Every finding on record at Sanford Chamberlain Care Center

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 residents identified as at risk for elopement (leaving the facility without staff knowledge) when one of one sampled resident (22) crawled out a window, and two of two sampled residents (51 and 52) exited the facility without the staff's supervision. Findings include: 1. Review of the provider's 11/26/25 SD DOH FRI report regarding resident 22 revealed on 11/26/25 around 3:15 p.m., she was observed walking past the kitchenette window outside the building by cook P. [NAME] P immediately notified licensed practical nurse (LPN) K, who then went to verify resident 22 was not in her room. Upon entering resident 22's room, cook P noticed resident 22 window was open, and her window screen was off the window lying on the floor. [NAME] P went and notified long term care (LTC) activities G of the elopement, who then notified minimum data set (MDS) coordinator V and licensed social worker (LSW) U. LSW U, executive assistant (EA) E, MDS coordinator V, and LTC activities G exited the facility to search for resident 22. At 3:40 p.m., LTC activities G notified MDS Coordinator V that she had found resident 22 walking past a housing development and heading toward the Lutheran church, which was one block from the facility. LTC activities G remained with resident 22 who was wearing two sweaters, with a flannel long sleeve shirt, blue jeans, and tennis shoes. When MDS coordinator V and LSW U arrived at resident 22's location LTC activities G returned to the facility. Resident 22 became hostile towards MDS coordinator V and LSW U and resident 22 continued walking and they continued to follow her. The police were notified of resident 22's elopement at 3:26 p.m., and they arrived at the apartment complex and tried convincing resident 22 to return to the facility. Resident 22 refused the police officer's advise multiple times. MDS coordinator V called LPN K at 4:10 p.m. as she had a good rapport with resident 22 and asked for her assistance with resident 22. LPN K was able to convince resident 22 to get into her vehicle, and go to the emergency room (ER) to get assessed since resident 22 was outside in the cold. The outside temperature was in the upper 30s. While at the ER resident 22 had her alcohol level drawn, which was within normal limits. Former director of nursing (DON) C, executive director (ED) D, and resident 22's primary physician was notified of elopement and of the resident 22's condition. Resident 22 returned to the facility at 6:30 p.m. with LPN K after being discharged from the ER with no injuries or adverse side effects. MDS coordinator V and former DON C initiated fifteen-minute visual checks on resident 22 to ensure her safety due to the cold weather and inability to get ahold of resident family members. Resident 22, they were to notify the Tribal Police and the facility so they could help 2. Review of resident 22's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included epilepsy (a chronic neurological disorder characterized by recurrent, unprovoked seizures), anxiety disorder, borderline personality disorder (severe emotional instability, impulsive behaviors, and deeply unstable relationships) post-traumatic stress disorder (mental health condition triggered by experiencing or witnessing a terrifying or life-threatening event), bi-polar disorder (a mental health condition that causes extreme, cyclical shifts in mood, energy, and activity levels), alcohol abuse, and weakness. Her care plan indicated Behavioral symptoms focus of attempts to elopement at times from facility and on outings initiated on 8/13/25. With a goal of she will not elope from the facility or on outings until next review. Interventions initiated on 11/28/25 educate about hazards or leaving during severe weather changes (below 20 degrees, high heat temps, lightning, tornado warnings/watches, etc.) and understand risks if were to leave or elope from facility, her care plan identifies resident is not to be left at appointments due to her risk of leaving, and all outings need to be approved by her family. Educate her regarding outings with family, appointments etc. about signing out of facility, signing bed-hold policy, getting medications sent with if leaving with family. Notify [NAME] PD if resident elopes and unable to find or get her to willingly come back to facility. Will become hostile at times when approached and does not want to come back to facility. Take to ER as needed for evaluation if questioning intoxication, injuries, or other health issues per police department or MD [medical doctor] recommendations. 3. Observation and interview on 7/15/26 at 12:28 p.m. with resident 22 in her room regarding her elopement revealed she was upset on 11/26/25 when she removed the screen from the window in her old room, opened the window, and climbed out of the window. The facility had removed the window handles a day or so after her elopement to prevent her from opening the window. Her current room had no window handles on the window, and the lock on the window frame was not locked. The window was tall and could open outwards away from the building. 4. Interview on 7/15/26 at 3:30 p.m. with cook P regarding resident 22's elopement revealed he was standing in the kitchenette doing dishes and he observed resident 22 walk past the window outside wearing a red checkered coat. He notified LPN K of the resident being outside. LPN K did not think that resident 22 was outside. [NAME] P went to the activities room at the end of the hallway and observed resident 22 walking on the road. When he walked past resident 22's room the window screen was out of the window, and the window was open. 5. Interview on 7/16/26 at 7:17 a.m. with LTC activities G regarding resident 22's elopement revealed twenty minutes before resident 22's elopement, she had delivered mail to resident 22, and she was in a good mood and had no complaints. LPN K notified all staff in the front of the building of resident 22's elopement on 11/26/25. Resident 22's window and all other window handles were removed after resident 22's elopement. 6. Interview on 7/16/26 at 7:29 a.m. with EA E regarding resident 22's elopement revealed she and LSW U took vehicles out to look for resident 22 following her elopement and law enforcement was notified. LTC activities G had located resident 22 by the church and resident 22 had refused to come back to the facility. EA E returned to the facility and asked LPN K to help get resident 22 to return to the building. EA E did not complete any education following resident 22's elopement. 7. Interview on 7/16/26 at 7:40 a.m. with LSW U revealed a staff member who she could not recall had notified her of resident 22's elopement. Resident 22 was found by the church and LSW U who had been out looking for her, encouraged resident 22 to return to the facility. She remained with resident 22 outside the church until resident 22 was taken to the ER. She was unsure if the window handles were still on resident 22's window when she eloped on 11/26/25. LSW U was working on a referral for resident 22 to be transferred to a different facility that could meet her needs. LSW U received education regarding the elopement policy following resident 22's elopement. 8. Interview on 7/16/26 at 9:33 a.m. with MDS coordinator V regarding resident 22's elopement revealed resident 22 had exited out her window on 11/26/25 and MDS coordinator V searched the surrounding area in her vehicle for resident 22. She received a call from LTC activities G that resident 22 was found and refused to return to the facility. LPN K came and convinced resident 22 to go to the ER, where she was evaluated. Following resident 22's elopement, the facility added chains and a lock block to resident 22's window so the window could only open so far. She was unsure if the window handle was on resident 22's window at the time of her elopement. The facility started 15-minute visual checks on resident 22 after her elopement, but MDS coordinator V was unsure when those ended. She thought the staff working on 11/26/25 were educated that day on elopements and the facility's procedures if they occurred. She completed the elopement education in February of 2026. 9. Interview on 7/16/26 at 10:25 a.m. with LPN K regarding resident 22's elopement revealed she drove to the site where resident 22 was located on 11/26/25. LPN K helped resident 22 calm down and offered her a ride in LPN K's vehicle to the ER to be evaluated. She remained with resident 22 until she was discharged from the ER and back at the facility. Resident 22 had calmed down by the time she returned to the facility. Resident 22 was wearing a hooded sweatshirt, jeans, a T-shirt, shoes and socks. Resident 22 never complained of being cold that day. LPN K thought the facility had provided education regarding elopements following the incident. Resident 22 was receiving behavioral health services. Resident 22 can be delusional at times. Resident 22 does not understand her diagnoses and how serious they are. Resident 22 was placed on 15-minute visual checks after her return to the facility for a couple days, maybe longer. The facility put slide locks on resident 22's windows after resident 22's elopement. 10. Review of the provider's 9/5/25 SD DOH FRI report regarding resident 51 revealed on 9/5/25 at 8:04 p.m., registered nurse (RN) W received a phone call that an elderly person was walking with a cane near the road. RN W notified the former director of nursing (DON) C at 8:05 p.m. that resident 51 had possibly eloped when he was let out of the facility by a certified nursing assistant (CNA) to smoke. Former DON C and licensed social worker (LSW) U arrived at the facility and initiated the facility's elopement protocol immediately after RN W called. The staff searched all the rooms within the facility and the surrounding area. The police were notified that resident 51 was missing and began searching within several miles of the facility. Minimum Data Set (MDS) coordinator V contacted resident 51's emergency contact, who verified that resident 51 was at a family member's house and was safe. The emergency contact informed MDS coordinator V that the family member would bring resident 51 back to the facility the following day, 9/6/25. The resident was not dropped off on 9/6/25, and neither the family member nor the resident contacted the facility. On 9/7/25, former DON C and LSW U identified that resident 51 was still absent, and they, along with LPN O, attempted to call his emergency contact and family member multiple times. After multiple failed attempts, former DON C and LSW U advised LPN O to call the Lower [NAME] Tribal police to request a welfare check on resident 51 at his family member's residence. Resident 51's family member called the facility and informed LPN O that on 9/5/25, resident 51 had gone outside to smoke and had left. He did not tell the family member where he was going, and they did not have any way of contacting him. Adult Protection Services (APS) and case workers were informed on 9/8/25 of resident 51's elopement and his last known location, and the case workers told the facility that if they found resident 51, they would advise him to sign an against medical advice (AMA) form if he did not want to return to the facility. Resident 51 never returned to the facility. The facility updated resident 51's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) to reflect he was an elopement risk and limited all residents' smoking time to 15 minutes while they were outside. The staff would monitor the residents while they were outside to smoke at designated smoking times set at 9:00 am, 2:00 p.m., and 7:00 p.m. The staff were educated regarding the facility changes, the provider's policy was updated, and the facility was going to improve the video surveillance on the sidewalk where the residents smoked. LSW U updated all the residents' assessments who were an elopement risk, and former DON C or the designee would audit the smoking times three times a week for six weeks. 11. Review of resident's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His 8/20/25 BIMS assessment score was 9, which indicated his cognition was moderately impaired. His diagnoses included nicotine dependence and alcohol use. His undated care plan indicated that on 8/15/25, resident 51 was evaluated and approved to go outside unsupervised to smoke and agreed to follow the facility's safe smoking policy. He was allowed to keep cigarettes in his room. On 9/7/25, interventions were added that he had the potential to elope from the facility and was not to leave the facility unattended. The staff were to redirect him when he attempted to go out of the facility doors and remind him that before he left with family, he should inform the nurse. His 8/14/25 physician's order indicated that he was allowed to smoke in the early morning at 7 a.m. and to monitor him for an elopement risk. His 9/28/25 completed elopement assessment indicated that he had an elopement on 9/5/25 and did not present the resident as an elopement risk. 12. Observation on 7/14/26 at 2:14 p.m. of the smoking area revealed resident 30 was outside, sitting in his wheelchair smoking on the sidewalk by the street. No staff were present outside of the building. 13. Observation on 7/14/26 at 2:24 p.m. resident 30 self-propelled his wheelchair to the facility door at the end of [NAME] hallway and pressed a doorbell to be allowed back into the facility. There was a sign on the facility door indicating the allowed smoking times for the residents were 9:00-9:15 a.m., 2:00-2:15 p.m., and 7:00-7:15 p.m. The sign also said, Please remember, residents must be observed by a staff member at all times while they are outside smoking. Please remember to offer the smoke apron as well. 14. Observation on 7/14/26 at 2:25 p.m. revealed that there were two video surveillance camera images on a monitor at the nurses' station. Neither image showed the street where the residents go to smoke or the facility door where resident 30 was at. CNA M let resident 30 back into the facility through the door. No staff entered with the resident from outside. 15. Interview on 7/14/26 at 2:28 p.m. with CNA M revealed that the process for residents who smoke was that they have a couple of residents who go out and smoke when they want to, and the residents just let the staff know when they are ready to come back in by using the doorbell. The door was locked from the outside. The staff does not have to watch them. There are times the residents are supposed to go out for a smoke, but they tell the staff when they want to go, and we let them out. 16. Review of resident 30's EMR revealed he was admitted to the facility on [DATE]. His 5/15/26 BIMS assessment score was 10, which indicated his cognition was moderately impaired. His diagnoses included cerebral palsy (a neurological disorder that permanently affects a person's ability to move, maintain balance, and sustain posture) and anxiety disorder. His 4/13/26 smoking assessment indicated he was able to take himself out to the designated smoking area. He could safely light his own cigarette and smoke the entirety of the cigarette without causing injury to himself. He was able to put out the cigarette and dispose of the cigarette butt in the designated trash can. His care plan did not indicate he smoked, that a smoking assessment was completed, or that he was safe to smoke independently. 17. Observation on 7/15/26 at 12:41 p.m. of the designated smoking area revealed resident 30 was out smoking on the sidewalk with no staff outside monitoring him. 18. Interview on 7/16/26 at 1:21 p.m. with DON B revealed LSW U completed the resident's elopement risk assessments upon admission. If a resident smoked, the resident was offered nicotine patches, and a physician's order would be requested. If a resident was identified as an elopement risk and someone who smoked, they were not able to go outside since January 2026. The designated smoking times were 9:00 a.m., 2:00 p.m., and 7:00 p.m., and were to be used by the residents who currently reside in the facility. The residents were allotted 15 minutes to smoke, but the current residents who smoke did not have to be monitored since they did not exhibit any concerns. The staff monitored smoking residents on a case-by-case basis. There were no cameras installed that viewed the designated smoking area. 19. Review of the provider's 9/9/25 smoking education revealed that the staff was educated that there were designated smoking times at 9:00 a.m., 2:00 p.m., and 7:00 p.m., effective immediately. These times were not optional and must be abided by all staff and residents. The residents would be limited to 15 minutes for each smoking session and must be observed by a staff member for the entire 15 minutes. Observation by the staff was required. Before a resident was allowed to go out to smoke, they were to be screened/assessed by former DON C or MDS coordinator V. The residents must be offered the smoke apron when they go out to smoke, and they were to smoke off the facility property, near the sidewalk by the road. When a resident was let out to smoke, the staff were to communicate who was going to monitor that resident. The education included the facility's smoking procedure and policy. indicated that 51 out of 60 nurses, CNAs, and certified medication assistants (CMAs) completed the education in person or by phone. 20. Review of the provider's reviewed 1/16/25 Safe Smoking Assessment revealed Purpose to provide an assessment to assess resident safety with smoking or tobacco use. To have a protocol for assessment and re-assessment. Each resident upon admission will be asked if they wish to smoke (including electronic cigarettes) or use tobacco products while a resident in long-term care. If the resident chooses to smoke, the following will occur: an assessment for safety while using tobacco products will be completed by occupational therapy or designated staff upon admission. Following the assessment the interdisciplinary team (IDT) will collaborate on the findings of the assessment and determine the recommendations for safety use of tobacco use. Resident and/or representative will be notified of final recommendations. Staff will be notified of the recommendations. A re-assessment will be completed on a quarterly and as needed basis (change of condition, non-compliance, safety issues identified) for continued assessment of safety with smoking or use of tobacco products. Ongoing monitoring by staff will occur as to the resident's ability to safely [safe] handle tobacco products and paraphernalia. 21. Review of the provider's 2/5/26 SD DOH FRI report regarding resident 52 revealed that on 2/5/26 at 2:12 p.m., executive director D found resident 52 outside, 75 feet from the main entrance of the facility. The outside temperature was 60 degrees and sunny with no wind. Resident 52 was wearing a long-sleeved shirt, pants, socks, and shoes. He did not have any injuries. He was not previously identified as an elopement risk and was not assigned a WanderGuard (a wearable door alarming device). Resident 52 was brought inside the facility where RN X took his vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate), which were all within normal range, and put a WanderGuard on him. His care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) was updated to indicate he was at risk for elopement and should be redirected by the staff if they found him wandering the facility. The facility's investigation indicated that at the time of resident 52's elopement, the main entrance door was unlocked and not alarmed. Following resident 52's elopement, the main entrance door was to be locked at all times and would alarm when opened. Visitors could call the nurse's station if they needed to enter the building. The staff were reeducated about the facility's elopement procedures and LSW W and DON B held elopement drills on each scheduled shift for five days and then monthly and conducted audits for eight weeks verifying that the facility's main entrance doors remained locked. 22. Observation on 7/15/26 at 8:00 a.m. revealed a sign on the main entrance door indicating the door was locked and that visitors should call the nurse's station to be let into the building. 23. A review of resident 52's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. He had a diagnosis of a neurocognitive disorder with Lewy bodies dementia (a progressive type of dementia affecting memory, thinking, and social abilities, characterized by severe fluctuations in alertness and visual hallucinations. His Brief Interview for Mental Status (BIMS) assessment score was 3, which indicated his cognition was severely impaired. His 2/5/26 care plan indicated he displayed confusion, forgetfulness, and restlessness. The staff should redirect him when he displayed wandering behaviors and remove him from other residents' rooms and unsafe situations. He required the staff's assistance with a gait belt (a waist strap gripped as support for safe mobility and transfers) when ambulating (walking) and supervision when he independently used his wheelchair or walker. His locomotion approach in the care plan read, Needs supervision around facility due to [being a] high fall risk and elopement risk. 24. Interview on 7/16/26 at 9:30 a.m. with administrator A confirmed that when resident 52 eloped on 2/5/26, he was not wearing a WanderGuard and was not considered an elopement risk. He hadn't displayed exit-seeking behavior, and he wasn't walking up and down the hall, she said. She expected that for any residents displaying exit-seeking behaviors, the resident would have been assessed for eloping and have a WanderGuard in place. The staff who observed exit-seeking or wandering behavior should walk with the residents to ensure they are safe, and redirect or distract them by offering an activity, a snack, or a one-to-one visit. 25. Interview on 7/16/26 at 9:38 a.m. with DON B revealed that three of the 42 residents wore WanderGuards. If the residents were observed wandering or trying to leave the building, she expected the staff to redirect them to a purposeful activity. She said resident 52 had worked in the construction industry, so an activity surrounding that which he would enjoy, or something else to capture his interest. 26. Interview on 7/16/26 at 9:48 a.m. with certified nursing assistant (CNA) I revealed that she expected the staff to follow residents who were seen wandering the facility, to talk to them and to redirect them back to coffee or try to engage them in an activity, something they would enjoy. 27. Review of the provider's elopement drill documentation revealed that following resident 52's elopement, 10 drills were conducted in February, followed by five monthly drills held from March through July. For each drill, the staff responded by following elopement drill policies and procedures. DON B documented that the front door was checked 40 times from 2/9/26 through 4/3/26, and each time it was found to be locked and alarmed. 28. Review of the provider's All Staff Meeting notes from 2/17/26 and 2/18/26 indicated that 18 of the 61 staff members attended the meeting, which included a review of the provider's elopement policy and procedures, and that anybody not in attendance was mailed a copy of the elopement policy on 2/20/26. 29. Review of the provider's 7/15/25 Security Alert: Missing Person-Elopement policy revealed that after a resident eloped from the facility, the resident's care plan would be updated to reflect the elopement and to include an appropriate plan of treatment and an elopement prevention plan. The policy indicated the facility's care planning team was responsible for preventing elopements and ensuring the safety of all residents. 30. Review of the provider's 7/15/25 Security Alert: Missing Person-Elopement policy revealed: To protect [a] resident from potential harm by identifying a process to follow when a resident is observed eloping from facility. To protect [a] resident from potential harm by identifying a process to follow when a resident has eloped from the facility. When it is determined a resident's whereabouts are unknown the procedure for elopements will be activated immediately. Any staff member observing an identified wandering resident attempting to leave the facility shall attempt to prevent such a departure. Should the attempt fail, the staff member shall obtain the assistance of other staff members in the immediate vicinity. If none are available, the staff member shall immediately notify administration or the nursing staff that the resident has left the premises and then return quickly to the resident and continue attempting redirect the resident safely back into the building. Staff members are not to leave the resident for any reason if the resident's safety is in immediate danger. A second staff member will assist in escorting resident back to the facility if first staff member is unsuccessful or may call the local law enforcement as the situation warrants.

