. 9. Interview on 7/1/24 at 12:05 p.m. with MDS nurse C revealed: *Resident 37 had moved to the SCU in April 2023. *CNAs were to fill out the GG charting (focuses on patient's functional abilities and goals). *That tells her how they are being transferred. *She stated resident 37 was chicken winging (lifting arms up) in the stand lift. *That was when he was changed to a total lift for transfers. *Staff had used the sit-to-stand lift as needed on resident 37 for a couple of weeks before the incident on 6/3/24 PRN. *She might have forgotten to have changed the date on his care plan when she updated it. *She was unsure of the date resident 37 was changed to a total mechanical lift transfer on his care plan. *She was not aware of any fainting-like episodes before 6/3/24. *She had updated the kardex. 10. Review of education for CNA I revealed: *Safe resident handling training was completed on 1/21/24 and again on 5/8/24 Review of education for CNA H revealed: *Safe resident handling training was completed on 4/26/23. 11. Review of the manufacturer's user manual for the EZ Way Smart Stand dated 9/29/23 revealed: *The EZ Way Smart Stand was designed specifically for toileting and changing briefs of patients. *The EZ Way Smart Stand can also be used for transferring the patient from chair, wheelchair, toilet or bed, and can be used for ambulation. *As patients do vary in size, shape, weight and temperament, these conditions must be taken into consideration when deciding if the EZ Way Smart Stand is suitable for their needs. *Patients should be able to bear some weight, have upper body strength and be able to follow simple commands. *If a patient does not meet each of these three criteria, an EZ Way total body lift must be used. Review of the manufacturer's user manual for the EZ Way Smart Lift dated 6/14/23 revealed: *The EZ Way Smart Lift was designed primarily to lift patients from the bed, chair, toilet and floor. *The maximum lifting capacity is located by the model and serial number of the lift. *The EZ Way Smart Lift was designed to be operated safely by one person. However, with some patients, it is best to use two people. 12. Review of the provider's Mobility support and positioning policy dated 5/6/24 revealed: Criteria: *The resident must weigh less than the maximum weight capacity of the total lift, sit-to-stand or stand aid and sling or harness. *A total lift should be used for those residents who are unable to provide weight-bearing assistance, have impaired sitting balance, are uncooperative, rigid, difficult to turn or unable to follow verbal cues. Safety: *Always check the kardex, or care plan/service plan prior to the transfer or repositioning task for type and amount of assistance needed Follow any specific lift/transfer instructions for the resident.

Based on record review interview, and policy review the provider failed to have a physician's order in place consistent with one of one (2) sampled resident's advance directive. Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *The banner at the top of his EMR when opened on [DATE] displayed DNR [do not resuscitate]. *He had a full code (permission for life-sustaining measures, including resuscitation) order dated [DATE]. *Interview on [DATE] at 5:10 p.m. with director of nursing (DON) B and Minimum Data Set (MDS) nurse C revealed: DON B stated she did not have a current order for resident 2's DNR and to talk to MDS nurse C. *MDS nurse C stated she had faxed the physician on [DATE] to request an order but did not have one in resident 2's chart. Review of provider's [DATE] advance directive policy including cardiopulmonary resuscitation (CPR) and automated external defibrillator (AED) procedure revealed: *1. Advance directive orders are to be reviewed with resident/healthcare decision-maker at each care plan meeting to ensure no changes are needed. Document this discussion in the PN-Care Conference Note. *2. If a resident who has an advance directive informs a staff member he or she has changed his or her decision, the resident's wishes for different measures will be followed and the physician will be contacted for updated orders. *5. Physician's orders in response to resident's requests and/or advance directives regarding life-sustaining measures must be specific, e.g., do resuscitate or do not resuscitate, whether to hospitalize, whether antibiotics are to be used, etc. Code or No Code orders do not have a universally accepted definition and therefore will not be accepted.

Based on observation, interview, and policy review, the provider failed to ensure proper hand hygiene was performed by 3 of 3 certified nursing assistants (D, G, and H) observed while performing care tasks. Findings include: 1. Observation on 5/3/22 at 9:23 a.m. while certified nursing assistant (CNA)/certified medication assistant (CMA) D performed personal care for resident #4 revealed she: *Put gloves on, adjusted resident 4's clothing and removed the wet incontinent product. *Using the same gloves hand, put one hand into a tub of A & D ointment and applied it to the resident's peri-area and then discarded that glove. *Without washing her hands, positioned a new incontinent product and adjusted the resident's clothing, then removed her other glove. *Took the garbage bag out of the garbage can, without gloves on, tied it shut and carried it with her while pushing resident 4 in her w/c towards the day room. -Stopped at the dirty utility room and discarded the garbage bag, and then washed her hands. *Pushed the resident w/c the rest of the way to the day room. *Went to the medication cart and used alcohol hand gel sanitizer on her hands. Interview on 5/3/22 at 9:50 a.m. with CNA/CMA D, revealed: *She agreed she had missed several opportunities for hand hygiene and glove changes. *She replied she usually does hand hygiene at the appropriate times. Interview on 5/5/22 at 12:40 p.m. with the director of nursing (DON) B, when asked about the above observation, revealed: *She agreed there had been several missed hand hygiene opportunities. *Her expectation was that staff perform hand hygiene at the appropriate times such as those listed in the following hand hygiene policy. Review of [NAME] Policy Hand Hygiene and Handwashing-Rehab/Skilled, Senior Living, last reviewed/revised on 4/6/21, revealed: *During Patient Care 1. Wash hands with plain soap and water or with anti-microbial soap and water: a. If hands are visibly soiled. b. If hands are visibly contaminated with blood or bodily fluids. 2. If hands are not visibly soiled or contaminated with blood or bodily fluids, use an alcohol-based hand rub (ABHR) for routinely cleaning hands: a. Before having direct contact with residents, patients, and children. b. After having contact with another person's skin. 2. Observation on 5/3/22 at 5:16 p.m. in the south neighborhood revealed CNAs G and H went to four different resident rooms without performing hand hygiene or using an ABHR before they had physical contact with each of the residents in those rooms to assist them to the dining area for the evening meal. Observation on 5/3/22 at 6:21 p.m. revealed CNA H did not perform hand hygiene between assisting each resident to eat; she was standing and walked from resident to resident seated around the tables in the south neighborhood dining area as she assisted each resident take a bite of food or drink some beverage. Interview on 5/5/22 at 10:34 a.m. with DON B confirmed CNAs G and H failed to follow proper procedures for hand hygiene.