Based on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent related to resident (36) no receiving her full dose of insulin, resident (38) not receiving her calcium/vitamin D/vitamin K due to incorrect labeling, residents (24 and 37) self-administering a medication with no assessment or orders from the physician. Those observed errors resulted in a medication error rate of 14.29%.Findings include:1. Observation on 7/15/26 at 11:30 a.m. certified medication assistant (CMA) N left Seroquel (an antipsychotic medication) (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions), 50 mg, 1 tab in a medicine cup on resident 24's bedside table to the left of her bed and did not watch her take the medication.2. Observation on 7/15/26 at 11:33 a.m. CMA N put Ipratropium-Albuterol 0.5 milligrams (mg)-3mg/3 milliliter (mL) 1 vial liquid nebulizer medication into the nebulizer machine for resident 37 and then left the room after the machine was turned on by resident 37.3. Review of resident 24's electronic medical record (EMR) indicated she admitted to the facility on [DATE]. Her 7/3/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.Her medication administration record (MAR) indicated she had a physician's order dated 6/25/24 for Seroquel 50 mg, 1 tab by mouth once a day at 12:00 p.m. There were no special instructions noted on this order to indicate that this medication was to be self-administered.Her diagnoses include anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), post-traumatic stress disorder (PTSD) (is a mental health condition that can develop after a person experiences or witnesses a traumatic event), epilepsy (s a chronic brain disorder characterized by two or more unprovoked seizures that are sudden bursts of abnormal electrical activity in the brain that can cause temporary changes in behavior, muscle control, awareness, or sensations), weakness, and chronic pain.She had a physician's order dated 10/13/25 that indicated that resident 24 may self-administer Triamcinolone Acetonide Cream (TAC) (a topical corticosteroid used to treat skin inflammation and itching), Lidocaine cream, TUCKS pads (pre-moistened medicated cooling pads relieves irritation, itching, burning and swelling), Estradiol cream (a prescription topical estrogen used to treat vaginal and genitourinary symptoms caused by low estrogen levels), Nystatin powder (a topical antifungal medication used to treat skin and mucous membrane infections caused by yeast), and Flonase (a corticosteroid that reduces inflammation in the nasal passages).Her 4/23/26 self -administration of medication assessment indicated the list of medications the resident would like to self-administer included TAC cream, Lidocaine cream, TUCKS pads, Estradiol cream, Nystatin powder, and Flonase. In this assessment, resident 24 voiced that she did not want to administer pill forms as she might spill, drop, or mess up. She had some difficulties with the use of her left arm d/t ROM limitations and a weak hand grip.4. Review of resident 37's EMR indicated he admitted to the facility on [DATE]. His 6/12/26 BIMS assessment score was 15, which indicated his cognition was intact.His MAR indicated a physician's order dated 5/11/2026 for Ipratropium-Albuterol solution for nebulization 0.5 mg-3 mg/ 3 ml, 1 unit dose inhaled 5 times per day. There were no special instructions on this order to indicate that this medication was to be self-administered.His diagnoses included chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), hemiplegia affecting right dominant side (paralysis affecting one side of the body), presbyopia (loss of near vision), emphysema (a chronic lung condition and a form of COPD caused by gradual damage to the alveoli, the tiny air sacs responsible for gas exchange), dysphagia (difficulty swallowing, which may involve trouble getting food or liquids from your mouth to stomach), and aphasia (a language disorder that affects the ability to speak, understand, read, or write).He had a physician's order dated 9/29/2015 that indicated resident 37 may self-administer Refresh Optive eye drops. He had a physician's order dated 10/7/2015 that indicated her may self-administer ProAir Hydrofluoroalkane (HFA) inhaler (a pressurized canister that contains medication mixed with liquid HFA, a propellant used in modern metered-dose inhalers).5. Observation on 7/15/26 at 12:03 p.m. of registered nurse (RN) J administering Novolog FlexPen (insulin aspart, a rapid-acting insulin in a prefilled pen. A needle attaches to the pen for medication administration) to resident 36. The ordered dose was 5 units (u). RN J injected the insulin into the resident's abdomen by pressing the medication dial at the end of the FlexPen. One second was counted from the start of the administration (when the pen is placed against the resident's stomach and the metered dose dial is pressed down) to the time the insulin pen was removed. She removed the pen from the resident's abdomen prior to the medication being fully dispensed into the resident's abdomen, as evidenced by when she pulled the insulin pen away from the resident; the insulin then expelled out of the needle onto the resident's skin.6. Review of resident 36's electronic medical record (EMR) indicated she admitted to the facility on [DATE]. Her 5/29/26 BIMS assessment score was 10, which indicated her cognition was moderately impaired.Her MAR indicated a 4/15/24 physician's order for Novolog FlexPen U-100 Insulin (insulin aspart U-100) 100unit/3mL, give 5 units subcutaneously with meals at 8:30 a.m., 12:00 p.m., and 5:30 p.m.Her diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar that causes damage to multiple peripheral nerves, usually leading to pain, numbness, or tingling in the hands and feet), chronic kidney disease stage 3 (moderate kidney damage indicating reduced kidney function), hypo-osmolality (low concentration of particles in the blood, usually from having too much water compared to electrolytes), and hyponatremia (sodium levels are low in the blood), chronic systolic (congestive) heart failure (a long-term condition where the heart's left ventricle weakens and can't pump blood effectively, leading to fluid buildup in the body), rheumatic mitral stenosis (a narrowing of the mitral valve caused by rheumatic fever, which restricts blood flow from the left atrium to the left ventricle and can lead to breathing difficulty and fatigue), nonrheumatic mitral insufficiency (also called mitral regurgitation, is when the mitral valve doesn't close properly allowing blood to leak backward from the left ventricle into the left atrium), and pulmonary hypertension (high blood pressure in the arteries that carry blood from the right side of the heart into the lungs, usually caused by narrowed or blocked lung vessels).7. Interview on 7/15/26 at 3:16 p.m. with CMA N revealed that she did not usually leave medications with residents, but if she did, then they should have a self-administer order. She did not know how to tell if a resident had a self-administer order on the MAR or if there was another place to look. If she did not know what to do, she looked at the previous worker's documentation to see what she should do.8. Interview on 7/15/26 at 4:28 p.m. with RN J revealed her process for insulin administration was that she would wait three seconds before removing the insulin pen from the resident to ensure the resident receives the full dose. She agreed that if the insulin was expelled onto the resident's skin when removing the needle from the injection site, the resident did not get her full ordered dose. RN J stated that if the resident did not get her full dose, she would tell the director of nursing (DON), monitor the patient, and notify the provider.9. Observation on 7/16/26 at 7:42 a.m. of CMA H during medication pass for resident 38 revealed two medication blister packs (a card with medications sealed in individual plastic bubbles) for the morning dose for LDR Vit C600+D3/MINS CHEW 60 EACH. Generic for LDR VIT C600+D3/MINS CHEW CENTURY, each containing one-half tab. CMA H prepared to give the morning dose by removing each half tab from the medication blister packs into a separate paper cup.10. Interview and EMR review on 7/16/26 at 7:50 a.m. with CMA H revealed a physician's order for Calcium 500 milligram (mg)-Vitamin D3 1000 u - Vitamin K 40 micrograms (mcg) chewable tablet 1 tab twice a day. CMA H acknowledged that the medication blister pack label and the physicians' orders in the EMR did not match. CMA H stated that she did not know the process for reporting that type of error, but I can tell the nurse or the DON. When we complete the medication card changeover to the new packs, the staff are supposed to double-check they match the MAR and previous cards.11. Interview on 7/16/26 at 7:56 a.m. with DON B revealed that she expected the medication cards would match the physicians' order on the MAR.12. Review of resident 38's EMR indicated she admitted to the facility on [DATE]. Her 4/17/26 BIMS assessment score was 12, which indicated her cognition was moderately impaired.Her diagnoses included weakness, age-related osteoporosis (a condition where bones become thin, weak, and more likely to break easily) without current pathological fracture, and chronic kidney disease stage 3 moderate kidney damage (indicating reduced kidney function).13. Interview on 7/16/26 at 1:21 p.m. with the DON B revealed she expected the residents to have a self-administration assessment completed by the minimum data set (MDS) coordinator V and an order from the residents' primary care provider before leaving the medications with the residents to self-administer. The orders for self-administration for the CMA's and nurses to see would be listed under the special instructions under each medication. DON B confirmed that residents 24 and 37 did not have self-medication administration orders for the observed Seroquel and Ipratropium-Albuterol nebulizer medications. She expected that the staff would stay with the residents until the medication was taken completely. She stated that a resident not receiving their full ordered dose of insulin, the resident's physician not being notified, and the lack of increased monitoring for resident 36 after the medication error were considered a significant medication error.14. Interview on 7/16/26 at 3:15 p.m. with DON B revealed that the label on the medication blister pack was incorrect for resident 38's calcium/vitamin D/vitamin K order. She expected the medication to have the correct label on it.15. Observation on 7/16/26 at 3:25 p.m. the medication blister packs for resident 38's calcium/vitamin D/vitamin K order were still in the medication cart.16. Review of the provider's reviewed 3/2/26 Medication Errors policy revealed the location will have medication error rates of five percent or less and those residents are free of significant medication errors. When a medication error occurs, it will be reported promptly to the attending physician, resident, and or responsible party and documented in the SAFE Event Reporting application. Definitions from the State Operations Manual Significant Medication Error one which causes the resident discomfort or jeopardizes his or her health and safety. Wrong Dose/Amount when the resident receives an amount of medication that is greater than or less than amount ordered by the prescriber.17. Review of the provider's reviewed 10/31/25 Resident Self-Administration of Medication policy revealed Purpose: to determine if the resident can safely self-administer medications. To identify which medications may be safely self-administered. Procedure: 1. Complete the resident self-administration of medications UDA to determine if the resident can safely administer medications and to create a plan to assist the resident to be successful in this process. The interdisciplinary team must determine whether each resident who expresses a desire to self-administer medications can do so safely. 2. The interdisciplinary team will determine if the resident has any specific educational needs or if he or she requires any accommodation to self-administer medications(s). 3. The interdisciplinary team will also determine where medications will be stored. 4. The interdisciplinary team will determine the location where the medication will be self-administered. Medication cannot be left within reach of another resident and must be under the control of the resident who is self-administering. 5. The interdisciplinary team will determine who will document the medication administration.18. Review of the provider's reviewed 3/30/26 Medication: Administration Including Scheduling and Medication Aides revealed The resident has the right to self-administer medications if the interdisciplinary team determines that this practice is safe for the individual resident and is documented in the care plan. An order from the provider is required for this activity. Procedure: Follow the Six Rights: right medication, right dose, right resident, right route, and right documentation. Perform three checks: read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication.

Based on observation, interview, record review, and policy review, the provider failed to notify the physician of one of two sampled residents (2) who had unplanned significant weight loss (a loss of 5% (percent) of body weight in 30 days, 7.5% in 90 days, or 10% in 180 days).Findings include:1. Observation on 7/14/26 from 9:52 a.m. to 2:32 p.m., resident 2 was asleep in bed.2. Interview on 7/14/26 at 2:32 p.m. with certified nursing assistant (CNA) I revealed that she refused breakfast and lunch that day. Resident 2 typically slept in during the day and will wake up in the evening. She slept in during the day and will wake up in the evening.3. Observation on 7/14/26 at 4:24 p.m., resident 2 was waking up but still lying in bed in the dark.4. Review of resident 2's EMR revealed she admitted to the facility on [DATE]. Her 6/19/26 BIMS assessment score was 0, which indicated her cognition was severely impaired.Her diagnoses included mild neurocognitive disorder due to known physiological condition with behavioral disturbances (a noticeable decline in cognitive abilities such as memory, attention, or problem-solving), psychotic disorder (a serious mental health condition characterized by a significant loss of contact with reality), unspecified disorder of adult personality and behavior (a mental health condition marked by enduring, inflexible patterns of thinking, feeling, and behaving that significantly deviate from cultural norms, cause distress or impair daily functioning), unspecified intellectual disabilities (significant limitations in intellectual functioning), depression, non-infective gastroenteritis and colitis (inflammation of the stomach, intestines, or colon that is not caused by an infection), and gastric ulcer without hemorrhage or perforation (an open sore on the stomach lining).Her weight on 7/12/26 was 121 lbs. Her weight on 4/12/26 was 134.5 lbs. This was a 10.04% weight loss in 90 days. Her weight on 7/12/26 was 121 lbs., and on 1/12/26 was 138.5 pounds (lbs.). This is a 12.64% weight loss in 180 days.Her documented weight on 5/17/26 was 127 lbs. This was a weight loss of 4 lbs. since the documented weight of 131 lbs. on 5/13/26. Her weight on 5/10/26 was 124.5 lbs., and her weight on 4/27/26 was 137 lbs., showing a weight loss of 12.5 lbs. Her weight on 2/11/26 was 130 lbs., on 2/10/26 135.5 lbs., and on 2/9/26 131.5 lbs., indicating weight variances of 4 or more lbs.Her 4/16/24 physician diet orders are for dysphagia (difficulty or discomfort in swallowing) diet, soft foods and with thin liquids.Her 6/26/26 care conference documentation indicated that licensed social worker (LSW) U, long-term care (LTC) activities G, minimum data set (MDS) coordinator V, and resident 2's power of attorney (POA) (someone designated on a legal document to act on behalf of a resident) were in attendance. They reviewed her diet and her weight loss and discussed options to see about getting the resident to gain weight, as she refused her supplements and was becoming more picky with what she eats. Resident 2's POA said she could bring resident 2 some snacks and have nursing regulate it more so resident 2 does not eat them all in one sitting. MDS coordinator V will talk with the dietician about a 'peanut butter cup' therapy to see if that might help some. The staff will continue to monitor her diet/weights.Her 6/30/26 nutritional risk progress notes indicated that the resident has been refusing her chocolate coffee (chocolate Ensure in coffee); she is being offered Magic Cups ice cream supplement at the noon meal. Staff reports that the resident's acceptance of this supplement is variable and inconsistent.5. Observation on 7/15/26 at 12:15 p.m. registered nurse (RN) J revealed that she woke resident 2 up for her medications and asked her if she wanted lunch. Resident 2 refused lunch.6. On 7/15/26 at 2:45 p.m., a request was made for documentation to resident 2's physician about weight variances. No documentation was received.7. Interview on 7/16/26 at 1:21 p.m. with director of nursing (DON) B revealed that residents' weights were checked weekly, and if they have a 4 lb. difference, then the nursing staff would notify a physician. If the weight is a significant loss, then the provider is notified by being seen directly in the clinic or, if more urgent, in the emergency room (ER).8. Review of the provider's reviewed 9/30/25 Weight and Height policy revealed purpose to ensure that the resident maintains acceptable parameters of nutritional status regarding weight. To report changes in a resident's clinical condition (significant weight change) to physician and family and/or resident. To accurately measure weight and height. To monitor weight loss or gain in a resident. Weight procedure: the licensed nurse should notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. Significant weight change is defined as five percent in 30 days, 7.5 percent in 90 days, and 10 percent in 180 days.

Based on record review, interview, and policy review, the provider failed to ensure two of two sampled residents (2 and 22) had a Preadmission Screening and Resident Review (PASRR) II completed.Findings Include: 1. Review of resident 22's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included bipolar disorder, post-traumatic stress disorder (PTSD) and depression. Her [DATE] Brief Interview for Mental Status (BIMS) assessment score was 14 which indicated she was cognitively intact. She had a Department of Social Services (DSS) letter dated [DATE] which indicated she had been approved for 365 days for admission or continued stay to a nursing facility effective as of the date of this letter. At that time, you may be appropriate for discharge to a lower level of care. As a result of the review, the following recommendations are made: Initiate mental health services-this may include psychiatric medication management and supportive therapy. A PASRR resident review was completed for resident 22 by licensed social worker (LSW) U on [DATE] for the facility on the screening form it was noted the end date of current PASRR was [DATE]. The screening indicated resident 22 had serious mental illness of bipolar disorder, PTSD, and depression. She was referred to Maximus (a clinical service that evaluates individuals applying for or residing in Medicaid-certified nursing facilities) on [DATE] at 10:36 a.m. for resident review. Maximus notice dated [DATE] to LSW U indicated resident 22 PASRR Level I Review determination had expired. The letter stated the Level I screen expired because your health care professional did not complete the Level I screening form and/or submit requested documentation within the required timeframe. 2. Interview on [DATE] at 2:00 p.m. with LSW U revealed she completed the PASRR paperwork for the facility. She had received the PASRR expiration letter for resident 22 and had submitted a PASRR Level I review on [DATE]. Resident 22 was referred to Maximus on [DATE] for a Level II review and she never received papers back from Maximus. Typically, Maximus sends the determination Level II letter to the facility (or to her) after the required information is sent to Maximus. 3. Follow-up interview on [DATE] at 7:48 a.m. with LSW U revealed she had heard back from Maximus and they want her to resubmit the Level I paperwork for resident 22 again. She is unsure why they did not receive the paperwork for resident 22 in 2024. She had not followed up on the letter. 4. Interview on [DATE] at 9:56 a.m. with director of nursing (DON) B revealed she would expect LSW U to complete and submit the PASRR Level I forms and resident reviews and take care of any recommendations made for the residents. 5. Review of resident 2's EMR revealed she admitted to the facility on [DATE]. Her [DATE] BIMS assessment score was 0, which indicated her cognition was severely impaired. Her diagnoses included mild neurocognitive disorder due to known physiological condition with behavioral disturbances (a noticeable decline in cognitive abilities such as memory, attention, or problem-solving), psychotic disorder (a serious mental health condition characterized by a significant loss of contact with reality), unspecified disorder of adult personality and behavior (a mental health condition marked by enduring, inflexible patterns of thinking, feeling, and behaving that significantly deviate from cultural norms, cause distress or impair daily functioning), unspecified intellectual disabilities (significant limitations in intellectual functioning). She had a Department of Human Services (DHS) letter dated [DATE], which indicated she had been approved for continued staff-provided services by the facility for 120 days, effective [DATE]. As a result of the review, the following recommendations were made: Please continue with skilled therapy services and/or restorative nursing services as appropriate. It is also recommended to obtain a psychological evaluation with a full-scale IQ and adaptive testing to assist in determining the most appropriate services to meet your needs. 6. Resident 2's PASRR level II paperwork was requested by the survey team on [DATE] at 10:11 a.m. 7. Interview on [DATE] at 1:56 p.m. with LSW U revealed that she did not submit the PASRR level II until it was requested by the survey team on [DATE]. She was not sure why it was not submitted before this date but said it should have been completed before the approved days expired. 8. Review of the provider's [DATE] Preadmission Screening and Resident Review (PASRR) policy revealed It is the policy to screen all potential admissions on an individual basis. As part of the preadmission process, [NAME] Care Center and Swing Bed will participate in the Preadmission Screening and Resident Review (PASRR) screening process (prescreening and Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition. Based upon the Level I screen, [NAME] Care Center and Swing Bed will not admit an individual with a mental disorder or intellectual disability until the Level II screening process has been completed and the recommendations allow for a nursing facility admission and [NAME] Care Center and Swing Bed's ability to provide the specialized services determined in the Level II screen process, the facility will coordinate with the South Dakota State ASA Nurse Consultant related to the individual needs of the resident as indicated. Annually and with any significant change of status, [NAME] Care Center and Swing Bed will complete the PASRR Level I screen for those individuals identified per the Level II screen requiring specialized services. The facility will report any changes as identified via the screen to the state mental health authority or state intellectual disability authority promptly.

Based on observation, interview, and policy review, the provider failed to maintain resident bathrooms in a clean and well-kept manner, free from damage to flooring, for one of one sampled resident (28). Findings include:1. Observation on 7/14/26 at 8:46 a.m. in resident 28's bathroom revealed a gouge in the flooring near the wall, measuring approximately 12 inches long by one inch wide. The flooring curled up around the edges of the gouge causing an uneven surface. 2. Interview on 7/16/26 at 9:27 a.m. with interim administrator A revealed that she expected the staff to notify the director of nursing or maintenance staff of any damaged flooring in resident rooms. She considered torn bathroom flooring to be a fall hazard for both the residents and the staff, which made it a priority to repair. 3. Interview on 7/16/26 at 9:37 a.m. with director of nursing (DON) B revealed that she considered the torn flooring to be a fall hazard and an uncleanable surface (an area heavily damaged or corroded that traps bacteria in its crevices and cannot be adequately sanitized). She said repair of items that pose a safety hazard should be fixed right away. 4. Interview on 7/16/26 at 9:07 a.m. with plant operations supervisor (POS) F revealed that he did not know the flooring was torn in resident 28's bathroom. He agreed the torn flooring was an uncleanable surface and a fall hazard. He expected the housekeeping staff to notify him as they encountered such situations during daily bathroom cleaning. Any staff member could request maintenance repairs by submitting a Microsoft Teams ticket, paging or calling him, or leaving him a handwritten note. POS F said the maintenance staff address repair requests as time allows, and resident room repairs are typically completed after a resident moves out of the room, before a new resident moves in. Urgent room repairs could be completed when residents were at an activity or a medical appointment, or the resident could temporarily relocate to a different room to avoid disruption of their routine. 5. Interview on 7/16/26 at 9:47 a.m. with certified nursing assistant (CNA) I revealed that she did not know the flooring was torn in resident 28's bathroom. She agreed it was a fall hazard that should have been reported to the maintenance team. We could catch a lift [a mechanical device used to assist residents during transfers to the toilet or a wheelchair] on it, or the resident could catch their foot on it and fall. 6. Review of resident 28's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. She had a diagnosis of unspecified dementia (a group of symptoms affecting memory, thinking, and social abilities) and a 5/1/26 Brief Interview for Mental Status (BIMS) assessment score of three, indicating she had severe cognitive impairment. Resident 28's 5/8/26 care plan indicated she relied on assistance from two staff members to transfer to and from the toilet, bed, recliner, wheelchair, and bath chair. She used her feet to independently propel herself in her wheelchair but required staff assistance to travel longer distances. Her care plan revealed she had a history of falling and that the staff should keep her environment free of clutter. 7. Review of the provider's current Assets Resource Packet revealed that assets (capital and physical properties used for facility operations and resident care, categorized as land improvements, buildings, and fixed or movable equipment) should be repaired or replaced if their condition did not meet code or safety standards.

Based on observation, interview, record review, and policy review, the provider failed to ensure that evaluations for self-administration of medication were completed for two of two residents (24 and 37) whose medications were left at the bedside by CMA N.Findings include:1. Observation on 7/15/26 at 11:30 a.m. certified medication assistant (CMA) N left Seroquel (an antipsychotic medication) (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions), 50 mg, 1 tab in a medicine cup on resident 24's bedside table to the left of her bed and did not watch her take the medication.2. Observation on 7/15/26 at 11:33 a.m. CMA N put Ipratropium-Albuterol 0.5 milligrams (mg)-3mg/3 milliliter (mL) 1 vial liquid nebulizer medication into the nebulizer machine for resident 37 and then left the room after the machine was turned on by resident 37.3. Review of resident 24's electronic medical record (EMR) indicated she admitted to the facility on [DATE].bHer 7/3/26 Brief Interview for Mental Status (BIMS) assessment score was 14, which indicated her cognition was intact.Her medication administration record (MAR) indicated she had a physician's order dated 6/25/24 for Seroquel 50 mg, 1 tab by mouth once a day at 12:00 p.m. There were no special instructions noted on this order to indicate that this medication was to be self-administered.Her diagnoses include anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), post-traumatic stress disorder (PTSD) (is a mental health condition that can develop after a person experiences or witnesses a traumatic event), epilepsy (s a chronic brain disorder characterized by two or more unprovoked seizures that are sudden bursts of abnormal electrical activity in the brain that can cause temporary changes in behavior, muscle control, awareness, or sensations), weakness, and chronic pain.She had a physician's order dated 10/13/25 that indicated that resident 24 may self-administer Triamcinolone Acetonide Cream (TAC) (a topical corticosteroid used to treat skin inflammation and itching), Lidocaine cream, TUCKS pads (pre-moistened medicated cooling pads relieves irritation, itching, burning and swelling), Estradiol cream (a prescription topical estrogen used to treat vaginal and genitourinary symptoms caused by low estrogen levels), Nystatin powder (a topical antifungal medication used to treat skin and mucous membrane infections caused by yeast), and Flonase (a corticosteroid that reduces inflammation in the nasal passages).Her 4/23/26 self -administration of medication assessment indicated the list of medications the resident would like to self-administer included TAC cream, Lidocaine cream, TUCKS pads, Estradiol cream, Nystatin powder, and Flonase. In this assessment, resident 24 voiced that she did not want to administer pill forms as she might spill, drop, or mess up. She had some difficulties with the use of her left arm d/t ROM limitations and a weak hand grip.4. Review of resident 37's EMR indicated he admitted to the facility on [DATE]. His 6/12/26 BIMS assessment score was 15, which indicated his cognition was intact.His MAR indicated a physician's order dated 5/11/2026 for Ipratropium-Albuterol solution for nebulization 0.5 mg-3 mg/ 3 ml, 1 unit dose inhaled 5 times per day. There were no special instructions on this order to indicate that this medication was to be self-administered.His diagnoses included chronic obstructive pulmonary disease (COPD) (a group of lung diseases that block airflow and make it difficult to breathe), hemiplegia affecting right dominant side (paralysis affecting one side of the body), presbyopia (loss of near vision), emphysema (a chronic lung condition and a form of COPD caused by gradual damage to the alveoli, the tiny air sacs responsible for gas exchange), dysphagia (difficulty swallowing, which may involve trouble getting food or liquids from your mouth to stomach), and aphasia (a language disorder that affects the ability to speak, understand, read, or write).He had a physician's order dated 9/29/2015 that indicated resident 37 may self-administer Refresh Optive eye drops. He had a physician's order dated 10/7/2015 that indicated her may self-administer ProAir Hydrofluoroalkane (HFA) inhaler (a pressurized canister that contains medication mixed with liquid HFA, a propellant used in modern metered-dose inhalers).5. Interview on 7/15/26 at 3:16 p.m. with CMA N revealed that she did not usually leave medications with residents, but if she did, then they should have a self-administer order. She did not know how to tell if a resident had a self-administer order on the MAR or if there was another place to look. If she did not know what to do, she looked at the previous worker's documentation to see what she should do.6. Interview on 7/16/26 at 1:21 p.m. with the DON B revealed she expected the residents to have a self-administration assessment completed by the minimum data set (MDS) coordinator V and an order from the residents' primary care provider before leaving the medications with the residents to self-administer. The orders for self-administration for the CMA's and nurses to see would be listed under the special instructions under each medication. DON B confirmed that residents 24 and 37 did not have self-medication administration orders for the observed Seroquel and Ipratropium-Albuterol nebulizer medications. She expected that the staff would stay with the residents until the medication was taken completely. 7. Review of the provider's reviewed 10/31/25 Resident Self-Administration of Medication policy revealed Purpose to determine if the resident can safely self-administer medications. To identify which medications may be safely self-administered. Procedure: 1. Complete the resident self-administration of medications UDA to determine if the resident can safely administer medications and to create a plan to assist the resident to be successful in this process. The interdisciplinary team must determine whether each resident who expresses a desire to self-administer medications can do so safely. 2. The interdisciplinary team will determine if the resident has any specific educational needs or if he or she requires any accommodation to self-administer medications(s). 3. The interdisciplinary team will also determine where medications will be stored. 4. The interdisciplinary team will determine the location where the medication will be self-administered. Medication cannot be left within reach of another resident and must be under the control of the resident who is self-administering. 5. The interdisciplinary team will determine who will document the medication administration.8. Review of the provider's reviewed 3/30/26 Medication: Administration Including Scheduling and Medication Aides revealed The resident has the right to self-administer medications if the interdisciplinary team determines that this practice is safe for the individual resident and is documented in the care plan. An order from the provider is required for this activity. Procedure: Follow the Six Rights: right medication, right dose, right resident, right route, and right documentation. Perform three checks: read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe, and just before administering the medication. Do not leave medication at the bedside or at the table unless there is a specific physician order to do so, and the resident has been evaluated for self-administration.

Based on observation, interview, and policy review, the provider failed to ensure that 1 of 1 sampled resident 17 had his call light in reach on 7/14/26, 7/15/26, and 7/16/26 after he returned from therapeutic leave. Findings include:1. Observation on 7/14/26 at 9:00 a.m. revealed resident 17 in his room in his bed. There was no call light within reach. There was no call light plugged into the wall outlet. Resident 17 stated he was there to recuperate from drinking and from fractures to both of his hips. He stated he could get up and walk around. He stated he did not need a call light. 2. Observations on 7/15/26 at 9:15 a.m. and 7/16/26 at 12:49 p.m. revealed resident 17 was not in his room and there was no call light plugged into the wall outlet near his bed. 3. Observation and interview on 7/16/26 at 12:50 p.m. with certified medication assistant (CMA) H revealed that resident 17's room did not have a call light plugged into the wall near his bed. She stated he had been on therapeutic leave from 7/10/26 to 7/13/26, and his room had been updated with new flooring. She stated his room had been cleared out, but items were brought back into the room, and his call light near the bed was not plugged back into the wall. She stated resident 17 had returned from his leave on 7/13/26 and acknowledged he must not have had a call light since he returned to the facility that day. 4. Interview on 7/16/26 at 1:15 p.m. with registered nurse (RN) J revealed she was not aware that resident 17 had not had his call light in reach since returning from his leave on 7/13/26. She acknowledged that residents should have a call light in reach for assistance at all times. 5. Review of the provider's 7/8/25 call light policy revealed that residents always had a method of calling for assistance.

Based on observation, interview, document review, and policy review, the provider failed to ensure appropriate hand hygiene was performed by one of one observed cook (Q) to meet professional food cleanliness standards. Findings include: 1. Observation of the noon meal on 7/14/26 at 12:13 p.m. revealed cook Q plating meals for the residents in the [NAME] Hall dining room. She stood between a serving table that held the residents' meal tickets and trays and a counter that held steam pans containing polish sausage, sauerkraut, and peas. A bag of hot dog buns sat on the counter near the steam pans. A sink, a box of gloves, and a trash can were next to the counter. Beside the serving table stood a rack of dessert bowls containing pears and potato salad. [NAME] Q was wearing gloves and a hairnet. At 12:22 p.m., cook Q used her left gloved hand to pick up a plate and her right gloved hand to take a hot dog bun from the bag and place it on the plate. She picked up a serving tong with her right hand and placed sausage on the bun, then used a different serving scoop to place sauerkraut on the plate, and a third scoop to place peas on the plate. Each utensil was returned to its steam pan after use. She then used her right hand to retrieve bowls of potato salad and pears from the rack, placing them on the plate she held in her left hand. At 12:24 p.m., wearing those same gloves, she set the plate on the serving table, left the serving line, walked across the dining room to the kitchenette area, opened the refrigerator door, retrieved a bottle of ketchup and a bottle of mustard, set them on the adjacent counter, and closed the refrigerator door. Carrying the ketchup in one hand and the mustard in the other, she walked back to the serving line, set the mustard bottle on the serving table, opened the ketchup bottle and used both hands to squeeze ketchup onto the sausage on the plate she had prepared. She set the ketchup bottle on the serving table, picked up the mustard bottle, opened it, used both hands to squeeze mustard onto the sausage, and set the mustard bottle on the serving table. She picked up the plate and gave it to certified nursing assistant (CNA) L, who took the plate to one of the residents. [NAME] Q removed her gloves, put them in a trash can near the sink, and put on a new pair of gloves without washing her hands. At 12:25 p.m., cook Q began to repeat the plating process. She held a plate with her left gloved hand and used her right gloved hand to retrieve a hot dog bun out of its bag, then access serving tongs and scoops to plate the sausage, sauerkraut, and peas. She retrieved bowls of potato salad and pears from the rack, placed them on the plate, and asked CNA L to put ketchup and mustard on the sausage, saying, I can't because I have gloves on. CNA L did so and took the plate to one of the residents. [NAME] Q picked up another plate, retrieved a hot dog bun out of its bag, and repeated the plating process. After handing the third plate to CNA L, cook Q picked up a pen with her right hand and wrote on a piece of paper by the residents' meal tickets while resting her left hand on the serving table. She set the pen down and turned back to the serving counter, picked up a plate, and used the tongs to retrieve a sausage. She used the serving tongs to hold the sausage in place while cutting it up with a pizza cutter, then plated the sauerkraut and peas before handing the plate to CNA M, who delivered it to one of the residents in the dining room. Between 12:30 p.m. and 12:33 p.m., cook Q prepared three more plates, retrieving the hot dog buns with her right gloved hand. Each time she handed a plate to CNAs L and M, cook Q rested her left hand on the serving table while using her right hand to write on a resident meal ticket. At 12:34 p.m., with those same gloved hands, cook Q reached above the serving counter, opened a cupboard door, retrieved a napkin, and closed the cupboard door. She placed the napkin on a meal tray which contained a plate of food, picked up the tray with both hands, and handed the tray to CNA L. She continued preparing plates without changing gloves or performing hand hygiene. At 12:38 p.m., wearing those same gloves, cook Q picked up a glass covered with saran wrap, removed the saran wrap, picked up the glass with her fingers surrounding the rim of the glass, and set the glass on a meal tray. She resumed the plating process, and after handing the plate to CNA L, she rested her left hand on the serving table and wrote on meal tickets with her right hand. At 12:40 p.m., with the same gloved hands, cook Q reached above the serving counter, opened a cupboard door, retrieved a meal tray, closed the cupboard door, and set the tray on the serving table. She placed silverware on the tray and prepared a plate with sausage, sauerkraut, and peas, then placed a plate cover on the plate and handed the tray to CNA L, who delivered the tray to a resident room. [NAME] Q then write on a meal ticket and resumed the plating process. At 12:43 p.m., cook Q pulled the serving tong and scoops out of the steam pans and placed them all on a single plate to take to the sink. She asked the residents in the dining room if they wanted anything else, and one resident asked for another sausage. [NAME] Q retrieved a hot dog bun from its bag with her right hand, put it on a plate, used the serving tong from the plate of dirty utensils to place sausage on the bun, put the tong back onto the plate of dirty utensils, and walked the plate over to a resident. She returned to the serving counter and loaded all the dishes onto a cart, which she took through the dining area to the kitchenette sink. She removed her gloves at 12:48 p.m. as CNA M told her a resident wanted another sausage. [NAME] Q walked over to the cart where she had placed the steam pans, put a glove on her right hand, picked up a plate and used her right gloved hand to retrieve a sausage from the steam pan. She told CNA M, The tongs are all dirty. This is acceptable, isn't it? That's what we do in the kitchen, and laughed. At 12:50 p.m. she left the kitchenette to take the cart of dirty dishes back to the main kitchen. 2. Interview on 7/15/26 at 11:05 a.m. with dietary manager T revealed that she expected her staff to change gloves and perform hand hygiene between each task. She should not pick up a bun with gloved hands if she is also using those hands to pick up serving utensils and open refrigerator or cupboard doors. 3. Observation on 7/16/26 at 7:44 a.m. in the kitchenette revealed cook Q frying eggs for residents eating breakfast in the [NAME] Hall dining room. [NAME] Q was wearing gloves and a hairnet. She walked away from the stove, opened the refrigerator door, retrieved a bowl of eggs, closed the refrigerator door, and set the bowl of eggs on the counter next to the stove. She walked through the dining room to the serving counter, opened a cupboard and retrieved a bowl, closed the cupboard, and took the bowl back to the stove area. She cracked two eggs into the pan on the stove, removed her gloves, put them in a trash can, and put on a new pair of gloves without performing hand hygiene. [NAME] Q then dispensed water from the coffee machine into two bowls and put them in the microwave to heat up the water. After setting the microwave timer, she placed her left gloved hand on the counter and her right gloved hand on the edge of the stovetop. When the microwave timer sounded, cook Q removed the bowls and placed them on a serving tray, made toast by handling the bread with her gloved hands, and took a tray of juice glasses out of the refrigerator. She put everything on the serving cart and rolled it through the dining room to the serving table. She opened cupboard drawers to retrieve silverware and individual containers of jelly. She used a spoon to stir oatmeal into the two bowls of hot water, put everything on individual meal trays and served the trays to the residents sitting at the dining room table. She retrieved silverware and another bowl from the cupboard, picked up a container of milk from the serving table, poured milk into the bowl, added oatmeal, stirred it, and served the bowl to a resident at the dining table. Wearing those same gloves, cook Q repeated the process for another bowl of oatmeal, dispensing water from the coffee machine and heating it in the microwave, resting her gloved hands on the counter and stove handle while she waited for the microwave to sound. She retrieved a new gallon of milk from the refrigerator, poured milk into a glass, put the milk back in the refrigerator, and carried the bowl of hot water and the glass of milk with her fingers surrounding the rim. She placed both items on a tray on top of a serving cart, took a spoon from a drawer and stirred oatmeal into the bowl, then wheeled the cart over to a resident at the dining table. She took the glass of milk off the tray with her fingers around the rim of the glass and set it on the resident's table. [NAME] Q continued moving between the dining room and the kitchenette, opening cupboards to retrieve dishes, napkins, and silverware, which she added to a tray on the serving cart. At 7:57 a.m. she left the kitchenette and wheeled the cart and a meal tray to a resident's room. She knocked on the door, announced herself, took the tray into the room, then wheeled the cart back to the kitchenette area. She removed her gloves, put them in the trash, washed her hands, retrieved a can of pop from the refrigerator and took it to one of the residents in the dining room. She proceeded to serve coffee to the residents and take dirty dishes to the kitchenette sink without wearing gloves or washing her hands. 4. Observation on 7/16/26 at 8:15 a.m. in the [NAME] Hall dining room revealed cook Q at the serving counter, opening a cupboard to restock individual containers of cream cheese and jelly. She was wearing gloves. At 8:17 a.m. she closed the cupboard door, removed her gloves, and put them in the trash. She did not perform hand hygiene. 5. Interview on 7/16/26 at 8:20 a.m. with cook Q revealed that she usually works in the main kitchen and was filling in for a dietary aide who was on vacation. I haven't worked in this dining room for a while. She said she wears gloves most of the time because she has a cyst on her finger that recently ruptured. She said that when wearing gloves, I make sure I don't touch the food. As long as I don't touch the food, then I don't have to change my gloves. 6. Review of the provider's personnel file training documentation revealed that cook Q completed hand hygiene training and glove use education on 4/5/21, and repeated hand hygiene training on 8/25/25. She also successfully passed a hand hygiene and food temperature competency assessment on 5/26/26. 7. Review of the provider's 7/14/26 Hand Washing and Glove Use-Food Nutrition Services policy revealed that staff were to use uncontaminated, disposable gloves for single tasks, and to wash hands when switching tasks and after performing any activity that could contaminate hands. The policy read, Employees involved in food preparation, distribution and serving must consistently utilize good hygienic practices and techniques, and that employees do not need to wear gloves when distributing food to residents at the dining table unless they have a cut or sore, which should then be double covered with a bandage and a glove. The policy revealed that employees should use proper utensils and single-use gloves for food handling to reduce the risk of cross-contamination. Hand washing should occur after touching any contaminated object including dirty utensils and dirty dishes, before and after using gloves, and between dirty and clean dish handling. Gloves should be changed before handling ready-to-eat foods, any time contamination is suspected, when touching a doorknob or faucet, and when coming in contact with something that may have been contaminated such as pots, pans, trays, and utensils. 8. Review of the provider's 12/26/24 Care Center Safe Meal Service, LTC policy revealed that when plating and delivering resident meals, food service staff should pay attention to potential contamination during delivery and complete proper hand washing or glove change if needed.