Based on observation, interview, record review, and policy review, the provider failed to provide an individualized activity program for one of nine resident (21) on the special care unit (SCU). Findings include: 1. Observation on 5/3/22 from 3:51 p.m. to 4:10 p.m. on the SCU revealed resident 21 wandering in the hallway. The May 2022 activity calendar posted in the dining room listed the 4:00 p.m. activity as Sing Along. There was no activity program conducted at 4:00 p.m. Observation on 5/4/22 at 8:41 a.m. on the SCU revealed resident 21 sitting in a lounge chair in the common area. The resident got up from the chair and walked down the length of the hallway and turned around to walk back. There was no activity programming being offered on the SCU at that time. Observation on 5/4/22 at 10:48 a.m. on the SCU revealed activities assistant (AA) V at a table in dining area with one unidentified resident. The activity calendar listed the 10:30 a.m. activity as Art with [AA V's first name]. AA V was using colored paper and talking to the one resident, but the resident was not physically involved in the activity. Resident 21 was sitting in a lounge chair in the common area, but was not involved in the activity. AA V made no attempt to include resident 21 or the other residents in the common area. Interview on 5/4/22 at 11:05 a.m. with activity coordinator M revealed: *She was responsible for the activity programming including the activity calendar for the SCU. *An AA was on the SCU unit for the mid-morning activities on Tuesday, Wednesday, and Friday and on weekday afternoons for the 4:00 p.m. activity. *There were two certified nursing assistants (CNAs) that provided activities throughout the day and on the weekends. *When residents admit to the SCU, she provided the family with a questionnaire to obtain information on the new resident's prior life and activity interests. Interview on 5/4/22 at 11:28 a.m. with director of nursing B and education coordinator N revealed: *CNA D, who was also a certified medication assistant (CMA), was a lead staff person on the SCU. *Both stated there were usually a lot of activities on the SCU. Interview on 5/4/22 at 11:44 a.m. with certified social worker O revealed the management of the SCU was an interdisciplinary team effort that involved nursing, dietary, activities, and social services. Review of resident 21's medical record revealed: *She was admitted on [DATE] to the SCU. *Her 3/11/22 admission minimum data set (MDS) assessment stated her need for activities would be addressed on her care plan. *Her 3/17/22 care plan had no problem, goal, or approaches addressing her activity need. Interview on 5/4/22 at 5:24 p.m. with MDS coordinator/infection preventionist C revealed: *The activities department usually completes the MDS assessment for activities and develops the activity care plan. *She was the back-up for the activity department to ensure the MDS and care plan were completed. *She stated there was a mix-up in communication that resulted in the care plan not being completed. *She confirmed there was no activity care plan for resident 21. Interview on 5/5/22 at 10:51 a.m. with CNA/CMA D revealed: *The SCU staff had not usually followed the programs listed on the activity calendar. *The 10:00 a.m. and 4:00 p.m. activity were conducted by one of three AAs on specific days. *The AA or SCU staff had not conducted an activity program that morning. *Activity programming on the weekends had not occurred very often. Review of the provider's 11/13/21 Screening And Admission to Special Care Unit policy revealed: *Purposeful activities would be integrated into the structured daily routine by nursing staff (CNAs) and activity staff. *Activities provided would reflect each resident's prior occupation, interest, and lifestyle as much as was feasible. *Daily routines would be structured seven days per week, recognizing the residents' need for therapeutic programming for all waking hours and at night when they awaken. *Specific activities or interventions to distract or occupy residents would be explored.

Based on observation, interview, record review, and policy review, the provider failed to report an incident of resident to resident nonconsensual sexual contact for one of one sampled resident (50) to the South Dakota Department of Health (SD DOH) within 2 hours required for abuse allegations. Findings include: 1. Observation and interview on 5/3/22 at 11:45 a.m. revealed: *Resident 50 was positioned sideways next to a dining table with a meal tray in front of her in the neighborhood dining area while seated in her wheelchair with her legs elevated and extended on leg and foot rests. Her eyes were closed. *The certified nursing assistant (CNA) that was assisting another resident at the same table confirmed resident 50 was asleep. Observation and interview on 5/3/22 at 3:45 p.m. revealed: *Resident 50 was positioned sideways next to the birdcage in the neighborhood dining area. *Her eyes were open, and she was repetitively saying, Help me. *When asked what she needed, the resident did not provide further explanation. Interview on 5/3/22 at 4:28 p.m. with resident 50's representative revealed: *He received a report that someone witnessed a male resident was molesting her and let him know about it. *That happened about 6 months ago and he had never heard what was done about it. Review of the facility report on file with the SD DOH revealed: *An incident that involved a male resident (19) and resident 50 occurred on a Sunday, 12/19/21, at approximately 9:30 a.m. *The initial report from the provider to the SD DOH was submitted on Wednesday, 12/22/21, at 1:43 p.m. *The provider submitted the final report with a completed investigation on Friday, 12/24/21, at 3:00 p.m. *Resident 19 was relocated to a different room in another wing where staff presence is more frequent, and the provider reached out to his physician for treatment options. Review of progress notes (PNs) in resident 50's electronic medical record (EMR) revealed: *There were no PNs documented on 12/19/21, the date of the incident. *A social service PN on 12/22/21 documented: -On 12/19/21 in AM [morning] (between 9AM and 11AM, although exact time is unknown) a CNA witnessed the resident 19 approach resident 50 while she was seated in the neighborhood dining area. -He did a quick scan of the area, walked up to resident 50, and then sexually touched her. -The CNA interrupted the resident contact and he left the area to his room. -The CNA did report this to the nurse on duty at the time of the incident. -Resident 50 did not appear to have any negative reaction to this event and did not respond in the moment. -Certified social worker (CSW) O contacted [the resident's] family on [Tuesday] 12/21/21 to describe above incident. Further review of resident 50's EMR revealed: *The 2/9/22 minimum data set (MDS) assessment coded the resident as moderately cognitively impaired and totally dependent on staff for physical movement with a limitation in arm movement on one side. *The 2/9/22 care area assessment (CAA) documentation noted: -Her cognition is generally poor day-to-day, she can make her needs known at times, but staff have taken on a stronger role in reference to anticipating or asking her about her needs. -She needs extensive/total assistance with all activities and does not walk. Review of resident 19's EMR revealed: *The 10/13/21 and 1/6/22 MDS assessments coded the resident as severely cognitively impaired and independent without staff oversight for all activities related to transferring between surfaces, walking, dressing, and toileting. *A Physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . *A psychiatry progress note dated 1/6/22 noted: -The resident was seen for an evaluation of sexual disinhibition with dementia. -He is pleasantly confused showing great difficulty recalling recent remote history. -When asked about the recent incident involving resident 50, he states he would not do that and hoped provider believed that is not his values. Interview on 5/4/22 at 4:45 p.m. with CSW O revealed: *The CNA that witnessed it reported the incident to me on Monday. *The incident happened over the weekend so the report to the state was late. * Staff have been educated to call her as soon as possible when something like this happens, but she has had to re-educate every once in a while. *She agreed perhaps there should have been a nursing physical exam after the incident. Interview on 5/5/22 at 10:34 a.m. with director of nursing B, who was not an employee for this provider at the time of the incident, revealed she absolutely would have expected the nurse to do a physical exam after the incident occurred. Review of the provider's Abuse and Neglect policy and procedure revealed: *Any and all persons who have reasonable cause to believe a resident/patient of this facility is being subjected to abuse and/or neglect .are responsible to report such suspicions. *The procedure to report a suspicion of abuse included, immediately notify the Senior Director, Directory [sic ] of Nursing (DON), LTC [long term care] Director of Nursing or Social Worker. If an incident occurs outside their regular hours, report to the supervising nurse who will assure reporting to the senior Director of DON. *An initial report is made within 2 hours if serious bodily injury or within 24 hours for all other reports.