Based on observation, interview, record review, and policy review, the provider failed to ensure residents were free from significant medication errors for one of one sampled resident (36), who was not administered his physician-ordered dose of insulin by registered nurse (RN) J, which increased his risk for having diabetic complications, including hyperglycemia (an abnormally high blood sugar level). Additionally, resident 38 did not receive his calcium/vitamin D3/vitamin K medication from certified medication assistant (CMA) H because the label on the medication did not match the medication.Findings Include:1. Observation on 7/15/26 at 12:03 p.m. of registered nurse (RN) J administering Novolog FlexPen (insulin aspart, a rapid-acting insulin in a prefilled pen. A needle attaches to the pen for medication administration) to resident 36. The ordered dose was 5 units (u). RN J injected the insulin into the resident's abdomen by pressing the medication dial at the end of the FlexPen. One second was counted from the start of the administration (when the pen is placed against the resident's stomach and the metered dose dial is pressed down) to the time the insulin pen was removed. She removed the pen from the resident's abdomen prior to the medication being fully dispensed into the resident's abdomen, as evidenced by when she pulled the insulin pen away from the resident; the insulin then expelled out of the needle onto the resident's skin.2. Review of resident 36's electronic medical record (EMR) indicated she admitted to the facility on [DATE]. Her 5/29/26 BIMS assessment score was 10, which indicated her cognition was moderately impaired.Her MAR indicated a 4/15/24 physician's order for Novolog FlexPen U-100 Insulin (insulin aspart U-100) 100unit/3mL, give 5 units subcutaneously with meals at 8:30 a.m., 12:00 p.m., and 5:30 p.m.Her diagnoses included type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar that causes damage to multiple peripheral nerves, usually leading to pain, numbness, or tingling in the hands and feet), chronic kidney disease stage 3 (moderate kidney damage indicating reduced kidney function), hypo-osmolality (low concentration of particles in the blood, usually from having too much water compared to electrolytes), and hyponatremia (sodium levels are low in the blood), chronic systolic (congestive) heart failure (a long-term condition where the heart's left ventricle weakens and can't pump blood effectively, leading to fluid buildup in the body), rheumatic mitral stenosis (a narrowing of the mitral valve caused by rheumatic fever, which restricts blood flow from the left atrium to the left ventricle and can lead to breathing difficulty and fatigue), nonrheumatic mitral insufficiency (also called mitral regurgitation, is when the mitral valve doesn't close properly allowing blood to leak backward from the left ventricle into the left atrium), and pulmonary hypertension (high blood pressure in the arteries that carry blood from the right side of the heart into the lungs, usually caused by narrowed or blocked lung vessels).3. Interview on 7/15/26 at 4:28 p.m. with RN J revealed her process for insulin administration was that she would wait three seconds before removing the insulin pen from the resident to ensure the resident receives the full dose. She agreed that if the insulin was expelled onto the resident's skin when removing the needle from the injection site, the resident did not get her full ordered dose. RN J stated that if the resident did not get her full dose, she would tell the director of nursing (DON), monitor the patient, and notify the provider.4. Observation on 7/16/26 at 7:42 a.m. of CMA H during medication pass for resident 38 revealed two medication blister packs (a card with medications sealed in individual plastic bubbles) for the morning dose for LDR Vit C600+D3/MINS CHEW 60 EACH. Generic for LDR VIT C600+D3/MINS CHEW CENTURY, each containing one-half tab. CMA H prepared to give the morning dose by removing each half tab from the medication blister packs into a separate paper cup.5. Interview and EMR review on 7/16/26 at 7:50 a.m. with CMA H revealed a physician's order for Calcium 500 milligram (mg)-Vitamin D3 1000 u - Vitamin K 40 micrograms (mcg) chewable tablet 1 tab twice a day. CMA H acknowledged that the medication blister pack label and the physicians' orders in the EMR did not match. CMA H stated that she did not know the process for reporting that type of error, but I can tell the nurse or the DON. When we complete the medication card changeover to the new packs, the staff are supposed to double-check they match the MAR and previous cards.6. Interview on 7/16/26 at 7:56 a.m. with DON B revealed that she expected the medication cards would match the physicians' order on the MAR.7. Review of resident 38's EMR indicated she admitted to the facility on [DATE]. Her 4/17/26 BIMS assessment score was 12, which indicated her cognition was moderately impaired. Her diagnoses included weakness, age-related osteoporosis (a condition where bones become thin, weak, and more likely to break easily) without current pathological fracture, and chronic kidney disease stage 3 moderate kidney damage (indicating reduced kidney function).8. Interview on 7/16/26 at 1:21 p.m. with the DON B revealed that a resident not receiving their full ordered dose of insulin, the resident's physician not being notified, and the lack of increased monitoring for resident 36 after the medication error were considered a significant medication error.9. Interview on 7/16/26 at 3:15 p.m. with DON B revealed that the label on the medication blister pack was incorrect for resident 38's calcium/vitamin D/vitamin K order. She expected the medication to have the correct label on it.10. Observation on 7/16/26 at 3:25 p.m. the medication blister packs for resident 38's calcium/vitamin D/vitamin K order were still in the medication cart.11. Review of the provider's reviewed 3/2/26 Medication Errors policy revealed the location will have medication error rates of five percent or less and those residents are free of significant medication errors. When a medication error occurs, it will be reported promptly to the attending physician, resident, and or responsible party and documented in the SAFE Event Reporting application. Definitions from the State Operations Manual Significant Medication Error one which causes the resident discomfort or jeopardizes his or her health and safety. Wrong Dose/Amount when the resident receives an amount of medication that is greater than or less than amount ordered by the prescriber.12. Review of the provider's reviewed 3/30/26 Medication: Administration Including Scheduling and Medication Aides revealed The resident has the right to self-administer medications if the interdisciplinary team determines that this practice is safe for the individual resident and is documented in the care plan. An order from the provider is required for this activity. Procedure: Follow the Six Rights: right medication, right dose, right resident, right route, and right documentation. Perform three checks: read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication.

Based on observation, interview, and policy review, the provider failed to ensure that two of two sampled residents (21 and 37) on oxygen had their tubing changed weekly.Findings include: 1. Observation on [DATE] at 9:20 a.m. revealed resident 21's oxygen tubing was dated [DATE]. Observation on [DATE] his oxygen tubing was dated [DATE]. 2. Observation on [DATE] at 9:34 a.m. revealed resident 37's oxygen tubing was dated [DATE]. Observation on [DATE] his oxygen tubing was dated [DATE] for the following Monday. 3. Observation and interview on [DATE] at 1:10 p.m. with Registered Nurse (RN) J regarding the dates on the resident's oxygen tubing revealed that resident 21 and 37's oxygen tubing were dated [DATE], which was the date it would expire and need to be changed. She stated the oxygen tubing should be changed weekly and dated at that time, not the date it expired. 4. Review of the electronic medical records for resident 37 indicated that the oxygen tubing had been changed weekly, but the dates on the tubing did not coincide with those records. Resident 21 did not have a physician's medical order to administer oxygen. 5. Interview on [DATE] at 2:36 p.m. with director of nursing (DON) B regarding resident weekly oxygen tubing change and dating revealed she expected the tubing to be changed weekly and dated at that time. 6. Review of the provider's [DATE] oxygen administration policy revealed that oxygen administration is carried out only with a medical provider order. The disposable equipment should be changed weekly or according to the manufacturer's instructions and marked with date and initials.

Based on observation, record review, interview, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for two of six sampled residents (2, and 30).Findings include: 1. Observation on 7/14/26 from 9:52 a.m. to 2:32 p.m., resident 2 was asleep in bed. 2. Observation on 7/14/26 at 2:14 p.m. resident 30 was in his wheelchair outside smoking a cigarette on the sidewalk, near the street, alone. 3. Review of resident 30's electronic medical record (EMR) revealed he was admitted on [DATE]. His 5/15/26 Brief Interview for Mental Status (BIMS) assessment score was 10 indicating he had moderately impaired cognition. He had diagnoses of cerebral palsy (a neurological disorder that permanently affects a person's ability to move, maintain balance, and sustain posture), chronic pain, and anxiety disorder. He had a smoking assessment completed on 4/13/26, which indicated he was able to wheel himself out to the designated smoking area. He could safely light his own cigarette and smoke the entirety of the cigarette without causing injury to himself. He was able to put out the cigarette and dispose of the cigarette butt in the designated trash can. His care plan did not indicate he was a smoker, or that a smoking assessment had been completed, or that he was safe to smoke independently. 4. Interview on 7/14/26 at 2:32 p.m. with certified nursing assistant (CNA) I regarding resident 2 revealed that she refused breakfast and lunch. She slept in during the day and will wake up in the evening. 5. Observation on 7/14/26 at 4:24 p.m., resident 2 was waking up but still lying in bed in the dark. 6. Review of resident 2's EMR revealed she admitted to the facility on [DATE]. Her 6/19/26 BIMS assessment score was 0, which indicated her cognition was severely impaired. Her diagnoses included mild neurocognitive disorder due to known physiological condition with behavioral disturbances (a noticeable decline in cognitive abilities such as memory, attention, or problem-solving), psychotic disorder (a serious mental health condition characterized by a significant loss of contact with reality), unspecified disorder of adult personality and behavior (a mental health condition marked by enduring, inflexible patterns of thinking, feeling, and behaving that significantly deviate from cultural norms, cause distress or impair daily functioning), unspecified intellectual disabilities (significant limitations in intellectual functioning), depression, non-infective gastroenteritis and colitis (inflammation of the stomach, intestines, or colon that is not caused by an infection), and gastric ulcer without hemorrhage or perforation (an open sore on the stomach lining). Her 4/16/24 physician diet orders were for dysphagia (difficulty or discomfort in swallowing) diet, soft with thin liquids. There was a general nursing order on 3/10/26 to give 1 cup of coffee with morning medications in the room before getting the resident up for the day. Notify dietary aide to get breakfast ready after medications were given to anticipate her needs. There were no further supplemental dietary orders input into the physician order report. Her 6/26/26 care conference documentation indicated that licensed social worker (LSW) U, long-term care (LTC) activities G, minimum data set (MDS) coordinator V, and resident 2's power of attorney (POA) (someone designated on a legal document to act on behalf of a resident) were in attendance. They reviewed her diet and her weight loss and discussed options to see about getting the resident to gain weight, as she refused her supplements and was becoming more picky with what she eats. Resident 2's POA said she could bring resident 2 some snacks and have nursing regulate it more so resident 2 does not eat them all in one sitting. MDS coordinator V will talk with the dietician about a 'peanut butter cup' therapy to see if that might help some. The staff will continue to monitor her diet/weights. Her 6/26/26 care plan indicated that resident 2 needed increased encouragement from the staff to get up and come out for meals. She was weighed weekly during her bath, and any increase or decrease of 4 lbs. would be reported to the charge nurse. Re-weights would be performed according to policy. Staff was to notify the provider of significant weight changes. Diet as ordered was a regular diet, International Dysphagia Diet Standardization Initiative (IDDSI) 6 soft and bite-sized, with tray set up as needed (prn). She was to be offered small to routine size portions at mealtimes. Staff were to ask her if she wanted second helpings. The second helpings offered were to be small portions. Fluid consistency was thin, but with a 2000 milliliter (mL) per day fluid restriction. Resident 2's care plan did not include information about offering supplements such as magic cup or peanut butter cup therapy, as indicated by care conference and dietary notes. It did not include interventions on how staff should encourage her to take part in mealtimes. Her care plan did not indicate a dysphagia diet as per the physician's order. Her 6/30/26 nutritional risk progress notes indicated that the resident has been refusing her chocolate coffee (chocolate Ensure in coffee); she was offered Magic Cups ice cream supplement at the noon meal. Staff reports that resident 2's acceptance of this supplement is variable and inconsistent. 7. Observation on 7/15/26 at 12:15 p.m. registered nurse (RN) J revealed that she woke resident 2 up for her medications and asked her if she wanted lunch. Resident 2 refused lunch. No additional supplements were offered at that time. There was no encouragement to attend lunch. 8. Observation on 7/15/26 at 12:42 p.m. of resident 30 was in his wheelchair outside smoking a cigarette on the sidewalk, near the street, alone. 9. Interview on 7/16/26 at 9:23 a.m. with minimum data set (MDS) coordinator V revealed care plans should be updated with changes as they occur, significant changes or MDS quarterly assessments. When asked if smoking would be on a resident care plan, she stated It depends on the resident, if we feel like they are safe to independently she would not put it on the care plan. Staff are updated on who can smoke by the smoking list. She would add it to the care plan if a resident needed certain safety precautions. 10. Interview on 7/16/26 at 10:01 a.m. with director of nursing (DON) B revealed she expects smoking to be on a resident care plan. Along with the smoking assessment information and any precautions needed for the resident would be on the resident's care plan. 11. Interview on 7/16/26 at 1:21 p.m. with DON B revealed that she would expect the care plan to include interventions for the staff to try to encourage resident 2 to get up to attend meals. She would also expect the care plan to include the supplements the staff should be giving her. She said the supplements were also on the medication administration record (MAR) or treatment administration record (TAR) so the nurses knew to give them to the residents. 12. Review of the provider's 12/1/25 Care Plan policy revealed: Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders.