Based on observation, interview, record review, and review of facility reported event received by the South Dakota Department of Health (SD DOH), the provider failed to ensure one of one resident (1) received care and services related to: *Pain management, including a pain identification system to accurately reflect the pain she had been experiencing. *Bathing and restorative services to promote her well-being and mobility. *Completion of grievance investigationd for the resident's concerns. *Implementation of physical therapy orders to prevent accidents and/or injuries. Findings include: 1. Review of the provider's reported event received by the SD DOH for resident 1 revealed: *She was being transferred by an unidentified certified nursing assistant (CNA) on the morning of 12/16/21. *The: -CNA was using a gait belt and completed a pivot transfer when the resident's legs gave out. -Resident had not felt like her foot was completely flat and felt it bent backward/sideways when she was lowered to the ground. -CNA and registered nurse (RN) stated that she had no complaints of pain, until the next day on 12/17/21. *On 12/18/21, complaints of pain continued, but relief with Tylenol was not effective. Staff were monitoring and questioning if foot was sprained, or other. *On 12/19/21 she was noted to have significant swelling and pain was not been able to be relieved, and more urgent care was sought . -She was found to have a distal tibia fracture (ankle fracture). *On 12/22/21 an interview was conducted with the resident, her daughter, and the provider's social worker (SW) D. During that interview: -Resident 1 stated no when asked if the fall had happened as the CNA described it. -The resident and daughter requested to not have the CNA work with the resident anymore. --[Provider name] was able to accommodate this request. Observation and interview on 2/2/22 at 1:30 p.m. with resident 1 revealed: *She was sitting in her wheelchair and had a boot on her right foot. *She had difficulty communicating but was able to say yes and would communicate with her tablet. *She was able to communicate her concerns with this surveyor. She: -Responded the CNA's report of the fall was not accurate. -Had a lot of pain after the fall. -Had not been wearing a gait belt. -Was aware right away that she had hurt her foot. -Had not felt they were addressing her pain. -Had concerns because the CNA was still providing care for her. -Had not felt safe. -Had felt it was not an accident. -Had not felt that she received weekly baths. -Had not felt that the staff completed exercises with her. -Confirmed she received therapy services. Phone interview on 2/2/22 at 3:00 p.m. with RN C regarding resident 1's fall revealed: *She had been told the resident was gently lowered to the ground, by CNA H. *She had a little bit of ankle pain, so she gave her Tylenol. *She had a hard time remembering the details of the event. *When asked how the resident's leg was when she came into the room, she stated: -Maybe it was bent a little, she had not remembered specifics, it was too long ago. Phone interview on 2/2/22 at 3:10 p.m. with CNA H regarding resident 1 revealed she: *Was getting the resident up for the day. *Had the resident standing up, and had a clean brief partly up when her leg just kind of gave out. *Had not wanted to let her go but had to lower her to the ground to use her walkie talkie to call for help. *Was unable to remember where her feet were at the time of the incident. *Was unsure how the fracture may have happened. *Had been informed by other staff she was a stand-pivot transfer. *Was not informed until after the fall that she was not a stand-pivot transfer. *Stated after the fall, they continued to stand-pivot transfer her until she went to the doctor on 12/19/21. -Then they started using the EZ-Stand lift. *Was informed by SW D the family had not wanted her working with the resident anymore. *Had been working with the resident. *Had asked the resident if she would like her to help transfer her and she stated the resident had said yes. *Had been told other CNAs had not helped the resident with restorative therapy. *Restorative aide (RA) G was responsible for completing restorative therapy for the residents. *Stated resident 1 had not liked RA G so he usually had not worked with her. Phone interview on 2/2/22 at 3:22 p.m. with RN F revealed: *He had worked with the resident after her fall. *He had not helped transfer her after the fall. *The resident's daughter came in on 12/19/21 and the decision was made to send resident 1 in to urgent care for an evaluation. *When asked about the resident's non-weight bearing (NWB) status he stated the resident was never NWB. *When asked if the resident had any swelling he stated she always had some swelling. Phone interview on 2/2/22 at 3:30 p.m. with resident 1's daughter revealed: *The facility had called her and informed her that her mom had been lowered to the ground on 12/16/21. *They had made it sound like it was no big deal so she did not come in to see her until 12/19/21. *On 12/19/21 she came in to see her mom, she: -Stated her mom was in her wheelchair screaming in pain. -Felt it had been obvious it was her foot because her mom would not let her come near her foot. -Stated her foot was so swollen it looked like someone had shoved a softball in her sock. -Felt it would have been hard for staff to not notice the swelling. -Took pictures of her mom's foot and emailed them to SW D. *Her mom was taken to the hospital because she insisted that she be seen. *RN F and an unidentified CNA stated her foot had been bothering her. *After the interview with SW D and CNA H took place, she requested that CNA H not work with her mom anymore. -She was told by SW D because of staffing they were unable to do that, but they would do their best. *She had asked the medical doctor (MD) on 12/19/21 to order physical therapy because her mom had not been receiving her restorative therapy exercises. Phone interview on 2/2/22 at 4:10 p.m. with RA G revealed he: *Oversaw restorative therapy for the residents. *Had often been pulled to the floor to work as a CNA. *Only had the restorative gym open twice in January because he had been working as a CNA on the floor. *Had not worked with resident 1 since November 2021. Phone interview on 2/2/22 at 4:20 p.m. with RN F revealed: *The resident was unable to give numbers for her pain, he looks at her behavior. *When asked how he monitored the effectiveness of the medication given, he stated by looking at her behavior. *When asked if they had ever implemented a pain scale such as a face pain scale or other non-verbal pain scale he said no. *The skin assessment he had completed for resident 1 on 2/2/22, he: -Usually checked the resident from head to toe. -Had not checked the resident's lower extremities. -Stated the CNA had already placed the resident's TED (anti-embolism stocking) hose on. -Had taken the CNA's word that there was not any swelling or redness. -Still regrets he had trusted the aide that there was no redness or swelling. Phone interview on 2/2/22 at 4:40 p.m. with SW D revealed: *A grievance had not been filled out regarding the interview with resident 1 and her daughter. *Resident 1's daughter had informed her that CNA H could work with resident 1 if there was another person present. Review of resident 1's 12/19/21 urgent care provider notes revealed: *She presented to urgent care with her daughter regarding her right foot pain. *The foot pain started on 12/16/21, when she was lowered to the floor during a transfer. *The resident was going to be placed in a tall boot, .However her swelling is so severe that we cannot strap the boot. I discussed sending the boot with down to [the facility name], elevating the leg, applying compression stockings; then hopefully in the morning we can apply the boot . * .She is set up for 4 or 5 days of restorative care each week and she only gets 1 day a week. I discussed placing a physical therapy evaluation and treatment as she will still need to be doing strengthening exercises whether that foot is fractured or not . * .The pain is just below the knee down to the foot. She is still unable to bear any weight due to the excruciating pain . *The provider ordered Tylenol and Ibuprofen daily. Review of resident 1's provider radiology notes revealed: *She had a distal tibial metaphyseal fracture and a subtle impaction type fracture involving the proximal fibula . *He had also noted soft tissue swelling. Review of resident 1's physical therapy (PT) notes revealed: *On 4/16/21, her discharge summary stated: -She had been seen for 24 PT sessions. -Her long term goals included she would participate in regular restorative therapy. *On 12/22/21: -She has hx [history] of [CONDITION(S)] [[CONDITION(S)] accident] with significant R [right] sided weakness and requires assistance with all ADLs [activities of daily living], mobility, and transfers. She sustained a R distal tib/fib [tibia/fibula] fracture this week during a transfer where she was lowered to the floor. Xrays indicated fracture and she was put into a tall CAM [controlled ankle motion] with instructions for NWB'ing [non-weight bearing] x 6 weeks [for six weeks]. Nursing state they are using the EZ stand for transfers but she is having difficulty with prolonged standing. Staff and MD are also concerned about her declining status and difficulty tolerating activity. Patient can somewhat verbalize she is having difficulty with mobility and has some pain in her R ankle. Review of