Number of residents sampled: Number of residents cited: Based on interview, record review and policy review the provider failed to have physician orders for therapeutic leaves, to ensure no disruption in wound cares and scheduled medications supplies for care were available and sent with one of one sampled resident (33) who left the facility for therapeutic leave home visits. Findings include:1. Interview on 8/13/25 at 8:43 a.m. with resident 33 revealed:*He would leave the facility for therapeutic leaves.*He made his own decisions.*He used his wheelchair for mobility. Review of resident 33 electronic medical record (EMR) revealed:*Resident 33 made his own decisions.*There was no physician's order to complete a head-to-toe assessment when he returned from therapeutic leave. *There was no physician's order for his therapeutic leave home visits*His therapeutic leave was not addressed on his care plan. *Resident 33 had the diagnoses of:- Pressure ulcer of sacral region, Shortness of breath, hypertension [high blood pressure], localized edema [swelling], pain, thrombocytopenia [low blood cells], Type 2 diabetes mellitus [insulin dependent] with foot ulcer [wound], peripheral vascular disease [narrowed blood vessels], iron deficiency anemia [not enough healthy blood cells to carry oxygen], alcohol dependence [alcohol use disorder], Insomnia [sleep disorder], Rash and other skin eruption, Methicillin resistant Staphylococcus aureus infection [bacteria resistant to antibiotics], hyperlipidemia [high levels of fat particles in the blood] , Osteomyelitis of vertebra [infection of the spine], sacral and sacrococcygeal [infection of the bone and bone marrow in the lower back] region, Gastro-esophageal reflux.*Resident 33 had physician's orders for medications including:-Albuterol sulfate inhaler (to treat difficulty breathing), amlodipine (treat blood pressure, Aldactone (helps the body get rid of excess fluid), diclofenac (used to treat swelling), aspirin (can treat pain, headaches, and swelling), calcium carbonate, (dietary supplement), clopidogrel (prevent blood clots), famotidine (reduce stomach acid), ferrous sulfate (iron supplement), folic acid (form of vitamin B), furosemide (for excess fluid), hydrocodone-acetaminophen (for pain), Lantus Solsotar insulin (regulates blood sugar), Lipitor (lowers cholesterol levels in the blood), losartan (treats high blood pressure), melatonin (regulates sleep), novolog flexpen Insulin (control high blood sugar), nystatin (antifungal medication), pantoprazole (treats acid reflux), potassium (chloride treats low blood potassium levels), lisinopril (treats high blood pressure). *Resident 33 was to receive treatments that included: Diabetic foot and nail care by charge nurse weekly, Heel lift boot to bilateral lower extremities at night, lymphedema pumps [compression device] to bilateral [both] extremities twice a day for 45 minutes, multipodus boot [a type of ankle-foot boot to treat various foot and ankle conditions] to the right lower extremities at all times, Santyl (colligenase clostidium histo) [ointment that removes dead tissue] twice a day applied to right heel, right 3rd toe, left transmetetarasal amp [amputation] site, apply twice daily then cover with dakins [Dakin's a brand of wound disinfectant] moistened gauze, ABD [gauze] pad, wrap with Kerlex [gauze bandage roll], Wear Tubi Grips [support bandage] for edema daily, weekly skin/wound assessment one [once] a day on Thursday, zinc oxide [prevent rash] one [once] a day cleanse with sage wipes [bacteria wipe] and wound cleanser and gauze. Apply Z guard [prevent skin irritation] to wound bed area. Cover with sacral bordered dressing [foam bandage]. Dakin's solution (sodium hypochorite) [wound disinfectant] every shift, Cleanse bilateral extremities with soap and water, cleanse open areas with wound cleanser and gauze. Apply clear aide to peri wound, apply dakin's [Dakin's] 0.125 % to moistened 2x2 gauze to open areas left achilles [heel]/ankle and posterior leg. Cover with dry gauze or abd pad as needed for drainage. Secure with Kerlix and tape. Tubigrip size G from toes to new bilateral lower extremities. Apply HLB to bilateral feet when in bed. Change dressings twice daily 4th and 5th toes-apply Dakins moistened gauze, cover all with ABDs, Kerlix, Edema wear from toes to knee on bilateral extremities. Aquaphor original (white petrolatum) one [once] a day apply moderate amount topically every day to right and left lower legs and feet. Bed Bugs notify maintenance: when [resident 33] returns from leave outside of facility, notify maintenance ASAP [as soon as possible] to come check and clean belongings, wheelchair, linens, etc. for bed bugs. Interview on 8/14/25 at 12:56 p.m. with licensed practical nurse (LPN) I regarding resident 33 revealed:*She confirmed resident 33 would leave the facility for therapeutic leave home visits.*His briefs and extra clothes would be sent with him for those home visits. *She stated they did not have a physician's order to send his medications with him and his medications were not sent with him, and she did not think wound supplies were sent out with him on those leaves, but thought he could get care from another care provider while out on those visits but did not know if he did. *She was aware he had come back with maggots in his wounds one time. *She stated after that incident, resident 33 would receive a shower when he returned to the facility, would be assessed from head to toe by the nurse, and his wheelchair and personal items were inspected by maintenance for bed bugs after he had returned with them from a prior home visit. *She stated he had refused those assessments and inspections at times and those refusals should be documented. Interview on 8/14/25 at 2:57 p.m. with director of nursing (DON) B regarding resident 33 revealed:*He agreed resident 33 did not have a physician's order for therapeutic leaves and should have.*He stated resident 33's wound supplies should have been sent with him when he left the facility. *Medications were not sent with resident 33. He thought there was a physician's order in place to not send medications with him on the therapeutic leaves due to the resident not returning with those medications and the facility having to repurchase them. *He could not provide that order. Interview on 8/14/25 at 2:57 p.m. with MDS coordinator C revealed:*She stated that resident 33's therapeutic leaves were not on the care plan.*She stated she did not expect resident 33's care plan to include his therapeutic leave, Not everything had to be on the [resident's] care plan. Review of the provider's 3/9/23 Physician/Practitioner Orders-Rehab/Skilled policy dated revealed:*To provide individualized care to each resident by obtaining appropriate, accurate and timely physician/practitioner orders.*Physician/Practitioner orders content 4.Therapeutic Leave Orders.*The policy did not include what medications or care supplies should be sent with the resident for therapeutic leave. Review of the provider's Nursing Services Philosophy and Care- R/S, LTC dated 7/29/24 revealed:*11. To maintain a level of excellence to the fullest extent possible in order to provide a quality of care that will meet the needs of every person. Review of the provider's 12/2/24 Care Plan- R/S, LTC, Therapy & Rehab revealed:*The care plan will emphasize the care and development of the whole person ensuring that the resident will receive appropriate care and services. It will address the relationship of items or services required and facility responsibility for providing these services. Review of the provider's 6/2/25 Absence-Temporary, From Location- R/S, LTC, Hospice Facilities [(therapeutic leave)] policy dated 6/2/25 revealed: *4. Provide the resident with any necessary medications, diet instructions, activity restrictions, etc., using the Discharge or Therapeutic leave Medication List UDA/Matrix/ or Hospice equivalent.