resident 1's nursing progress notes revealed: *On 12/16/21: -Staff was assisting resident with AM [morning cares]. When staff went to transfer resident to wheelchair the residents legs gave out and she was lowered to the floor . *On 12/17/21, about 30 hours after the fall: -Resident had complaints of right leg pain. PRN [as needed] Tylenol given and did provide relief. *On 12/18/21 RN F had completed a skin assessment. *On 12/18/21 at 1:35 p.m.: -[resident's name] continues to c/o [complain of] right leg pain indicating she may have strained or twisted something during recent fall. [resident's name] does voice some relief with prn APAP [Tylenol]. *On 12/19/21 at 12:32 p.m.: -[Resident's name] continues to c/o right leg pain and voices no relief with prn APAP today. [Daughter's name] here this morning and as she communicates with [resident's name] seems to isolate the discomfort around [resident's name] right ankle. [Resident's name] also indicated discomfort she is experiencing has occurred in conjunction with recent fall . *On 1/16/21 a note was made: -This afternoon the CNA was helping resident and her I Pad flipped onto the ground and the bracket turned and got wedges between her chair and leg. The bracket was putting pressure on her leg. To relieve the pressure from the bracket, the CNA pushed down on resident's right thigh to get the bracket wedged out from between the chair and the resident. A bruise may form on her right thigh from pushing down on it . Interview on 2/2/22 at 3:45 p.m. with LPN E regarding the note she documented on 1/16/21 revealed: *She had put the note in just in case there was a bruise. *When asked who the CNA was and she stated, [CNA H's name]. Review of resident 1's Medication Administration Record [MEDICAL RECORD OR PHYSICIAN ORDER] *She received a dose of Tylenol on 12/16/21 and 12/17/21. -They had both been marked as effective for pain control. *On 12/18/21 she had received Tylenol and it had been marked as somewhat effective. -Although it was somewhat effective, she had not received any additional doses. *On 12/19/21 Tylenol was marked as given at 11:13 a.m. and noted to be not effective. Review of resident 1's bathing records from 12/1/21 through 1/31/22 revealed she: *Had not received any baths for 23 days, from 12/1/21 through 12/23/21. *Received one bath on 12/24/21. *Received her next bath on 1/1/22, 8 days later. *Had her next bath was 10 days later, on 1/18/22. Interview on 2/2/22 at 4:30 p.m. with RN J regarding resident 1's missing baths revealed: *Surveyor asked if there was additional baths, as surveyor was unable to verify resident had received consistent bathing. -They are working on improving their process regarding baths being completed and documentation of the completed baths. *She had been unable to state if resident 1 had received any additional baths. Review of the CNA's flowsheets for resident 1 revealed the only exercise that had been listed was for stretching upper and lower extremities with cares. Review of resident 1's 11/18/21 care plan and Kardex revealed: *PT/occupational therapy's recommendations of transferring the resident with two staff for a manual assist had not been added, until after her fall. -In the submited event report, SW D stated it had been updated after her fall. *For pain management: -Monitor pain. Non drug interventions: Reposition. Administer pain medications as ordered. Assess pain management effectiveness. *Restorative needs had not been on her care plan. *Her bathing preferences had not been on her care plan. Interview and review on 2/2/22 at 4:55 p.m. with administrator A and chief nursing officer (CNO) B regarding resident 1's fall incident report revealed: *They had recalled the fall being discussed. *When asked if they had been aware about the resident and her daughter's wishes to not have CNA H care for her anymore CNO B stated: -If he had been aware of the situation they would have done their best to not have CNA H work with the resident. *Implementing a pain rating scale such as the faces pain tool could have been beneficial for resident 1. *They would expect staff to follow physician orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Review of the provider's November 2021 Pain policy revealed: *Pain is a subjective phenomenon, generally related to the extent and location of tissue disruption or disease process (i.e. arthritis). In non-responsive residents or cognitively impaired residents, it may be manifested by non-verbal behaviors. *Regarding pain assessment guidelines: -Identify the individual's cognitive function, physiologic and developmental expressions of pain. -Use the appropriate and preferred pain assessment tools. -Pain assessment and interventions are guided by: a numerical pain rating, physiologic and developmental indicators of pain, achievement of individual comfort goal, ability to perform at anticipated level for therapies and activities. Review of the provider's November 2021 Falls, Promoting a Safe Environment policy revealed: *Care planning will address specific interventions to decrease the risk of falls, injuries related to those falls, and minimize the use of unnecessary restraints. *If a resident fall occurs, the charge nurse will complete a head-to-toe assessment with neuro checks .

Based on observation, interview, electronic medical record (EMR) review, and facility event report received by the South Dakota Department of Health (SD DOH) revealed the provider failed to ensure staff had updated one of one resident's (1) care plan regarding transfer needs, who sustained a fracure after a pivot transfer had been completed by one of one certified nursing assistant (CNA) H. Findings include: 1. Interviews and resident 1's EMR review completed during an onsite complaint survey on 2/2/22 revealed: *Resident 1 had an annual evaluation completed by physical therapy (PT) and occupational therapy (OT) on 12/1/21. *Their recommendations included that the resident be transferred by two staff manually or for staff to use the EZ-Stand lift. -OT and PT recommendations had never been implemented. *On 12/16/21 the resident was transferred by CNA H using one staff and a gait belt and was gently lowered to the ground. -As a result of this incident she sustained a tibia and fibula fracture to her right lower leg. Review of resident 1's OT notes revealed: *On 12/1/21 she was seen by both OT and PT for her annual evaluation: -PT has recommended that pt [patient] transfer with 2 staff or stand lift. PT has given approval for family to ambulate with pt using hand rail. Pt is inconsistent with participation with restorative therapy which also has limited availability. *Regarding transfers: - .As of May 2021, is [it] has been recommended that pt complete transfers with 2 staff and the use of hemi-walker or with stand lift. Review of the provider's February 2022 Transfer Activities policy revealed: *Follow individualized plan of care for specific intervention for amount of assistance and equipment needed. *Obtain assistance of another individual if necessary for safe transfer. Position gait belt. *If resident is able to participate in transfer, have resident place unaffected foot under the ankle on the affected side. If necessary, place unaffected foot under the affected knee and slide down to ankle . Refer to F684.

Based on record review, observation, interview, and policy review, the provider failed to ensure professional standards were followed for three of eight observed residents (34, 45, and 57) who were at risk for skin breakdown. Findings include:1. Review of the updated 6/20/19 certified nursing assistant (CNA) careplan for resident 34 revealed: *Supportive devices: -Wheelchair (w/c) pedals on. -ROHO w/c cushion. -W/C back insert with lateral support. *Toileting: -Extensive incontinent/continent bowel/bladder. Assist of two every two hours and routine. -Check and change two times at night. -Foley and provon wipes per protocol. *Ambulation: Locomotion -Independent to extensive with w/c. -Assist fluctuates. *Transfers: -Extensive assist one or two. -Stand lift (E-Z lift). *Positioning: -Independent/extensive assist of one or two. -Off load every hour.*Skin care:-Maceration to buttocks.-Utilize open to air and fan. Observation and interview on 7/16/19 between 7:53 a.m. and 3:07 p.m of resident 34 revealed:*At 7:53 a.m. she had been in her bed.-She had been laying on her back.*At 8:30 a.m. she had been in her bed.-She had been laying on her back.--She was in the same position.-She stated she was not repositioned on a regular bases.-She was only repositioned on her left side when her husband was in the room.--That way she could see him.*At 11:12 a.m. she had been sitting in her w/c in her room.-She stated she would like to sit in her recliner, but she slides out of it.--That recliner was new and made from a black vinyl material.-That recliner was not utilized by her due to the EZ-stand not fitting underneath it.-That made it so she could not be positioned far enough back in the recliner. --That had caused her to slide out of the recliner.*At 11:54 a.m. she had been in her bed.-She was laying on her back.*She stated it felt better when she was positioned on her side, because her butt did not hurt. Interview and observation on 7/16/19 at 11:57 a.m. with CNA C with resident 34 revealed:*He was transferring her from her bed into her w/c.*He had not put her in her electric recliner, because she slides out.-She had also pushed the button on the recliner remote, reclined up, and slid out of the recliner.