Based on observation, interview, and policy review the provider failed to follow standard food safety practices, maintaining sanitary conditions in the kitchenette on [NAME]-wing, and processes to prevent foodborne illnesses for:*One of one cook (H) who had not worn gloves or performed hand hygiene (handwashing) while serving one of one sampled resident's (4) food items to prevent foodborne illnesses. Findings include: 1. Observation on 8/14/25 at 8:15 a.m. with cook H while preparing a meal for resident 4 in the kitchenette of [NAME]-wing revealed he:*Did not wash his hands or put on gloves. With his bare hands, he removed a Ziploc bag of frozen sausage links out of the refrigerator freezer and placed them on a plate.*Touched the panel of the microwave to enter a cook time and put the plate with the sausage links in the microwave.*Took one raw egg, broke it open into a frying pan on the stove top.*Touched the top surface of the plate he placed the food on.*Touched the spatula on the counter.*Touched a dirty towel that was on the counter.*Touched his eyeglasses that he was wearing.*Removed the plate with the sausage links from the microwave.*Removed the cooked egg from the frying pan, with the same spatula he had touched the counter with and placed it onto the plate.*Did not check the temperature of the sausage or the egg.*Removed two slices of bread from a bagged loaf of bread.*Placed those two slices of bread into the toaster and touched the toaster knob to toast the bread.*Removed the 2 slices of toasted bread and buttered them with a knife.*Served resident 4 that plate of food.*He did not wear gloves or wash his hands at any time during the above observation. Observation on 8/14/25 at 8:20 a.m. of the dining area on [NAME]-wing revealed:*An opened tub of butter without a lid on it. A large butter knife was resting on top of it the butter tub, and both contained a significant amount of food crumbs.*There were several uncovered 8-ounce cups of milk and juice sitting on a serving cart that were open. Several residents and staff were observed entering and exiting the areas where they were. Interview on 8/14/25 at 8:17 a.m. with Registered Nurse (RN) K revealed:*Residents could choose what they would like to eat for breakfast.-He indicated that the kitchen cooking staff would make resident requests for foods such as fried eggs, sausage, and toast. Interview on 8/14/25 at 8:41 a.m. with cook H revealed he:*Had not used gloves or completed hand hygiene while he prepared the breakfast food items for resident 4.*Should have used gloves and hand hygiene while preparing meals in the kitchenette.*Had not checked the temperature of the sausage links and the egg prior to serving them to the resident, but he should have. Further interview and observation on 8/14/25 at 8:47 a.m. with cook H in the kitchenette of [NAME]-wing revealed he:*Verified the internal temperature of the Malt O Meal hot cereal was 185-degrees Fahrenheit (F) and the internal temperature of the eggs was 162-degrees F. Those foods were in metal bins on the serving cart warmer. -Documented those temperatures on the food service temperature log for [NAME] kitchen.-Verified he had not temp checked the temperatures of the Malt O Meal hot cereal or the eggs when they were delivered from the main kitchen at 7:00 a.m.-Verified the temperature of the hot Malt O Meal cereal and the eggs had not been checked prior to being served to the residents.*He indicated the uncovered cups of milk and juice without lids sitting on the serving cart, were to be served to residents who had not yet had their breakfast.-Those had been sitting uncovered at room temperature since 7:30 a.m. Interview on 8/14/25 at 8:54 a.m. with nursing assistant (NA) F revealed:*The residents on [NAME] wing were assisted to the dining room starting at 7:00 a.m.*She had indicated that there had not been any residents who had been sick with any gastrointestinal symptoms. Interview on 8/14/25 at 9:10 a.m. with director of nursing (DON) B revealed:*He expected dietary cook H wear gloves and to completed hand hygiene while preparing and serving food to residents. Interview on 8/14/25 at 9:30 a.m. with dietary manager E revealed:*She expected the dietary staff to wear gloves and to complete hand hygiene while preparing food for the residents.*She expected the dietary staff to check the food temperatures before they were served to residents to ensure they were within the safe temperature ranges. Interview on 8/14/25 at 9:49 a.m. with resident 4 revealed:*He confirmed that cook H had made him one fried egg, 3 sausage links, and toast with butter on it for breakfast.-He stated, It tasted fine. Interview on 8/14/25 at 10:50 a.m. with administrator A and business office manager (BOM) J revealed:*They felt improper hand hygiene and glove use by staff was a major concern.*They had indicated that they had already spoken with dietary cook H and all the staff who had been working in the main kitchen about improper hand hygiene and glove use. Interview on 8/14/25 at 3:48 p.m. with quality measures control program/infection preventionist (IP) G revealed the facility had an infection prevention and control program that included specific policies for hand washing and glove use for all employees of the facility. Review of the provider's August 2025 food service temperature log for [NAME] kitchen revealed:*Danger zone for bacterial growth is 40-140-degree[s].*All potentially hazardous foods must meet [the[ regulation minimum internal cooking temperature.- Ground meat/eggs [must remain at]: 165-degree[s] for 15 seconds.- Fresh shell egg for immediate service [must remain at]: 145-degree[s] for 15 seconds.- Reheating food [must remain at]: 165-degree[s] for 15 seconds [and be reheated] (within 2 hours). Review of the provider's revised 3/29/22 [NAME] Policy Enterprise: Infection Prevention: Hand Hygiene revealed:Purpose: To guide compliance for hand hygiene with the Centers for Disease Control and Prevention (CDC) and the World Health Organization's Moments of Hand Hygiene recommendations:- To establish hand hygiene as the single most important factor in preventing the spread of disease-causing organisms to patients and personnel in healthcare setting.- To provide guidance regarding lotion use, glove use, and fingernail care. Review of the provider's revised 12/26/24 [NAME] Policy Location [NAME], South Dakota: Food and Nutrition: Rehab/Skilled and Long-Term Care: Care Center Safe Meal Service, Long-Term Care-[NAME] revealed: Purpose: To ensure the resident dining environment remains free of accident hazards as possible. Policy: Providing a safe environment for serving resident meals at the care center and keeping the resident environment safe. Three meals are served daily with no more than 14 hours between evening meal and breakfast the next day. Procedure: Food Service staff will plate up residents' meal and may deliver if assistance from nursing staff is unavailable and resident is able to feed self safely. Staff need to remember to pay attention to potential contamination during delivery and complete proper hand washing or glove change if needed.- No bare hand contact with ready to eat foods is allowed. Staff should use utensils, such as tongs, or use a gloved hand to handle ready to eat food.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, observation, record review, and interview, the provider failed to implement, review and revise interventions to reduce the risk of falls for two of two sampled residents (1 and 2) with a history of falls and to prevent subsequent falls. Findings Include: 1. Review of the provider's 6/1/25 SD DOH FRI revealed: *[Resident 2] was found on [the] floor at 1910 [7:10 p.m.] by a CNA [certified nursing assistant] .he was attempting to self transfer out of wheelchair by [his room]. *Resident 2 sustained a closed fracture of [his] left hip. *Before the fall, resident 2 was changed from [needing to use] a stand aid [a mechanical device that lifts a resident from a sitting position to a standing position] to a stand pivot with two [staff] assist [assistance]. Interview and review of the 6/1/25 video footage on 6/12/25 at 10:12 a.m. with director of finance N, director of nursing (DON) B, and licensed social worker (LSW) O revealed: *Resident 2 was seated in his wheelchair by certified medication assistant (CMA) G at her medication cart two minutes before he fell. *CMA G entered a resident's room across from her medication cart, and resident 2 propelled himself in his wheelchair down the hall. Used the railing in the hallway, stood from his wheelchair, took approximately six to eight small steps, and fell. *Registered nurse (RN) F responded and provided care to resident 2. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE] and received hospice services from 2/17/25 until 5/10/25. *Resident 2 had been evaluated by physical therapy (PT) on 5/15/25. *His 5/23/25 MDS assessment indicated he was rarely understood or able to understand others and was severely cognitively impaired. *A 5/27/25 PT progress note indicated .will change program to add SPT [stand pivot transfer] in addition to stand aid until all staff [are] more comfortable with transfer and staff are aware. *Resident 2 fell on 5/29/25. *A 5/29/25 Fall Risk Assessment indicated resident 2 was Not at Risk for falls and to Continue with Plan of Care. *His 5/29/25 fall incident report did not indicate any interventions were implemented or revised to prevent subsequent falls. *Resident 2's Post-Fall Investigation Tool Recommendations for future prevention revealed toilet more frequently. -His care plan was not updated to include that intervention. *Resident 2 fell on 6/1/25 and sustained a closed fracture of his left hip and was hospitalized . *He was readmitted to the facility on [DATE] and admitted to Hospice Services that same day. Review of resident 2's current care plan revealed: *A 3/5/25 last reviewed/revised problem area of ADL's Functional Status with approaches that indicated: Transfers Dependent x2 [on the assistance of two staff members] for transfers using [a] Hoyer lift [a mechanical lift and sling used to lift a person's full body] to/from toilet, recliner . *A 3/5/25 last reviewed/revised problem area of Falls [resident 2] has a history of falling and is at risk for injury from fall with Approaches that indicated: Posey bed alarm system [a device used to alert caregivers when a resident attempts to exit their bed, designed to help prevent falls] activated while in bed. Keep bed in low position. Provide proper, well-maintained footwear. Provide resident [2] an environment free of clutter. *A 2/17/25 initiated problem area Terminal Care [resident 2] is on [provider name] Hospice d/t [due to] terminal prognosis of Alzheimer's Disease. That was last reviewed/revised on 3/14/25 with an approach that indicated: -Air mattress overlay .to prevent skin breakdown while in bed. *His care plan had not been updated to indicate: -His transfer status had changed to a stand pivot transfer on 5/27/25. Any new or revised fall prevention interventions after his 5/29/25 fall. He had been admitted to hospice services on 6/5/25. He did not have an air mattress overlay on his bed. 2. Interview and review of the 4/6/25 video footage on 6/12/25 at 10:12 a.m. with director of finance N, DON B, and LSW O revealed: *Resident 1 fell on 4/6/25 at 12:45 p.m., 6:04 p.m., 6:12 p.m., and at 6:51 p.m. *At 12:45 p.m., resident 1 stood up from his Broda Pedal Wheelchair (a specialized high-back reclining wheelchair with upper body support that allows a person to self-propel with their hands or feet) that was positioned at the counter in front of the nurses' station. CNA D approached resident 1. Resident 1 swung his arm at her. CNA D stepped back, and resident 1 fell to the floor. -Without requesting assistance or notifying a nurse, CNA D reached around resident 1 and, from the back, grabbed both of his forearms, lifted him off the floor by herself while he was fighting her, and placed him into the wheelchair forcefully. Her movements were quick and rough. She placed his wheelchair at the counter and locked his wheelchair brakes, which prevented him from moving his wheelchair. *At 6:04 p.m., resident 1, still positioned at the nurses' station, stood up from his wheelchair and fell to the floor. CNA D was seen from behind the wheelchair, extending resident 1's arms above his head as he lay on the floor. Without requesting assistance or notifying a nurse, CNA D then stood beside resident 1, placed her arms behind him, attempted to hoist him back into his wheelchair, and lifted him from the floor multiple times before seating him roughly into the wheelchair while he resisted her assistance. *At 6:12 p.m., resident 1, still positioned at the nurses' station, stood up from his wheelchair and again fell to the floor for a third time. Without requesting assistance or notifying a nurse, CNA D lifted resident 1 from the floor and sat him roughly into the wheelchair while he resisted her assistance. *At 6:50 p.m., resident 1, still positioned at the nurses' station, stood up from his wheelchair and again fell to the floor for a fourth time. He was provided with a pillow, by a staff member and was not observed having been assessed by the nurse or assisted off the floor in that video footage. *After each fall observed on that video footage, resident 1 was returned to his wheelchair and positioned facing the counter at the nurses' station. No new interventions were implemented to prevent subsequent falls. Review of resident 1's EMR revealed: *He was admitted on [DATE]. *His 3/28/25 MDS assessment indicated he was rarely understood or able to understand others and was severely cognitively impaired. *His diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance (a mental state where a person loses touch with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood energy and behavior), general anxiety disorder, Alzheimer's Disease, Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors), and conduct disorder (a mental health condition that involves a persistent pattern of aggressive and antisocial behavior). *Resident 1 experienced 15 falls between 3/11/25 and 5/7/25. *Five of resident 1's falls occurred on or before 4/6/25. Review of resident 1's Fall Risk Assessments indicated: *On 4/6/25, he had a high risk for falls, and a referral to a Falls Prevention Program may be appropriate, and Continue Current Plan of Care were marked. -Resident 1 fell four times between 4/7/25 and 4/15/25. *On 4/15/25, he had a high risk for falls, and No Referrals Necessary, and Continue Current Plan of Care were marked. -Resident 1 fell four times between 4/16/25 and 4/26/25. *On 4/26/25, he had a high risk for falls, and a referral to a Falls Prevention Program may be appropriate, and Continue Current Plan of Care were marked. -Resident 1 fell two times between 4/27/25 and 5/7/25. *On 5/7/25, he had a high risk for falls, and a referral to a Falls Prevention Program may be appropriate, and Plan of Care Updated, and safety signs in room were marked. -At least eight of resident 1's falls occurred outside of his room. Review of resident 1's fall incident reports and interventions implemented to prevent subsequent falls revealed: *On 4/6/25 at 12:40 p.m., staff were to keep resident 1 in Line of sight for the next couple of hours. *On 4/6/25 at 6:10 p.m., 6:15 p.m., and 6:20 p.m., 4/14/25 at 11:40 a.m., and 12:25 p.m., no documented interventions were put in place. *On 4/15/25 at 11:00 a.m. and 4:00 p.m., UNKNOWN was indicated. *On 4/16/25, resident 1 was agitated and left alone on floor with [a] pillow per [his] care plan. -No other documented intervention was put in place at that time to prevent him from subsequent falls. *On 4/26/25, We let resident [1] lay on the floor until he was ready to get up was documented. -No other intervention was put in place at that time to prevent him from subsequent falls. -On 5/7/25 at 2:45 p.m., Safety signs placed was documented. Review of resident 1's Post-Fall Investigation Tool Recommendations for future prevention revealed: *On 4/14/25 at 11:40 a.m. and 12:25 p.m., 4/15/25 at 4:00 p.m., 4/16/25, 4/18/25, 4/26/25, 4/22/25, and 5/5/25 that section had not been completed. *On 4/15/25 at 11:00 a.m. Quit isolating dementia Pts [patients] was documented. *On 5/7/25, Signs in room was documented. Review of resident 1's care plan revealed: *A problem area indicated Falls [resident 1] at risk for falling R/T [related to] dementia, incontinence, and ambulatory status was last reviewed/revised on 4/24/25. -A 5/7/25 Approach (intervention) indicated Posted signs or pictures to cue [resident] for toileting /assistance prior to [the resident] getting up. -A 4/7/25 Approach indicated Provide toileting assistance every 2-3 [two to three] hrs [hours] while awake and PRN [as needed]. --Resident 1 was Dependent [on the] assistance x2 [of two staff members] for walking on/off unit. --Resident 1 was Able to pedal [his wheelchair] with [his] feet [for] short distances. --Resident 1 was Dependent [on the] assistance x 1-2 [of one to two staff members] for toileting. *Resident 1's care plan had not been updated with interventions to reduce his risk for falls after he fell nine times between 4/7/25 and 5/7/25. 3. Phone interview on 6/12/25 at 11:19 a.m. with RN F revealed: *Resident 1 had many falls. *He was the nurse on duty when resident 2 fell on 6/1/25. *CMA G had been with resident 2 just before he fell and had called him to assess resident 2 after he fell on 6/1/25. *After a resident fell, the staff members on duty would have a post-fall huddle (meeting) to discuss the fall and how to prevent further falls. *The post-fall sheet had a place to indicate new interventions. *A list of fall interventions had been posted at the nurses' station recently, and nurses had been told that they needed to update the residents' care plans after each fall. *He had not received education on how to update the care plan. *He would email MDS RN C to let her know if they had tried a new intervention. *He would look in the residents' EMR for their care plans, but he was not sure where the CNAs would find the interventions since they had stopped using pocket care plans (a portable document that outlines a resident's care needs). 4. Interview on 6/12/25 at 1:07 p.m. with CMA G revealed she: *Had not attended any recent training on preventing falls. *Had worked on 6/1/25 when resident 2 fell. *Recalled resident 2 had been with her at her medication cart at the end of the hall. The resident in the room across from her was standing in his room. She entered that resident's room to assist that resident and heard resident 2 fall. *She had only been away from resident 2 a couple of minutes before he fell. *She was unsure how resident 2 transferred or when he had been last used the bathroom before his fall. *The nurse would give a verbal a report, or the CNAs would do walking rounds to share resident status information. *She does not look at the care plan in the EMR and was not sure where to locate resident fall interventions. 5. Interview on 6/12/25 at 1:35 p.m. with MDS RN C regarding resident fall interventions revealed: *She had posted a laminated list of fall interventions at each nurse's station for nurses to reference when they updated the resident care plans after a fall. *She expected new interventions to be implemented and added to the resident care plans in real time after a resident's fall to reduce the resident's risk for falls. 6. Interview on 6/12/25 at 2:23 p.m. with DON B regarding fall interventions revealed he expected care plans to be updated with new fall interventions after a resident had a fall to reduce the resident's risk for falls. Review of the provider's 3/1/24 Fall Prevention & Follow-Up Reporting policy revealed: *The interdisciplinary team will review and discuss [fall] preventatives at weekly Mini-Managers meetings. *The QMI [quality management and improvement Committee will review resident falls every month to determine what new, preventative [fall] measures [interventions] should be put in place.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, video footage review, interview, and policy review, the provider failed to protect the resident's right to be free from physical abuse by: *One of one certified nursing assistant (CNA) (D) who responded to falling incidents with physical force and restraint for one of one sampled resident (1) with cognitive impairment. *Eight additional staff members (E, G, H, I, J, K, L, and M), identified as present at the time the physical abuse occurred, who did not intervene or report those incidents to a supervisor at the time those incidents occurred. Findings include: 1. Review of the provider's 4/7/25 SD DOH FRI revealed: *On 4/7/25, the provider reviewed video footage of resident 1's falls from 4/6/25. *The video footage revealed CNA D assisted [resident 1] roughly back into his wheelchair after he had fallen. *CNA D pushed him [resident 1] up to the desk and locked the brakes on his wheelchair so he was not able to move around . *CNA D did not get the nurse when he fell to do an assessment. *[The] Nurse completed [an] assessment on 4/7/2025 and [resident 1] has some bruises on his arms. *Resident 1 was showing signs of increased anxiety during his interactions with CNA [D]. *CNA D did state that she did become frustrated . and should have stepped away. *[Licensed practical nurse (LPN) J] stated that she was in report [staff communication of residents' status] when these events took place, and no one reported these events until after report. *On 4/14/25, when interviewed by director of nursing (DON) B and licensed social worker (LSW) O, Certified medication assistant (CMA) I reported that CNA D had transferred [resident 1] back into his wheelchair after his fall without the nurse assessing him first. *CMA I noted that [CNA D] was laughing at [resident 1's] statements, but did not recall any specific instances where [CNA D] was rough with [resident 1]. *Education was immediately [on 4/7/25] provided to all nurses and CNAs regarding proper procedures after a fall, including notifying the nurse of the fall so they can complete an assessment . All staff was [were] also educated on proper times to lock wheels on wheelchairs, and safely transferring residents. *Resident cares with [resident 1] will also be audited randomly for the next 2 months and then prn [as needed] to ensure appropriate interactions from staff. *New staff will be trained upon hire on managing residents with dementia. *CNA D was terminated immediately after her interview on 4/7/25, no longer allowing her to provide resident care at that facility. 2. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/28/25 Minimum Data Set (MDS) assessment indicated he was rarely understood or able to understand others and was severely cognitively impaired. *His diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance (a mental state where a person loses touch with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood energy and behavior), general anxiety disorder, Alzheimer's Disease, Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors), and conduct disorder (a mental health condition that involves a persistent pattern of aggressive and antisocial behavior). *His care plan indicated, Inappropriate behaviors related to dementia. He demonstrates behaviors which include restlessness, wandering, combative, resists cares, verbally abusive, disruptive to other[s], [and] varying mood. -His care plan Approaches included: --Resident will have 2 staff assist [assistance of two staff] with cares when given due to aggressive behaviors. --If [Resident 1] becomes restless try these [non]pharmacological interventions like having the dog sit with him, wheel him around the facility in his wheelchair, visiting with him in a quiet setting or listening to calming music, resting on the couch in dining room with lights lowered and giving him snacks or something to drink. --When approaching [resident 1] come from the front and not behind or on his sides as this can startle him. *Resident 1 was out of the facility and unavailable for interview throughout the survey. 3. Interview and review of the 4/6/25 video footage on 6/12/25 at 10:12 a.m. with director of finance N, DON B, and LSW O revealed: *Resident 1 fell on 4/6/25 at 12:45 p.m., 6:04 p.m., 6:12 p.m., and at 6:51 p.m. *At 12:45 p.m., resident 1 stood up from his Broda Pedal Wheelchair (a specialized high-back reclining wheelchair with upper body support that allows a person to self-propel with their hands or feet) that was positioned at the counter in front of the nurses' station. CNA D approached resident 1. Resident 1 swung his arm at her. CNA D stepped back, and resident 1 fell to the floor. -Without requesting assistance or notifying a nurse, CNA D reached around resident 1 and, from the back, grabbed both of his forearms, lifted him off the floor by herself while he was fighting her, and placed him into the wheelchair forcefully. Her movements were quick and rough. She placed his wheelchair at the counter and locked his wheelchair brakes, which prevented him from moving his wheelchair. -CNA M, LPN J, and nutrition and food services supervisor L were all visible on the video footage present in the area of the nurses' station, and did not intervene or offer assistance to resident 1. *At 6:04 p.m., resident 1, positioned at the nurses' station, stood up from his wheelchair and fell to the floor. CNA D was seen from behind the wheelchair, extending resident 1's arms above his head as he lay on the floor. Without requesting assistance or notifying a nurse, CNA D then stood beside resident 1, placed her arms behind him, attempted to hoist him back into his wheelchair, and lifted him from the floor multiple times before seating him roughly into the wheelchair while he resisted her assistance. -CMA G, CNA H, and food service assistant E were all visible on the video footage and present in the area of the nurses' station, and did not intervene or offer assistance to resident 1. *At 6:12 p.m., resident 1, still positioned at the nurses' station, stood up from his wheelchair and again fell to the floor for a third time. Without requesting assistance or notifying a nurse, CNA D lifted resident 1 from the floor and sat him roughly into the wheelchair while he resisted her assistance. -CMA I, CNA D, and food service assistant E were all visible on the video footage and present in the area of the nurses' station, and did not intervene or offer assistance to resident 1. *At 6:50 p.m., resident 1, still positioned at the nurses' station, stood up from his wheelchair and again fell to the floor for a fourth time. He was provided with a pillow, by a staff member and was not observed having been assessed by the nurse or assisted off the floor in that video footage. -He threw the pillow at the staff member and remained on the floor for approximately an hour. -CMA G, CNA K, CNA H, LPN J, and food service assistant E were all visible on the video footage and present in the area of the nurses' station, and did not intervene or offer assistance to resident 1. *CNA D's employment was terminated on 4/7/25 for her actions observed in the video footage immediately after the footage had been reviewed by management on 4/7/25. *CNA K had been a contracted travel employee and was unavailable for interview. Her contract had ended. *CNA H had been a contracted travel employee and was unavailable for interview. Her contract had been terminated due to another incident. *LPN J had been a contracted travel employee and was unavailable for interview. She had terminated her contract three or four days after the incident with resident 1 on 4/6/25. 4. Interview on 6/12/25 at 8:42 a.m. with CMA Q revealed she had recently received training on fall protocols, but did not recall any recent training on abuse and neglect. She completed abuse and neglect training when she was hired and annually online in the Success Center. 5. Interview on 6/12/25 at 9:31 a.m. with LSW O regarding staff training and education revealed: *Monthly All Staff Meetings were mandatory. -Employees were allowed to attend in person, by phone, via a WebEX (an online meeting platform) or were required to read and sign the attendance sheet before their next working shift. *The monthly staff meeting binder was kept in the employee break room. *New employee orientation and annual education were provided on the provider's online Success Center. -Those trainings were assigned by corporate. *Training was also provided in person, by text, and by email. 6. Interview on 6/12/25 at 1:07 p.m. with CMA G revealed she: *Stated she had not worked on 4/6/25, the day that resident 1 had fallen four times. *Did not recall any times that CNA D had been rough when providing care to resident 1. *Had not attended any recent training on abuse, neglect, or falls. *CMA G was seen in the video footage of 4/6/25 at 12:45 p.m., at 6:04 p.m., and at 6:51 p.m. 7. Interview on 6/12/25 at 2:19 p.m. with LSW O revealed she: *Assisted with the completion of audits and had not been aware of any current audits of resident 1's care. *Was unaware that the FRI had indicated, Resident cares with [resident 1] will also be audited randomly for the next 2 months and then prn [as needed] to ensure appropriate interactions from staff. 8. Interview on 6/12/25 at 2:23 p.m. with DON B revealed: *On 4/7/25 administrator A, DON B, director of finance N, and LSW O had reviewed the video footage of resident 1's 4/6/25 falls. -They felt that the video was embarrassing, and had shown everything that should not have been done. --The footage revealed CNA D had been really rough with resident 1 and had locked his wheelchair while it was positioned at the nurse's station. --LPN J had been present on the video footage on 4/6/25 at 12:45 p.m. and 6:51 p.m. and had not assessed resident 1 after his falling incidents. *An assessment of resident 1 had been completed on 4/7/25 after review of the video by Minimum Data Set (MDS) registered nurse (RN) C and DON B, and they had confirmed that bruises on resident 1's forearms correlated with where CNA D had placed her hands while lifting resident 1 after his falls. *The video verified abuse had occurred, and CNA D's agency [travel] employment contract had been terminated immediately. *Education had been provided to LPN J on 4/7/25 on proper transfer techniques and completing a resident assessment after a fall. *In-person staff education was initiated on 4/7/25 on not locking wheelchair brakes, ensuring an assessment was performed by a nurse before transferring a resident after a fall, and proper transfer techniques. *Education on resident abuse and neglect was provided through the online Success Center during orientation and annually. -There had not been any recent training provided on resident abuse and neglect. *Dementia training was ongoing, and a training was scheduled in July with the local ombudsman (resident rights advocate). *DON B expected CNA D to have: -Alerted the nurse when resident 1 fell. -Ensured that resident 1 had been assessed by the nurse before she transferred resident 1 back into his wheelchair. -Asked for assistance when transferring resident 1. -Requested another staff member to take over when she became frustrated with resident 1. *DON B expected the other staff members identified as present when the incidents in the video occurred to have: -Assisted when resident 1 fell. -Stopped CNA D when she attempted to transfer resident 1 alone. -Alerted the nurse when resident 1 fell to complete an assessment to ensure he was not injured. -Attempted other interventions to prevent him from falling. -Contacted him to report the incident. *He was unaware that the FRI had indicated, Resident cares with [resident 1] will also be audited randomly for the next 2 months and then prn [as needed] to ensure appropriate interactions from staff. An interview with CMA I was requested and set up for 6/12/25 at 3:00 p.m. A voicemail was left, and no return call was received. All Staff training completed since 4/1/25, including materials provided and staff who attended, including any additional PRN training/education completed, was requested from administrator A and DON B during the survey entrance conference. Review of the provider's staff training/education documentation since 4/1/25 revealed: *Education on Timeliness of DOH Reports was provided to four employees between 4/28/25 and 5/5/25 and one employee on an undisclosed date. *Neuro [assessment of nervous system function] Vital [vital signs such as blood pressure, temperature, pulse, respirations, and blood oxygen level] Documentation (Falls) education was provided to: -Two employees in December 2024. -Twelve employees in January 2025. -One employee in February 2025. -Two employees in March 2025. *A Falls Investigation packet did not identify the date the training was provided or include a signature sheet for attendance. *The provider's All Staff Meeting Binder revealed: -The 4/24/25 Care Center Monthly Meeting Agenda did not include education on the topics of abuse or neglect. -Out of 66 employees, 33 had attended the meeting or signed that they had reviewed the information in the binder. *The 5/30/25 Care Center Monthly Meeting Agenda did not include education on the topics of abuse or neglect. -Out of 45 employees, 18 had attended the meeting or signed that they had reviewed the information in the binder. *The provider's In Person Dementia Training education staff attendance sheets from 1/8/25 through 5/27/25 did not include documentation of the content of the education provided in that training. *The provider's Ombudsman Dementia Training education staff attendance sheets from 1/28/25 through 5/29/25 did not include documentation of the content of the education provided in that training. *LPN J received training on 4/7/25 on proper assessment techniques after a resident fall, that included resident 1 should have been helped back up to his wheelchair immediately after [an] assessment [of the resident had been completed], not left to lay on the floor .for nearly an hour, and ensuring brakes are not locked on wheelchair that is a restraint . -That training did not include resident abuse and neglect. *Education dated 4/7/25 included notify the nurse immediately so they can assess the resident for injury, and brakes also should not be locked when a resident's wheelchair is stationary, that is considered a restraint, was provided to 26 employees between 4/7/25 and 4/18/25. -Food service assistant E, nutrition and food services supervisor L, and CNA M had not received that education. Interview on 6/12/25 at 4:00 p.m. with executive assistant P regarding abuse and neglect training revealed: *Abuse and neglect training was provided to staff on the Success Center online learning platform. *CNA D was a contracted travel employee from 2/24/25 until 4/8/25 and had not received abuse and neglect training. *CNA H was a contracted travel employee from 4/2/25 until 4/14/25 and had not received abuse and neglect training. *CNA K was a contracted travel employee from 2/26/25 until 5/24/25 and had not received abuse and neglect training. *LPN J was a contracted travel employee from 2/13/25 until 4/9/25 and had not received abuse and neglect training. *Food service assistant E was hired on 8/23/21. Executive assistant P was unable to find documentation that food service assistant E had received abuse and neglect training. *Nutrition and food services supervisor L was hired on 9/19/11. Executive assistant P was unable to find documentation that nutrition and food services supervisor L had received abuse and neglect training. *CNA M was hired on 2/19/25 and received abuse and neglect training on 2/20/25. *CMA G was hired on 5/28/19 and had received abuse and neglect training on 3/8/25. *CMA I was hired on 3/18/24 and received abuse and neglect training on 2/4/25. Review of the provider's 7/10/24 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 subject to any kind of abuse by anyone, 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. *Abuse means the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish. Abuse also includes the deprivation by an individual, including a caretaker of goods and services that are necessary to attain or maintain physical, mental and psychosocial wellbeing. This presumes that instances of abuse of all patients and residents even those in a coma, cause physical harm or pain or mental anguish. *Physical Abuse includes .restraining or confining a patient/resident to control behavior . *Policy To require facility staff to report suspected abuse or neglect of vulnerable adults. *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.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for two of two sampled residents (1 and 2). Findings include: 1. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/28/25 Minimum Data Set (MDS) assessment indicated he was rarely understood or able to understand others and was severely cognitively impaired. *His diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), psychotic disturbance (a mental state where a person loses touch with reality), mood disturbance (a serious mental illness that causes persistent and intense changes in a person's mood energy and behavior), general anxiety disorder, Alzheimer's Disease, Parkinson's disease (a disorder of the central nervous system that affects movement often including tremors), and conduct disorder (a mental health condition that involves a persistent pattern of aggressive and antisocial behavior). *Resident 1 experienced 15 falls between 3/11/25 and 5/7/25. *Five of resident 1's falls occurred on or before 4/6/25. Review of resident 1's Fall Risk Assessments indicated: *On 4/6/25, he had a high risk for falls, and a referral to a Falls Prevention Program may be appropriate, and Continue Current Plan of Care were marked. -Resident 1 fell four times between 4/7/25 and 4/15/25. *On 4/15/25, he had a high risk for falls, and No Referrals Necessary, and Continue Current Plan of Care were marked. -Resident 1 fell four times between 4/16/25 and 4/26/25. *On 4/26/25, he had a high risk for falls, and a referral to a Falls Prevention Program may be appropriate, and Continue Current Plan of Care were marked. -Resident 1 fell two times between 4/27/25 and 5/7/25. *On 5/7/25, he had a high risk for falls, and a referral to a Falls Prevention Program may be appropriate, and Plan of Care Updated, and safety signs in room were marked. -At least eight of resident 1's falls occurred outside of his room. Review of resident 1's fall incident reports and interventions implemented to prevent subsequent falls revealed: *On 4/6/25 at 12:40 p.m., staff were to keep resident 1 in Line of sight for the next couple of hours. *On 4/6/25 at 6:10 p.m., 6:15 p.m., and 6:20 p.m., 4/14/25 at 11:40 a.m., and 12:25 p.m., no documented interventions were put in place. *On 4/15/25 at 11:00 a.m. and 4:00 p.m., UNKNOWN was indicated. *On 4/16/25, resident 1 was agitated and left alone on floor with [a] pillow per [his] care plan. -No other documented intervention was put in place at that time to prevent him from subsequent falls. *On 4/26/25, We let resident [1] lay on the floor until he was ready to get up was documented. -No other intervention was put in place at that time to prevent him from subsequent falls. -On 5/7/25 at 2:45 p.m., Safety signs placed was documented. Review of resident 1's Post-Fall Investigation Tool Recommendations for future prevention revealed: *On 4/14/25 at 11:40 a.m. and 12:25 p.m., 4/15/25 at 4:00 p.m., 4/16/25, 4/18/25, 4/26/25, 4/22/25, and 5/5/25 that section had not been completed. *On 4/15/25 at 11:00 a.m. Quit isolating dementia Pts [patients] was documented. *On 5/7/25, Signs in room was documented. Review of resident 1's care plan revealed: *A problem area indicated Falls [resident 1] at risk for falling R/T [related to] dementia, incontinence, and ambulatory status was last reviewed/revised on 4/24/25. -A 5/7/25 Approach (intervention) indicated Posted signs or pictures to cue [resident] for toileting /assistance prior to [the resident] getting up. -A 4/7/25 Approach indicated Provide toileting assistance every 2-3 [two to three] hrs [hours] while awake and PRN [as needed]. --Resident 1 was Dependent [on the] assistance x2 [of two staff members] for walking on/off unit. --Resident 1 was Able to pedal [his wheelchair] with [his] feet [for] short distances. --Resident 1 was Dependent [on the] assistance x 1-2 [of one to two staff members] for toileting. *Resident 1's care plan had not been updated with fall prevention interventions after falling incidents that occurred between 4/7/25 and 5/7/25. He had experienced nine falls during that time. Resident 1 was out of the facility and unavailable for an interview throughout the survey. 2. Review of the provider's 6/1/25 SD DOH FRI revealed: *[Resident 2] was found on [the] floor at 1910 [7:10 p.m.] by a CNA .he was attempting to self transfer out of wheelchair by [his room]. *Resident 2 sustained a closed fracture of [his] left hip. *Before the fall, resident 2 was changed from [needing to use] a stand aid [a mechanical device that lifts a resident from a sitting position to a standing position] to a stand pivot with two [staff] assist [assistance]. Observation and interview on 6/11/25 at 11:10 a.m. with resident 2 revealed: *He was seated in his recliner, fully reclined, holding a cup of water with a straw. *He answered questions with one to two words, smiled, and laughed. *There was no air mattress overlay on his bed. Review of resident 2's EMR revealed: *He was admitted on [DATE] and received hospice services from 2/17/25 until 5/10/25. *Resident 2 had been evaluated by physical therapy (PT) on 5/15/25. *His 5/23/25 MDS assessment indicated he was rarely understood or able to understand others and was severely cognitively impaired. *A 5/27/25 PT progress note indicated .will change program to add SPT [stand pivot transfer] in addition to stand aid until all staff [are] more comfortable with transfer and staff are aware. *Resident 2 fell on 5/29/25. *A 5/29/25 Fall Risk Assessment indicated resident 2 was Not at Risk for falls and to Continue with Plan of Care. *His 5/29/25 fall incident report did not indicate any interventions were implemented or revised to prevent subsequent falls. *Resident 2's Post-Fall Investigation Tool Recommendations for future prevention revealed toilet more frequently. -His care plan was not updated to include that intervention. *Resident 2 fell on 6/1/25 and sustained a closed fracture of his left hip and was hospitalized . *He was readmitted to the facility on [DATE] and admitted to Hospice Services that same day. Review of resident 2's current care plan revealed: *A 3/5/25 last reviewed/revised problem area of ADL's Functional Status with approaches that indicated: Transfers Dependent x2 [on the assistance of two staff members] for transfers using [a] Hoyer lift [a mechanical lift and sling used to lift a person's full body] to/from toilet, recliner . *A 3/5/25 last reviewed/revised problem area of Falls [resident 2] has a history of falling and is at risk for injury from fall with Approaches that indicated: Posey bed alarm system activated while in bed. Keep bed in low position. Provide proper, well-maintained footwear. Provide resident [2] an environment free of clutter. *A 2/17/25 initiated problem area Terminal Care [resident 2] is on [provider name] Hospice d/t [due to] terminal prognosis of Alzheimer's Disease. That was last reviewed/revised on 3/14/25 with an approach that indicated: -Air mattress overlay .to prevent skin breakdown while in bed. *His care plan had not been updated to indicate: -His transfer status had changed to a stand pivot transfer on 5/27/25. Any new or revised fall prevention interventions after his 5/29/25 fall. He had been admitted to hospice services on 6/5/25. He did not have an air mattress overlay on his bed. 3. Interview on 6/11/25 at 2:08 p.m. with CNA R regarding resident 2 revealed: *Resident 2 was on hospice. *CNA R used the care plan located in the EMR system to know how to care for resident 2. 4. Observation and interview on 6/12/25 at 8:42 a.m. with resident 2 and CNA Q revealed: *CNA Q confirmed resident 2 did not have an air mattress or overlay on his bed. -She indicated he had one when he had previously received hospice services, but it had been removed. *CNA Q used the care plan in their EMR system to know how to care for resident 2. 5. Phone interview on 6/12/25 at 11:19 a.m. with registered nurse (RN) F revealed: *After a resident fell, the staff members on duty would have a post-fall huddle to discuss the fall and how to prevent further falls (interventions). *The post-fall sheet had a place to indicate new interventions. *Minimum Data Set (MDS) RN C updated the care plans. *A list of fall interventions had been posted at the nurses' station recently, and nurses had been told that they needed to update the residents' care plans after each fall. *He had not received education on how to update the care plan. *He would email MDS RN C to let her know if they had tried a new intervention. *He would look in the residents' EMR for their care plans, but he was not sure where the CNAs would find the interventions since they had stopped using pocket care plans (a portable document that outlines a resident's care needs). 6. Interview on 6/12/25 at 1:35 p.m. with MDS RN C regarding resident care plans revealed: *Each department was responsible for its portion of a resident's care plan. *She updated the nursing sections of the resident's care plan when she completed the MDS and expected all nurses to update the care plans as changes occurred. *Staff had been educated on updating care plans in January 2025. *She had posted a laminated list of fall interventions at each nurse's station for the nurses to reference when they updated the resident care plans after a fall. *She expected that resident 2's care plan would have been updated when he was discharged from hospice services in May. *She expected the resident care plans to be updated in real time to reflect the resident's current care needs. *She acknowledged that resident 1 and 2's care plans did not reflect their current care needs. 7. Interview on 6/12/25 at 2:23 p.m. with director of nursing (DON) B regarding resident care plans revealed he expected care plans to be updated to reflect the resident's current care needs. Review of the provider's 1/31/25 Comprehensive Care Plan and Care Conferences policy revealed: *To develop a person-centered care plan for each resident that includes measurable objectives and timetables to meet his or her physical, mental, spiritual and psychosocial well-being. *The care plan is driven by identified resident issues/conditions and their unique characteristics, strengths and needs. When implemented in accordance with the standards of good clinical practice, the care plan becomes a powerful, practical tool representing the best approach to providing quality of care and quality of life. *Person-centered care - To focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. * .The care plans must be revised as the resident's needs/status changes.

Based on South Dakota Department of Health (SD DOH) 1/2/25 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure there was a plan of action implemented following an incident where one of one sampled resident (1) had become physically aggressive with staff and had struck another resident (2) in the face during the interaction. *Ensure one of one sampled resident (1) who had cognitive impairment was free from psychological and physical abuse by three of three certified nursing assistants (CNA) (G, K, and L) during an episode of the resident having had increased agitation and aggression. *Ensure extended education and training on how to take care of residents with dementia and psychosocial behaviors for all staff had occurred to help them assist one of one sampled resident (1) during episodes of increased agitation and aggression. *Ensure all direct care-givers had knowledge of how to access and review updated care plan changes for the residents. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 1/8/25 at 4:57 p.m. to licensed social worker (LSW) A, executive assistant D, and director of finance M for F600: *The provider failed to have an immediate plan of action in place and implemented following an incident that occurred on 1/2/25. *When resident 1 had become physically aggressive with staff and had struck resident 2 in the face during that occurrence. *His behaviors are impulsive, unpredictable, and have the potential to cause harm to both the residents and staff. *Through interviews, document review, and video review, it was identified that there was no plan or education presented to the staff on how to address their ongoing concerns about how to assist the resident during those episodes to ensure the safety of the residents and staff had occurred. *A plan for the removal of the immediacy was requested at that time. IMMEDIATE JEOPARDY REMOVAL PLAN On 1/9/25 at 4:43 p.m. the provider gave the following acceptable immediate jeopardy removal plan: *On 1/8/2025 1309 [1:09 p.m.] a message was sent to residents' psychiatric provider with updates on behaviors. Verbal orders were received by a nurse 1-9-2025 from Psych Provider stated to discontinue Hydroxyzine [allergy and anxiety medication] and to use the PRN [as needed] Seroquel [antipsychotic]. He is also scheduled with the Psychiatric provider for a revisit on 1/13/25. PRN pain medication Tylenol has been scheduled instead of PRN, and Labs CBC, and CMP are ordered by PCP. *1/8/2025 starting at 0645 pm [6:45 p.m.] In person Dementia training Lewy Body Dementia What Everyone Needs to Know was given to staff from day shift and for the overnight. [Name] Administrative Assistant who is Teepa Snow Dementia certified. Training will resume in the morning at 0630-830 [6:30 a.m. - 8:00 a.m.], 12-2 [12:00 noon - 2:00 p.m.], and 3:30-5:30 [3:30 p.m. - 5:30 p.m.] and will continue until all staff are educated before their next scheduled shift. Monitoring of efficacy will be done by scenario role playing drills of all staff by picking random 5 people per week for 1 month and 5 random people a month for 6 months will be documented. *1/9/2025 education on how to find care plans was sent to all staff via email and put on each kiosk, and by the nurse's station computers. Will do one to one education with each staff and they will sign they have received the education. Care plan updates will be added to the 7-day sheet which is communicated in the report to nurses and CNA. MDS [Minimum Data Set] or designee will monitor care plan documentation to the seven-day sheet for updates only from the care plans that were updated weekly for 3 months. *1-8-2025 Residents whole care plan was reviewed to ensure appropriate for resident and if any updates needed to be established. Care plan was updated with ways to approach resident from the front instead of the side or from behind do [due] to diagnosis of dementia. Resident is care planned one to one. One to one is provided as definition of one to one is 1 person assigned to resident that focuses on 1 person needs, abilities, strengths, and interests during staff to resident one to one situation while awake. *Cameras will be monitored especially on nights and weekends random 1-hour snips will be viewed 5 times per week for 1 month 3 times a week for 6 months and will be reviewed at that time for further discussion. *To ensure the safety of all the residents who are likely to suffer or have suffered serious adverse outcomes we are doing current medication review for the resident. We have been in contact with his Psychiatric provider in person. Education for staff including training on dementia before working next shift and setting up quarterly training through the state's ombudsman program. The immediate jeopardy was removed on 1/9/25 at 4:43 p.m. after the survey team verified the provider had implemented their removal plan through document review and staff interviews. After the removal of the immediate jeopardy, the scope and severity of the citation level was an H. Current census was 44. 2. Review of the provider's 1/2/25 submitted SD DOH FRI regarding resident 1's interaction with resident 2 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was zero which indicated he was severely cognitively impaired. *[Resident 1's name] was laying on the floor next to the window, CNA attempted to assist resident off the floor, [the resident] attempted to go after another CNA chasing her, swung his arms as he was running and hit another resident in the face [and] made contact with her right cheek. *Investigation Conclusion: -Investigation started. Separated the resident and staff tried to get [resident 1's name] out of dining room. LSW [licensed social worker] came in and assisted to get his [him] calmed down and then got him ready for bed. Staff stated [resident 1's name] got upset and threw up his arms and hit [resident 2's name]. -Called and updated [resident 1's name] PCP [primary care provider] and will update his psych [psychiatry] provider tomorrow. Plans going forward will continue to monitor [resident 1's name] and will wait and see if his providers make any changes. -The facility has reached out to HSC [Human Service Center] and [behavioral health provider's name] through November and December and have been told his [he] [resident 1] doesn't need an inpatient stay. *No documentation that indicated how the staff should have monitored and assisted resident 1: -To ensure the safety of the other residents and staff during episodes of increased agitation. -Until they received further direction from his providers. -To help decrease his agitation and aggressive behaviors. -No documentation that indicated if resident 2 had been assessed for injury after being struck in the face by resident 1. 3. Observation on 1/7/25 at 12:50 p.m. of resident 2 in the dining room revealed: *She had been sitting at the dining room table visiting with another resident. *She was pleasantly confused and answered simple questions. *They had just finished lunch and the dirty dishes remained on the table. *She repeatedly made gestures towards the dirty dishes and had commented several times that we needed to pick them up. *No visible injury had been observed to her face. Observation on 1/7/25 at 1:10 p.m. of resident 1 in his room revealed: *He was attempting to get out of his bed. *His legs were hanging over the edge of the mattress and he was waving his left arm while yelling hey, hey. *LSW A went into his room and assisted him with getting out of bed. 4. Interview on 1/7/25 at 1:15 p.m. with CNA N revealed: *All of her dementia and abuse training had been online. *She was not aware of any additional dementia training outside of those online course. Interview on 1/7/25 at 1:20 p.m. with resident 5 in her revealed: *Her room was located across the hall from resident 1's room. *She would have left her room once a day to exercise per her preference. *She had: -Changed the time of day that she exercised to avoid resident 1. -Not felt safe from resident 1 and could hear interactions he had with staff and other residents. *She stated: -He goes into other people's rooms. -He tried to come into my room once but an aide stopped him.-We can't lock our doors to keep him out. -I've never seen it, but I know he hits the aides because I hear everything that's going on out there. -About four days ago they gave him a bath and he was fighting, yelling, and screaming the entire time. -He has a bad mouth and says the F word all the time and I find it very offensive. -I don't want to be around him either. Interview on 1/7/25 at 1:50 p.m. and again on 1/8/25 at 11:00 a.m. with CNA E revealed: *She was a traveling CNA and had been working at the facility for approximately two months. *Her dementia and abuse training had been through the mandatory online courses. -She had completed those upon hire at the facility. -There had not been additional training on dementia care outside of those online courses. *She had worked with resident 1 frequently and he had required a lot of staff to take care of him when he was agitated. *She stated: -Nothing will trigger him and he will just start throwing stuff, like chairs, anything in front of him. -He pushes and hits at the staff. -He'll start fighting with you when you try to take care of him. Sometimes it takes three of us to work with him. -He's hit other residents too. -It's happens almost daily. -He only likes the office staff. -The office staff take him to their office sometimes when he is awake. -When they're not here we just have to deal with it. -Yeah, it's scary because I don't want to get hit. -I just get the nurse or someone who knows him when he acts like that. *He had required one to one (one staff assigned to one resident) monitoring when he was awake. *The CNAs were assigned to him and when he was awake someone had to stop helping on the floor and stay with him. -No additional staff were scheduled to work with him. *She stated: -When there are just two CNAs, one of us stops helping on the floor and work just with him. -If the other CNA needs help with a transfer the med [medication] aide had to help or the nurse if she could. -The med aide was supposed to stop what she was doing and help. *She confirmed that unit where resident 1 resides had nine residents who required two staff to assist with a transfer. *There had been times when resident 1 was calm and she would have left him to assist with other residents. *She stated: Usually I was not far [away] and was in the area where he was. *She confirmed: -His behaviors had been unpredictable, quick, and aggressive. -Those behaviors had placed the other residents at risk for being struck by him when staff were not sitting with him. *She stated When he's awake, he's the priority over the others. *She had been working on 1/2/25 when he had an aggressive outburst with the staff and struck resident 2. -He was awake and had required a one to one to follow him around. -The incident happened in the dining room and he had been sitting on the floor. -After the staff tried to help get him up off the floor he turned around and started running after CNA K. She had been assigned to be his one to one. -His arms were waving around and he had punched resident 2 in the cheek. She had been sitting at the dining room table. -The hit had left a red mark on resident 2's cheek. -The police had been called and came to the facility. *Resident 2: -Was confused and had forgotten the incident shortly after it had occurred. -Her husband had recently passed away and she would wander around the two wings looking for him. *Since that incident: -There had been no additional training and education on how to take care of resident 1 or those residents with dementia and behaviors. -There had been an all-staff meeting in December but she had not attended it. To her knowledge those meetings were not mandatory. -The one to one monitoring had been in place prior to the 1/2/25 incident. *She: -Knew where the care plans were located in the electronic system but would not have checked it. -Was not aware if the care plan information was located in the electronic kiosk system where the CNAs charted on the residents. -Had relied upon the nurses and other staff to inform her of care changes for the residents. -Had not been instructed on what the policy and process for one to one monitoring was. -Had relied upon the other staff to tell her. Interview on 1/7/25 at 2:26 p.m. with CNA H revealed: *She was a traveling CNA and was on her fourth contract with the facility. *She had been involved in two incidents with resident 1 where he had hit her. *Regarding the first incident: -She had her hands full of laundry, he came up from behind her, and without warning started hitting her in the head. -She had required medical treatment, had two knots on her head, and missed two days of work. -The travel staffing agency would not allow her to work with him after that incident. *Regarding the second incident she: -Had been on vacation for two weeks and was not informed he had moved to another wing. -Happened to be outside of the room where he had moved to, he came out of his room, and started to punch her in the face. -Had no interaction with him that shift prior to him coming out of his room and hitting her. -Stated: I had no idea he was even down that wing. I was told to take a breather. *His behaviors had been impulsive, unpredictable, and quick. *He had attacked other residents during his episodes of increased agitation. *She stated: -I heard he hit [resident 2's name] in the face, I think it was last week. -Such a sweet lady, but very confused. -She wanders down here [from the other wing] looking for her husband. -The only dementia training we've had is the required course online. -He's a one to one now. Someone has to be with him when he's awake. *There had not been any recent training on abuse, dementia care, or how to take care of residents with aggressive behaviors. Interview on 1/7/25 at 3:15 p.m. with CNA N revealed: *Regarding resident 1: -When he was calm he was a peach. -He could chit-chat with you but he could not have a full conversation. -He was unpredictable and the staff could not tell what triggered his aggressive behaviors. -When he would become aggressive with residents and staff she would have called LSW A to help work with him. -She had been scared of him at times depending on the situation. -He would not have targeted anyone during one of his episodes unless someone was in his way at that time. -He was to have one to one monitoring while awake. -There was no extra staff scheduled to monitor him and the staff had been pulled from the floor to perform one to one monitoring of resident 1. *She stated: -That leaves us one person short on the floor to help with transfers and answer lights. -He is very unpredictable and quick, there is no plan for his outbursts. -He hurt [resident 2's name] last week. -He hit her on the cheek and it left a mark across it. *A dementia training had been offered a couple of months ago. -The training had been offered from 11:00 a.m. to 3:00 p.m. and was not mandatory. -Anyone working during that time, students, and the night shift staff would not have been able to participate in that training. -She was unsure if it had been recorded. *She was not aware of a plan on how to take care of residents like resident 1. *She was not aware of any mandatory or updated training and education after above incident between residents 1 and 2. Interview on 1/7/25 at 3:45 p.m. with CNA G revealed: *He had been a college student and only worked during holiday leave. *He was required to catch-up on additional trainings and education prior to working. *Regarding resident 1: -He had worked frequently with the resident and was aware of his episodes of increased agitation and aggression. -The resident was to have one to one monitoring by staff when awake. -He was sporadic in allowing assistance with personal cares and toileting. -At times it would take two or three CNAs to assist him. -He had a history of biting, kicking, screaming, spitting, and hitting at staff when they had tried to calm him down or assist him with cares. -He had increased behaviors almost daily. Those behaviors occurred mostly during the evening hours when the office staff had left for the day. -No one was aware of what triggered his behaviors. Those behaviors were sporadic and hard to control. -There had not been extra staff scheduled to take care of him when he was awake. -A CNA would have been pulled off the floor to work with him during those times. -That would have left them short staffed on the floor to assist other residents with transfers, cares, and to answer their call lights. -LSW A would have been called to assist with watching him during the daytime hours. -When he was awake he became a priority over the other residents. *CNA G had been working on 1/2/25 when resident 1 had become upset and aggressive towards others. -The resident had sat down on the floor and he attempted to help him get up. -He had been told by the nurses to pick him up and not leave him on the floor. -After staff had assisted resident 1 in getting up, he had taken off after resident 2 and hit her in the face. -He ran to the refrigerator at the nurse's station and threw some yogurt on the floor. -Staff had attempted to get him to sit down in his Broda chair [specialized positioning wheelchair]. *After the incident CNA G had been told he was not following resident 1's care plan and had been reprimanded. -He was not aware that one of the resident's interventions was to let him lay on the floor when he had put himself there. *He was not aware of where the care plans were or how to locate them. *He stated: -I think they are in a book down the hallway. -I don't know, I just do what the nurses tell us to do. *He had not received any extra training on residents with dementia and how to take care of them. -The training he had completed was on the provider's online training site and had been required to be completed on a yearly basis. *He was not aware of any updated training or plan on how to take care of resident 1. *He was not aware of additional training on one to one monitoring or a policy for that. Interview on 1/8/25 at 8:30 a.m. with the interim Minimum Data Set (MDS) coordinator J revealed: *She had been hired: *She started a 13-week contract on 11/4/24 as the interim MDS coordinator until the full-time MDS coordinator returned. *She had been working on 1/2/25 when resident 1 had become upset, aggressive, and hard to calm down. -The incident happened just after dinner and during the nurse's shift report. -He had sat down on the floor and the staff assisted him up off of the floor. -He had bumped into another resident on his way out of the dining area. -He went into the kitchen area and was assisted into a Broda chair. -The police were called per the direction of the on-call staff. -Being in the Broda chair calmed him down and he was calmer by the time the police arrived. -He had not hit resident 2 but rather brushed up against her. She did not have a red mark on her face, it appeared to be an age spot. -Resident 2 had been uninjured and did not remember the incident shortly after it occurred. -There had been a video recording of the incident and she had watched it. -After resident 1 was assisted off the floor he had taken off with his arms flying and brushed up against resident 2. *She had provided verbal education to the staff at that time on resident 1's care plan interventions. -He should have been left to lay on the floor per his wishes. *She stated: -We talk about him all the time and we tell the staff what they should do. -He is a priority, we talk about him daily. -Those staff should tell the other staff. *There was no documentation that indicated she had provided that verbal education. *There was a clipboard at the nurse's station that contained updated resident care plan information. -Sometimes those updates were given verbally to the direct care staff. -She agreed if it had not been documented there was nothing to support that education had been provided. -She would have expected those staff to inform the other staff of any care plan changes/updates. *She stated: Everyone knows to use it [regarding the clipboard at the nurse's station] they use it every day. *Resident 1 was on a one to one monitoring plan and staff were assigned to take care of him on the daily sheet at the nurse's station. -The staff had been pulled off the floor to work with the resident when he was awake. -The nurse and med aide had been expected to assist with transferring and answering other residents' call lights during that time. -During the daytime hours, resident 1 spent a lot of his time with the office staff to help assist with the one to one monitoring. -Those office staff had not been there on weekends or after daytime hours to have assisted with resident 1. *She was not aware of any additional training, education, or updates regarding resident 1's episode on 1/2/25. *She stated: -There is extra hands-on training for dementia care in the works. -In the meantime we are trying to keep him a one to one. -No, the one to one is not a new change for him. *She agreed the staff should have had hands-on dementia care training sooner. Interview on 1/8/25 at 9:56 a.m. with licensed practical nurse (LPN) F revealed: *She had been working the evening of 1/2/25 when resident 1 had an outburst. -He had been agitated prior to her leaving the area for the nurse's change of shift report. -She had walked with him until he had calmed down prior to that meeting. -A CNA came and got her out of the report room to help with resident 1. -Resident 1 had sat on the floor and the staff had attempted to assist him with standing. -He became upset and ran after CNA K and in the process had hit resident 2 in the face. -He was uncontrollable and was in the kitchen area going through the refrigerator. -The staff helped him to sit down in his Broda chair. -Most of the time the Broda chair was a comfort for him. -She called the on-call administrator and was instructed to call the police. -She checked resident 2's right cheek and it had a large reddened area and measured it. It was not raised or hurtful to the resident. *The CNA assigned as resident 1's one to one that evening was fearful of him and had been involved in other episodes of his agitated and uncontrolled aggressive behaviors. *Resident 1: -Had frequent, almost daily outbursts of uncontrollable and aggressive behaviors. -During those episodes he had been hard to calm down and would start hitting, scratching, biting, and kicking at staff. -There had been times when LPN F had walked with him during those episodes and he hit and scratched at her. -She had received bruises from his hitting. -She had not filled out an incident report on all of those resident-to-staff occurrences because she thought nothing would have changed with his plan. -His behaviors were unpredictable because they were sporadic, quick, and it was hard for staff to tell what would have triggered an onset of increased aggression. -Most of the staff had been scared of him because of his aggressive behaviors. -During the daytime hours through the week days he spent most of the time in LSW A's office. She thought the LSW had a good relationship with the resident. *He had been placed on one to one monitoring after the last complaint survey on 10/31/24. -The direct caregivers working the floor had all been assigned to do that task. -Whoever was available would take over the one to one task with him when he was awake. *No extra staff had been scheduled to provide his one to one monitoring only the already scheduled staff. -At times this would have left them short staffed on the floor to assist the other residents with transfers, cares, and answering resident call lights. -The nurses and med aides had been expected to assist him or the other residents during those times. *She had been told he was a priority when he was awake. *She helped the staff on the floor and with his one to one as much as she could. -She had other tasks that she was responsible for and had to finish herself. *She confirmed: -Nine out of the twenty-two residents that lived on the same wing as resident 1 had required two staff for assistance with transfers. -Those nine residents had to wait at times for assistance when resident 1 was awake and required one on one. *There had been no changes since the last episode with resident 1 on 1/2/25. -There had been no changes to the staffing to accommodate the needs of resident 1. -Resident 1's plan of care had not been updated or shared with staff if it had been updated. -No mandatory education was provided on how to work with him or residents who had dementia and increased behaviors. *She had completed dementia and abuse training that year. -That training was mandatory and part of the yearly required online trainings. *The staff had not been educated on what the provider's one to one monitoring policy requirements were. -She was not sure if they had a policy or process in place on how to take care of resident 1. *She was not part of the care planning process and was not aware of how that process worked. *She did not know how to access the care plans to check for any changes. *She had not been informed of any resident care plan updates or changes. *She stated: -I would think I should be updated on any care plan changes so we know how to take care of the residents. -I'm in charge of the residents and staff and new myself so I would think I should know these things. -I don't think there is a good plan in place to take care of [resident 1's name] and if there is I'm not aware of it. *The all-staff meetings had not been mandatory. -There was one in December and dementia care was scheduled to be discussed. -She had not attended it because it was not mandatory, she had not worked that day, and had other obligations. -It was optional for the staff to attend the dementia training and all staff meetings. Interview on 1/8/25 at 11:54 a.m. with LSW A revealed: *She had assisted the staff with one to one monitoring of resident 1 during the week and during the daytime hours. *A staff had not been assigned one to one monitoring for resident 1 until December. -The office staff had been providing the one to one monitoring since the last complaint survey on 10/31/24 to support that plan of correction. *To her knowledge there had been extra staff to provide the one to one, but she was not responsible for the scheduling. *Since the incident on 1/2/25 they had been in touch with the Ombudsman to try and set-up additional dementia care training for the staff. -To her knowledge there had not been any other changes or updates to resident 1's care plan to help the staff with taking care of him. *She stated: -He is just fine with me and I'm not scared of him. -I talk to the staff all the time on different things they can do to help keep him calmer. -He has problems with his peripheral vision and I'm not sure if that's a part of his care plan. -But the care plan doesn't explain the one to one expectations either. -The expectation is that staff keep him, other residents, and staff safe. *She agreed: -The peripheral vision difficulties should have been a part of his care plan so the staff would have known how to approach him better.-One to one monitoring expectations should have been a part of his care plan so the staff would have known how to take care of him. *They had mis-interpreted the CMS guidance for gradual dose reductions and his antipsychotic medication had been discontinued a few months ago. -Since then his behaviors had increased and the Seroquel had been restarted. He was not quite to the dose he had been on before it was discontinued. *She had no response when asked if the staff had been properly educated on: -How to take care of resident 1 or residents with dementia and aggressive behaviors. -What the one to one monitoring expectations for resident 1 had been. Interview on 1/8/25 at 12:42 p.m. with CNA K revealed: *She had been working there for approximately 6 months. *She had been working the evening of 1/2/25 during the episode with resident 1. *The expectation was for her to be with him at all times while he was awake. -That had included walking with him, giving him things to do, and assisting him with his care needs. *She had been walking with him when he laid down on floor in the dining room. *She and CNA G had not been aware that when he sat or laid down on the floor he was to have been left there. *CNA G assisted resident 1 up off the floor and he ran after her. *In the process of running after her, he had hit resident 2 in the face. *Resident 1 ran into the kitchen area and rummaged through the refrigerator. *They had tried to help him sit down in the Broda chair but he kept trying to get out. *She stated: -I was afraid of getting hit. -Honestly, I'm scared of him and so are some others. -Leadership knows we are, they just ignore it. *She confirmed: -Resident 1 had required one to one monitoring when he was awake. -She had not received extra training on what the one to one person should have done when working with him. -There had not been extra staff scheduled to assist or monitor him when he was awake. -Whoever was available would have provided the one to one monitoring. -That staff person still had other residents to take care of and tasks. -The needs of the other residents had to wait until a staff person was available to assist them. -She had been instructed that the one to one resident had taken priority over the other residents. -She thought resident 1 had been neglected because of his increased behaviors. There had been times he had sat in his bowel movement because they had been to scared to change him. *She stated. Sometimes it takes up to three of us to change him or work with him so that no one gets hurt or kicked. *She had: -Not felt that she had the proper training to help take care of resident 1 and other residents with similar behaviors. -Not been aware of any updates or changes to his plan of care since the incident on 1/2/25 to ensure the safety of others and himself. -Had not been kept informed of when the resident's care plans had updated or changed. *She stated. One time a resident's diet changed to puree [food blended to a smooth consistency] and the only reason I knew that was because it was on the sheet they checked to see what the resident's wanted. *She had not completed any dementia care training and to her knowledge the online course was not mandatory. *She stated: -I've been told there is an upcoming training. -But they also said it won't be for a while now because all the students were going back to school Interview on 1/8/25 at 1:43 p.m. with director of nursing (DON) B revealed: *The online dementia training that should have been completed by 11/29/24 per their plan of correction from the 10/31/24 survey was for their ancillary staff only. -Such as, dietary, maintenance, and housekeeping. *The online dementia training was mand