*He stated:-She had asked to be put into her bed earlier.-They should get her out of her w/c and into her bed more but it did not happen as much as it should.Observation and interview on 7/16/19 at 3:07 p.m. with resident 34 and her husband revealed:*While she was positioned on her left side with a pillow behind her, she was able to see her husband as he was seated in her w/c.*She would like to sit in her recliner. -They shared her previous recliner had been replaced when they were told it had rip's in it which made it an uncleanable surface.2. Review of the updated 3/20/19 CNA careplan for resident 45 revealed: *Supportive devices: -W/C pedals on. -Gel cushion. -High density foam mattress. -Hoyer lift. *Toileting: -Total assist incontinent bowel/bladder. -Check and change briefs. -Perineal (peri) care two times a day and as needed. *Ambulation: -Total assist. -W/C with cushion. *Transfers: -Total assist of two. -Hoyer lift. *Positioning: -Off load every hour in w/c. -Assist of one or two. -Reposition every 2-3 hours when in bed. *Skin care: -Moisturizing lotion as needed. -Asses skin daily with cares. -Pericare. Random observation on 7/16/19 from 7:40 a.m. through 3:03 p.m. of resident 45 revealed: *At 7:40 a.m. she was in her w/c in the main dining room at the assistance table. *At 8:52 a.m. she was in her w/c in the neighborhood commons area in front of the TV. -At 9:16 a.m. she was in her w/c in the neighborhood commons area in front of the TV. -She was in the same position as she was at 8:52 a.m. *At 11:27 a.m. she was in her w/c and was pushed up to the neighborhood dining table. -She was waiting for and to be assisted with lunch. *CNA C began feeding her her lunch at 12:22 p.m. *That was a total of four hours and forty-two minutes of sitting in her w/c. *At 3:01 p.m. she was in her bed laying on her back. Interview on 7/16/19 at 3:01 p.m. with CNA H concerning resident 45 revealed: *They had just checked on her. -She was unable to ask for help or use the call light. *She did not believe this resident was on a repositioning/turning schedule. *She did not believe this resident was at risk of developing pressure ulcers because she had not seen her with one. *She stated she was just winging it, as she was not usually on this wing. -CNA G was telling her what to do as she was more familiar with those residents. *CNA H agreed resident 45 was incontinent and depended on the CNAs for her care. -Yes, she is totally dependent on us. 3. Interview on 7/17/19 at 8:50 a.m. with the DON concerning the above observations revealed: *They did not have a written policy/procedure for the repositioning of residents. *If repositioning was on their careplan's it would be specific. -If not on the careplan it was to be the standard protocol. *The standard protocol was taught when employees were hired and during the skills fair. -The skills fair was mandatory, and it was held yearly. Interview on 7/17/19 at 3:10 p.m with the nursing supervisor/education coordinator revealed: *They had story board education that was *Story board education that was done on initially being hired and annually. -They were tri-fold poster type boards approximately three feet high by four feet wide. -They were filled with pictures and education. -There were a total of forty-six different story boards that she went through with them. *She stated she would need to look at story board thirty-seven for the repositioning guidelines named pressure ulcers. *Storyboard thirty-seven had the following: a. Lesson: -Even low pressure over a long period of time can cause tissue damage. -One way to avoid tissue damage is through a consistent turning schedule. -Bed bound is every two hours. -Chair bound residents are every hour. --Encourage these residents to shift weight every 15 minutes if possible. b. Pressure reduction -Repositioning schedule, individualized. --Minimum turn: every two hours in bed. --Minimum shift: Every 15 minutes in chair. ---Teach resident to do this. --Minimum shift: Every hour in chair by staff. *She stated those were the protocols to be followed if there were not specific turning/repositioning requirements in the care plan. Interview on 7/17/19 at 4:18 p.m. with the DON revealed: *The CNA care plan was what was used by the CNAs to take care of the residents. *She produced a 6/17/19 physician's orders [REDACTED]. -She stated the MDS coordinator was responsible for updating the CNA care plan. -The MDS coordinator had not removed the open to air and fan order. *Repositioning should still have been completed. *Agreed flow sheets should have been initialed each shift when completed. *Agreed if not initialed/documented it was not done. *Agreed the orders should have been carried out and completed. 4. Review of resident 57's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to assist her with all activities of daily living (ADL). -That had included bed mobility, transfers, toileting, personal hygiene, and bathing. *At times she had increased confusion and could not always voice her needs, thus she was dependent upon the staff to anticipate her needs. *She was: -At risk for skin breakdown and required the use of pressure relieving devices. -At risk for wounds and injury to her feet/legs and required the use of pressure relieving Rook type boots. -Dependent upon the staff to ensure her skin was assessed weekly and remained free from injury. Review of resident 57's 7/16/19 comprehensive care plan revealed: *She was at risk for pressure ulcers. *The staff were to have: -Assisted her with toileting every two to three hours during the day. -Assisted her with offloading every hour. --She could have offloaded herself independently. *She was incontinent of both urine and bowel and required staff support with her toileting needs. *She required staff support to ensure all of her ADL had been met. Observation on 7/15/19 at 4:00 p.m. of resident 57 revealed: *She had been sitting in a wheelchair (w/c) by the fireplace in the visitor/sitting area. *Her head was bent forward, and she was sleeping while trying to sit-up in the w/c. *Her feet were positioned on foot pedals and were covered with sheepskin type Rook type boots. Interview on 7/16/19 at 7:40 a.m. with CNA C regarding resident 57 revealed: *She: -Was confused, not interviewable, and was dependent upon the staff to anticipate her needs. -Required staff assistance with all activities of daily living (ADL). *The surveyor requested to observe the CNA when he assisted the resident with any type of care including transfers and personal care. Random observations of resident 57 on 7/16/19 from 7:45 a.m. through 12:15 p.m. revealed: *From 7:45 a.m. through 10:00 a.m. she was in the same position and the same appearance as observed above. -She had been sleeping with her mouth open, and drool was running out of her mouth and all over the front of her shirt. *At 10:30 a.m. she had been attending the church service. -She had been sleeping with her head bent forward, feet on the foot pedals, and continued to drool all over her shirt. -CNA C was again reminded by the surveyor that she would like to observe him assisting the resident with any and all types of care. *From 11:00 a.m. through 11:55 a.m. she continued to sit in her w/c but now had been moved to a table in the dining area of the west wing. *From 11:57 a.m. through 12:15 p.m. she remained at the dining room table eating her lunch. *She was not observed attempting to offload or shift herself while sitting in the w/c. Interview on 7/16/19 at 11:46 a.m. with CNA C regarding resident 57 revealed: *The staff had not assisted the resident with any type of repositioning, toileting, or personal care since she had been out of bed at 6:25 a.m. *He confirmed she: -Had been up approximately five or more hours without any type of assistance. -Was incontinent of both urine and bowel and required staff assistance to ensure she remained clean and free from skin breakdown. *The staff would not have assisted her with incontinent care, personal care, offloading, repositioning, or toileting until after lunch time. -That had been her usual schedule for the day. *He confirmed: -She was at risk of skin breakdown and should have been repositioned at a minimum of every two hours per the facility policy. -She would have sat in her w/c for six or more hours every morning without any type of assistance or repositioning from the staff. *He agreed that was not a best practice and that schedule had placed her at further risk for skin breakdown to have occurred. Interview on 7/16/19 at 4:45 p.m. with licensed practical nurses (LPN) F and I regarding resident 57 revealed: *They confirmed the medical record review for the resident. *They were not aware the staff would not have repositioned her for several hours at a time. *Residents who were at high risk for skin breakdown should have been repositioned every two hours unless indicated. *They would have expected the staff to have followed that facility policy. Interview on 7/17/19 at 3:57 p.m. with the DON regarding resident 57 revealed: *She stated On a normal day that would not have happened. Either myself or one of the nurses would have told them to assist her. *She confirmed: -Those residents who were at risk for skin breakdown should have been moved every two to three hours. -The medical record review on the resident. *The above observation was again reviewed with her along with the multiple attempts and requests from the surveyor to observe them when they had assisted her with any type of care. -No further comment was made by the DON.

Based on observation, interview, policy review, and manufacturer's guidelines review, the provider failed to maintain a clean, homelike, sanitary environment for: *One of two shared resident whirlpool tub (w/p) rooms (north wing). *Resident use equipment to include: -Six of eight observed wheelchairs (w/c) for residents (10, 18, 42, 45, 57, and 215). -Pressure relieving rook boots for one of two sampled residents (57). -Mechanical lift Hoyer slings for one of two sampled residents (45). Findings include: 1. Observation on 7/16/19 at 10:25 a.m. of the north wing w/p tub room revealed: *Inside the room there was a large whirlpool tub, toilet, hand sink, and an area to take a shower. *The w/p tub had: -The capability of using a hand-held shower hose. --The shower head was hanging from the side of the tub and placed inside a bucket on the floor. -A handwritten note taped to it by the hand-held shower instructed staff not to use the hand-held shower as it was not in working order. *There were three large openings on the base of the tub. -Two out of those three openings had been covered by a locked door. *There was one opening on the right side of the tub that was not coved with a locked door. -That opening allowed for access to change the chemicals used to clean the tub and some of the mechanical pieces. *The w/p tub had several edges and seams along the outside surface that were soiled with gray colored dust and dirt. -The surveyor was able to run her finger through several of those areas. *There was a large opening and door on the left side of the tub. -The black seal attached to the inside of the door was unattached along the top corner of it. *There was standing water on the floor along the wall by the toilet and hand sink. -That water extended out into the tub room area approximately two to three feet. *The entire floor was covered with a white colored tile. -In several areas the grout inside of the tile was black/gray in color had a soiled appearance. *There were several pieces of missing tile along the bottom edges of the opening into the shower area. -Those missing tile had exposed the wall board underneath of the tiled area. Interview on 7/16/19 at 10:30 a.m. with certified nursing assistant (CNA) A at the time of the above observations revealed: *She had been aware the hand-held shower was not working. *She was not sure how long it had not been working. *She stated, It hasn't been working for at least two weeks or more. *She was not sure but had assumed another staff member had put in a request to the maintenance department to fix it. *She had noticed the seal around the tub door was coming off. -She agreed that was a concern for when the tub was filled with water and the potential for water to leak out of the tub. -She was not sure if that had been reported to the maintenance department for repair. *She was not sure where the door was to cover the opening on the tub area containing the cleaning chemical and some of the mechanics of it. -She agreed that had created a safety concern for residents and staff using the tub. *She confirmed the outside surfaces and edges of the w/p tub were dirty. *She stated: -We don't clean the outside of the tub. -The housekeeping staff clean the toilet, sink, and the outside of the tub. -We are supposed to clean the inside of it between resident baths. *She confirmed the standing water in the tub room and the safety risk it had created. *She stated: -Sometimes when we open the door too soon water will run out of the tub. -That is probably what happened. -We are not supposed to do that. *She offered no comment on the appearance of the tile and grout nor the missing tile by the shower area. *She agreed the tub room did not create a homelike, safe, and sanitary environment for the residents when taking a bath. Observation and interview on 7/16/19 at 10:35 a.m. with both CNA A and housekeeper B regarding the concerns identified in the w/p tub room revealed: *Housekeeper B: -Would have cleaned the toilet, sink, and swept or mopped the floor. -Would not have cleaned the outside nor the inside of the w/p tub. -Stated The CNAs are responsible for cleaning the tub and that includes the outside of it. -Would not have done a deep or more thorough cleaning of the tub room. *CNA A had not been aware the housekeeping department would not have cleaned the outside of the w/p tub. *They both agreed: -Someone should have been responsible for the cleaning of the outside of the tub. -The room should have required a more thorough cleaning on a routine basis. Observation and interview on 7/16/19 at 10:45 a.m. with the maintenance department director of the w/p tub room revealed he: *He was not responsible for the housekeeping department nor their duties. *He agreed the room could have used a deep cleaning to ensure a clean, homelike environment for the residents had occurred. *He was not aware: -The hand-held shower was not working properly. -The seal around the w/p tub door opening was coming off. -The door for one of the openings on the w/p tub was missing. *His department had tried to fix the missing tile by the shower area in the past, but they came off again. *He would have: -Expected the staff to have put in a work order in through their computer system to inform him of the repairs the tub room needed. -Given those repairs to one of his staff members to fix. *If able they would have fixed any repairs or concerns within a day unless parts had to be ordered. Observation and interview on 7/16/19 at 3:15 p.m. with the environmental services director and director of nursing (DON) of the w/p tub room revealed: *They: -Had not been aware of all the concerns in the room identified above. -Confirmed the staff at times would have opened the door too soon and water ran all over the floor. --The staff had been educated multiple times not to do that. *The staff should have put in a request for repairs to the DON, and then she forwarded those onto the maintenance department director. -She confirmed the maintenance department was prompt to respond and fix any concerns they might have. *The housekeeping department: -Was not responsible to clean any resident use items that was movable such as intravenous poles, wheelchairs (w/c), and walkers. --The w/p tub had been included in that list of items. -Had attempted to clean the tiled floor and the grout with bleach and special equipment, but neither of those had helped with the cleanliness and soiled appearance of it. *After further review they agreed: -The outside of the w/p tub should have been considered a part of the bathroom fixtures and cleaned by the housekeeping department. -The room had not been maintained to create a clean, sanitary, and homelike environment for the residents, and it should have. 2. Random observations on 7/16/19 from 7:45 a.m. through 3:45 p.m. of residents 10, 18, 57, and 215 revealed: *They had all required the use of a w/c to ensure their mobility needs had been met. *Those w/cs had been visibly soiled on multiple surfaces. -There had been dried food particles, dirt, dust, grime, and dark spots on those surfaces. *Those surfaces and areas of concerns had been on the bars, w/c cushions, underneath the w/c cushions and on the seats, brakes, and pedals.Surveyor Random observations on 7/16/19 from 8:08 a.m. through 2:38 p.m. of residents 42 and 45 revealed: *They had all required the use of a w/c to ensure their mobility needs had been met. *Those w/cs had been visibly soiled on multiple surfaces. *There had been dried food particles, dirt, dust, grime, and dark spots on those surfaces. *Those surfaces and areas of concerns had been on the bars, w/c cushions, underneath the w/c cushions and on the seats, brakes, and pedals. *Resident 42's right and left w/c arm rests were covered in a dark blue plastic material. -That material was cracked with pieces missing making those surface's uncleanable.Surveyor Group interview on 7/16/19 at 2:20 p.m. with CNAs C, D, and [NAME] regarding the above w/c observations revealed they: *Confirmed multiple resident w/cs were soiled with food particles, dust, dirt, dried on liquids, and dust. *Were unsure what the process was for cleaning of the resident's w/cs. -Some of them would have wiped the w/cs off with disinfectant wipes when they had appeared to be soiled. *Thought the night shift had been responsible for the cleaning and upkeep of the w/cs. *Used to have a w/c cleaning machine, but it had broken some time ago. *Agreed the staff were responsible for the cleaning and upkeep of the residents' w/cs. Interview on 7/16/19 at 4:45 p.m. with licensed practical nurse (LPN) F regarding the cleaning process for the residents' w/cs revealed: *The night shift was responsible for the cleaning and upkeep of the resident's w/cs. *They should have been cleaned weekly on Sunday. *The staff had a checklist for them to follow to ensure that had occurred. *She: -Agreed there were several w/cs in the facility that had more than a week or two worth of soil and grime on them. -Would have tried to wipe some off herself as time allowed. Interview on 7/17/19 at 4:07 p.m. with the director of nursing (DON) confirmed the interview with LPN F. She would have expected them to have followed that checklist. 3. Random observations on 7/15/19 at 4:00 p.m., and on 7/16/19 from 7:45 a.m. through 3:50 p.m. of resident 57 revealed: *She had been sitting up in her w/c. *Her feet had been resting on the w/c pedals. *Her feet/legs were covered with gray colored sheepskin lined Rook boots to ensure pressure relief had occurred. *Those boots were soiled in multiple areas with a red colored substance. Interview on 7/16/19 at 3:55 p.m. with CNA G regarding resident 57's Rook boots revealed she: *Confirmed they were soiled and had been in need of cleaning. *Stated: -This is her only pair, and she is supposed to wear them all the time. -When we have sent them to laundry in the past it has taken forever for them to come back. -I guess she could wear those blue ones that are in her recliner but she doesn't use those anymore. Interview on 7/17/19 at 2:30 p.m. with the DON regarding resident 57's Rook boots revealed she: *Had been aware the resident's Rook boots could get quite soiled. *Was not aware there was currently an issue with the process for her to have them cleaned. *Stated: -She has two pairs for her to use, I ordered them myself. -They are quite expensive, so there should not be a problem with this. -She doesn't wear those blue ones anymore, because they were cutting into her skin and causing problems. 5. Review of the provider's undated Penner Spas Aqua-Aire Sit-Bath System 6900 Safe Operation & Daily Maintenance Instructions revealed: *Transfer out of the tub: -Drain the tub by pulling the drain plug from the drain and allow the tub to be drained completely. -WARNING FAILURE TO HAVE THE TUB COMPLETELY DRAINED BEFORE UNL[NAME]KING THE DOOR COULD CAUSE INJURY TO THE OPERATOR AND RESIDENT. *Daily maintenance: To properly maintain the Cascade Sit Bath System, perform the following daily maintenance procedures: -WARNING: FAILURE TO PERFORM THE DAILY SAFETY CHECKS AND TAKE CORRECTIVE ACTION, WHEN REQUIRED, PRIOR TO THE OPERATION OF THE EQUIPMENT EACH DAY COULD RESULT IN INJURY TO THE RESIDENT OR OPERATOR. -WARNING: IF ANY PART OF THE SYSTEM IS NOT FUNCTIONING PROPERLY, CEASE ALL BATHING ACTIVITIES UNTIL THE PROBLEM IS CORRECTED BY MAINTENANCE. THE SYSTEM MUST BE MAINTAINED ON A SCHEDULED BASIS TO ENSURE IT IS FUNCTIONING PROPERLY. FAILURE TO HEED THESE PRECAUTIONS COULD RESULT IN INJURY TO THE OPERATOR OR RESIDENT. -Seal wear - Open the door and check to see that the seal is not cracked or peeling away from the door. Review of the provider's 11/19/18 Requisition for Service or Repair revealed: *Online program (name of program) will be used to request maintenance work within the (name of facility) facilities. *The originator (person completing the form) will fill in the urgency, location, work to e done, requested by, date and contact information of who to notify when completed. *Maintenance staff will use the system to input when work is completed or if they (there) will be a delay and the requester will receive notification by email. *The requests are not intended to be used as a substitute for a good, well planned schedule of preventive maintenance and grounds upkeep, but as a tool to quickly and efficiently correct the unplanned failure of equipment or repair damaged furnishings. Review of the provider's 1/30/19 infection Control in LTC (long-term care) Nursing Services policy revealed: *Purpose: To define procedures for cleaning, storage, and handling of equipment and supplies and the maintenance of a sanitary environment. *Policy: There will be established cleaning protocols for the general department environment and equipment and for safe storage and handling of equipment and supplies. *Cleaning & Disinfection of Work Surfaces & Resident Care Equipment: Broda Chairs, Wheelchairs, Lap trays, Wheelchair cushions, * Bridges: -After use on a resident, these items should be placed in the Care Center soiled utility room, thoroughly washed, disinfected and dried before placed in storage again. -During resident use, these items should be washed, disinfected and dried on a weekly basis (refer to cleaning schedules). Review of the provider's 10/28/18 Disinfection of Whirlpools policy revealed no documentation to support who was responsible for the cleaning and upkeep of the outside surfaces of those tubs. 4. Observation on 7/16/19 at 2:51 p.m. of resident 45 in her room revealed:*She was laying in her bed.*There was a Hoyer sling sitting on her w/c.*The straps of the sling that attached to the Hoyer lift were dark in color.-They looked soiled.*The back center sling strap had been torn with a tear the size of a quarter.*There were approximately five dark areas on the sling that looked like dried blood.Review of the reviewed/revised 1/30/19 Infection Control in LTC Nursing Services policy revealed: *3.11.7 Care center weight scales, Hoyer lifts, slings, bath lifts: -The Hoyer lifts and weight scales are to be cleaned and disinfected weekly.

Based on observation, interview, record review, and policy review, the provider failed to obtain the proper acknowledgement and signature to remove money from one of one sampled resident's (34)trust account at the facility. Findings include:1. Observation and interview on 7/16/19 at 3:07 p.m. with resident 34 and her husband revealed: *While she was positioned in her bed, on her left side with a pillow behind her, he was seated in her wheelchair (w/c). -She would have liked to sit in her recliner.--That recliner looked new and was made of a black vinyl material.*This recliner was not utilized by her due to the EZ-stand not fitting underneath it.-That had made it so she could not be positioned far enough back in the recliner.--That had caused her to slide out of the recliner.*Previously she had a recliner in her room that she used.*The director of nursing (DON) had told the husband the old recliner needed to be replaced.*He was told by the DON that there were rip's in it and it was an uncleanable surface.-It had been removed by staff. *He had told them, he did not have money to buy another recliner.-They told him they had found some extra money.-They took three-hundred and some dollars out of her account.*Both stated they had not been asked about using money from the account for the recliner.-He stated, they had taken the money without their knowledge. Interview on 7/16/19 at 5:15 p.m. with the director of nursing (DON) concerning resident 34 revealed:*She had been the one who had talked to the resident's husband about the recliner needing to be replaced.-It was funny leather that had rips in it creating an uncleanable surface.*She told them there was not enough money in her account to pay for one.*The husband stated he did not have money to buy a new recliner.*She told him they would take what was in her account and come up with the rest of the money needed.-She did not want him to know she was personally putting the extra money in.*She stated at the time he said it was okay to remove the money from her account.-Then he had come to her and said he did not know where the money had gone from his wife's account.*She explained to him she had told him she was going to remove money from that account.-That money was going to be used to buy her a new recliner.*He must have only heard We were going to get her one.*The DON was unable to produce any documentation of the above:-Date.-Time.-Encounter.*There were no computer notes or handwritten notes.Interview on 7/17/19 at 8:48 a.m. with the DON regarding the above interview revealed:*She had a receipt for the recliner that had been bought online.*It was bought using the DON's personal credit card.*Order summary of cost and taxes with free shipping was $386.58.-Had arrived on 4/3/19.*A handwritten note stated -300 (resident name) RT.*She stated she had been reimbursed on 4/9/19 for $300.00.*She talked with the quality coordinator this morning, and they had decided they would have the family member sign or they would note the okay to remove funds from her account.*They only had the receipt and no notes of the conversation.Interview on 7/17/19 at 9:08 a.m. with the billing manager/patient access supervisor concerning the above for resident 34 revealed:*She took care of the personal funds for the long term care residents.*Her monthly statements were sent to her husband.*Normally an employee would let her know when a resident wanted funds.-A resident trust cash withdrawal sheet would have been filled out.-The employee would take it to the resident and have them sign it.-It would be brought back to her, and the funds would be released.*She knew about the recliner being purchased before funds were reimbursed to the DON.*She was going on the word of the DON who had said she had ordered a recliner for the resident.-She said the family was okay with it, and she had charged it to her personal credit card.-She was going to need to be reimbursed.*Other employees had also bought items for residents.-The employee would bring in the receipt and fill out the residents trust cash withdrawal.-She would fill in there was a receipt.-The employee was reimbursed from the resident's account.*She did not get a prior authorization from the resident or the family.*She only documented the withdrawal.*She did not check to see that the resident got the items that were on the receipt.*The husband had made a comment to her when he had come in to deposit money on 5/15/19 into his wife's account.-That was after the recliner had been purchased.-He said something about he does not have much money because they bought a chair.*She stated she had been doing this job for six or seven months.-That was how she had been trained.*She stated based on the above they needed to have the family or the resident sign an okay for a cash withdrawal.Continued discussion on 7/17/19 at 9:56 a.m. with the billing manager/patient access supervisor concerning the above for resident 34 revealed:*She had not given a receipt of the recliner to the family or resident.*She did not normally look to see who the financially responsible party was.*She did not ensure the responsible party okayed or signed for the funds.*She did not question the DON about the funds.-She did not ask whether she had permission.*No one was required to have an account with the facility.*She agreed there were loopholes in the current system and that was not a totally safe process for residents' funds.Interview on 7/17/19 at 10:38 a.m. with the DON concerning the above for resident 34 revealed:*The financially responsible party should have signed for the $300.00.-It was withdrawn from the resident's account on 4/9/19.-The DON was the one who had signed for the money.-The resident or financially responsible party had never signed.-That left a balance in the account of $41.91.Interview on 7/17/19 at 10:50 a.m. with the administrator of the medical center regarding the above for resident 34 revealed:*He had no expectations about the recliner, because he had just learned about it five minutes ago.*He believed there had been no abuse of funds.-He trusted the DON.*He stated as a result of this in the future he would expect better documentation.Record review of the Resident Trust Account document for resident 34 revealed:*On the resident name line:-Her name was handwritten in.*On the Resident/Legal representative line:-It had been signed by her husband.-It had not been dated.Review of the reviewed/revised 7/10/18 Resident Trust Accounts policy revealed:*I. Purpose:1.3 To assure compliance with Federal and state regulations for handling of resident trust Account.II. Policy:2.1(NAME)Care Center Vermillion shall give each resident the option of maintaining a Resident Trust Account, to be managed by administration.III. Procedure:3.2 Each resident with money in the Resident Trust Account shall have a personal account sheet showing all transactions on their account. 3.5 Resident's may withdraw money from their trust account by contacting the receptionist, social worker, administration, or nursing staff who keep a record of each transaction. 3.8 Receipts will be given for all transactions, deposits, and withdraws to the resident/responsible family member. The accountant will retain a copy of all receipts. The provider had not followed their policy.

Based on record review and interview, the provider failed to appropriately investigate an injury from an unknown source for one of one sampled resident (57) who was dependent on staff to meet her mobility needs, and who had been assessed for bruises on both of her hands. Findings include: 1. Review of resident 57's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She was dependent upon the staff to assist her with all activities of daily living (ADL). -That had included bed mobility, transfers, toileting, personal hygiene, and bathing. *At times she had increased confusion and could not always voice her needs, thus dependent upon the staff to anticipate her needs. *She was dependent upon the staff to ensure her skin was assessed weekly and remained free from injury. Review of resident 57's interdisciplinary progress notes from 5/26/19 through 7/15/19 revealed: *On 7/4/19 at 6:34 a.m. a skin risk assessment was completed. -The resident had a bath that morning. -The nurse had assessed her skin and noted a bruise on both of her hands and right forearm. -There was no documentation to support: --The size, color, and discomfort level of those bruises. --If an incident report and investigation had been initiated to rule out abuse and support how she had received those bruises. --If the family and physician had been notified of those bruises. *On 7/5/19 at 11:07 a.m. the Minimum Data Set assessment nurse had documented on her quarterly assessment for dates 6/27/19 through 7/3/19. -There was no documentation on her skin assessment to support she had bruises on both of her hands and right forearm. *On 7/11/19 at 10:04 a.m. her skin risk assessment was completed. -The nurse had documented fading bruising to both of her hands and forearm. *There was no documentation to support: -An investigation was completed by the nursing department or interdisciplinary care team to support how those bruises had occurred. -The family and physician were notified that day and had been aware of those bruises. Interview and medical record review on 7/17/19 at 3:10 p.m. with licensed practical nurse (LPN) I regarding resident 57 revealed and confirmed: *Those bruises would have been caused from an unknown origin and should have been investigated to identify the cause. *There was no documentation to support an incident or investigation had been initiated on those bruises. Interview on 7/17/19 at 3:56 p.m. with the director of nursing confirmed the above interview and record review with LPN I. They would have followed the South Dakota Department of Health guidelines for completing and reporting an investigation on an injury of an unknown source. They had not developed a separate facility policy and process for completing and reporting incidents of concern.

Preceptor: Based on observation, testing, interview, and record review, the provider failed to maintain an environment that was free of accident hazards including: *Hazardous hot water temperatures as high as 138.2 degrees Fahrenheit (F) in three of three areas (north, south, and west wings) in the facility. *Chemicals and medications unattended in the special care unit (SCU) accessible to residents, including those residents with cognitive impairment. Findings include: 1. Observation and testing of water temperatures on 1/29/13 in the following areas revealed: *The bathroom sink in resident 2's room at 7:18 a.m. on the north wing was immediately 136.9 degrees F upon testing. *The bathroom sink in resident 8's room at 7:30 a.m. on the west wing was 136.4 degrees F. *The bathroom sink in resident 26's room at 7:32 a.m. on the south wing was 138.2 degrees F. *The hall sink at 8:00 a.m. on the west wing was 135.5 degrees F. *The bathroom sink in a resident's room 144 at 8:03 a.m. on the west wing was 135.1 degrees F. *The bathroom sink in a resident's room 150 at 8:06 a.m. on the west wing was 135.1 degrees F. *The hall sink at 8:17 a.m. at the nurses' station was 138.2 degrees F. *The hall sink at 8:20 a.m. on the north wing special care unit (SCU) was 135.8 degrees F. Immediately upon notification of the hazardous hot water temperatures on 1/29/13 at 8:31 a.m. to the administrator, director of nursing, and the plant manager, a plan was put in place to correct the conditions. The plan included: *The temperatures had been lowered to 125 degrees F on the hot water meter dial approximately five minutes before the notification per the plant manager. *The administrator directed the plant manager to reduce the temperature to 115 degrees F. Observation and testing of water temperatures on 1/29/13 in the mechanical room located on the south wing revealed: *At 8:40 a.m. the hot water meter dial located on the hot water storage tank was set at 125 degrees F. -The plant manager adjusted the hot water meter dial located on the hot water storage tank to 115 degrees F. -According to the thermometer located on the top of the hot water storage tank the temperature was at 140 degrees F. -According to the digital display thermometers on three on-demand water heaters located above the hot water storage tank the temperatures were set at 140 degrees F. *At 8:50 a.m. the hot water storage tank temperature was at 133.5 degrees F. -The three on-demand water heaters were set at 140 degrees F. *At 8:51 a.m. the hot water storage tank temperature was at 131.5 degrees F. *At 8:52 a.m. the hot water storage tank temperature was at 129.5 degrees F. Observation and testing of water temperatures on 1/29/13 in the SCU's hand sink in the hallway next to the entrance doors revealed: *At 8:53 a.m. the temperature was 133.7 degrees F. *At 8:59 a.m. the temperature was 138 degrees F. On 1/29/13 at 9:02 a.m. an announcement was made by the plant manager via the provider's intercom system to all staff and residents to not use the hot water until further notice. Observation and testing of water temperatures on 1/29/13 in the mechanical room located on the south wing revealed: *At 9:02 a.m. the three on-demand water heaters were set at 130 degrees F. *At 9:03 a.m. the three on-demand water heaters were adjusted by the plant manager to 120 degrees F. -The hot water storage tank temperature was at 122.5 degrees F. *At 9:04 a.m. the three on-demand water heaters were set at 120 degrees F. -The hot water storage tank temperature was at 118.9 degrees F. *At 9:06 a.m. the three on-demand water heaters were set at 120 degrees F. -The hot water storage tank temperature was at 117.5 degrees F. *At 9:08 a.m. the hot water storage tank temperature was at 116.6 degrees F. *At 9:09 a.m. the hot water storage tank temperature was at 116.2 degrees F. Observation and testing of water temperatures on 1/29/13 at 9:10 a.m. in the SCU's hand sink in the hallway next to the entrance doors revealed a temperature of 135.8 degrees F. Observation and testing of the hot water temperatures on 1/29/13 at 9:15 a.m. by the main nurse's station hand sink on the north wing revealed a temperature of 111.9 degrees F. Observation and testing of the hot water temperatures on 1/29/13 at 9:17 a.m. in the SCU's hand sink in the hallway next to the entrance doors revealed a temperature of 123.8 degrees F. On 1/29/13 at 9:22 a.m. an announcement was made by the plant manager via the provider's intercom system to all staff and residents that the hot water was available for use. Interview on 1/29/13 at 8:36 a.m. the plant manager stated "Not keeping regular logs (of water temperatures) and will be keeping daily logs." Review of the provider's temperature monitoring log forms revealed no temperatures had been recorded for 2012 and January 2013. Only checks and lines were recorded on the water temperature spaces indicating temperatures had been taken. Preceptor: 2. Observation on 1/29/13 at 8:00 a.m. and 11:45 a.m. and on 1/30/13 at 9:00 a.m. revealed: *A bucket on top of the counter contained a spray bottle labeled "Ecolab multi-purpose quat cleaner" (photo 1 and 2). *Residents had been sitting at the dining room table approximately three feet from the bucket and spray bottle. *The SCU had residents that ambulated independently in the SCU. *The bucket had been easily accessible for any residents that had walked by it. 3. Random observation on 1/30/13 of resident 12's room revealed: *At 8:45 a.m. there had been a bottle of Zeasorb (a medicated powder) sitting on her night stand by her bed and her recliner. *At 1:45 p.m. Zeasorb was still on her night stand. She had been resting soundly in her recliner by the night stand. 4. Observation on 1/29/13 at 6:45 p.m. revealed medication aide (MA) H: *Had bottles of Tylenol, Senna plus, milk of magnesia, Metamucil, and calcium setting on top of the medication cart while he was administering medications to residents in the SCU unit. There was a plastic medication cup that contained some red liquid also setting on the top of the medication cart. *Left the medication cart unattended and out of eye sight when he walked down to resident room 120 to administer medications to a resident. *There were residents with cognitive impairments, surveyors, and staff present in the area of the medication cart. Interview at that time with MA H revealed: *He usually did not leave medications on top of the medication cart when it was unattended. *The red liquid was Depakote (medication to control seizure activity) he planned to administer to a resident. The plastic medication cup also should not have been left setting on the top of the medication cart.