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy the provider failed to ensure one of one sampled resident (1) consumed adequate fluid intake to alleviate and prevent dehydration. Findings include: 51472 Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review the provider failed to ensure one of one sampled resident (1) consumed adequate fluid intake to prevent dehydration and one of one sampled resident (1) had neurological checks completed after a fall. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *On 12/8/24 at 1:41 p.m. resident 1 was found on the floor beside his bed. *He stated that he was trying to get up into his wheelchair. *On 12/9/24 resident 1 complained of back pain and staff documented confusion and lethargy (decreased consciousness, fatigue, drowsiness, or sleepiness). *On 12/9/24 resident 1 was sent to the clinic for an appointment due to the inability to collect a urine sample. -At the clinic appointment he was diagnosed with three rib fractures, a urinary tract infection (UTI), and dehydration. -Resident 1 received intravenous (through a vein) fluids and an antibiotic. *On 12/9/24 returned to facility with orders to start oral antibiotics on 12/10/24 and follow up with the provider on 12/11/24. Observation on 12/26/24 at 3:00 p.m. of the water pitchers in the residents' rooms revealed: *There were pitchers with a clear liquid in the residents' rooms. *Some pitchers were full, and others were partially full. *Some pitchers contained ice and others did not. *Resident 1's water pitcher was in his room and was full of a clear liquid with ice present. Interview on 12/26/24 at 3:20 p.m. with certified nursing assistant (CNA) G revealed: *Water was passed out to the resident rooms around 2:00 p.m. *Resident 1 was able to request a refill of water. *Resident 1 often requested staff refill his water. *With meals resident 1 usually drinks coffee, juice, and water. *Dietary staff documented the residents' fluid and food intake at meals. *Nursing staff did not document fluids taken by residents outside of meals unless the resident was on a fluid restriction. Interview on 12/26/24 at 3:30 p.m. with licensed practical nurse (LPN) I revealed: *Water was to be passed out to the resident rooms at 2:00 a.m. and 2:00 p.m. *LPN I was the nurse on duty on 12/8/24 at the time of resident 1's fall. *Resident 1 did not describe to her how the fall happened, but LPN I stated that resident 1 was unsteady and fell . * She stated that resident 1 had been more unsteady and she was unsure how he had not fallen more than he had. *She stated that resident 1 wants to be more independent than he is safe to be, and he did not follow recommendations made by staff. *She reported that at the time of resident 1's fall, he denied pain. *She explained that his right rib pain documented after the fall was also documented before the fall. *She stated that there was a urine sample ordered before his clinic appointment on 12/9/24 but it was unable to be obtained due to incontinence. Observation and interview on 12/26/24 at 3:50 p.m. with resident 1 revealed: *He was self-propelling in his wheelchair rapidly. *He had no trouble getting water. *He could get water out of his sink or go get a pop. *His gave a urine sample about four days ago that was pure yellow. *His urine was not usually that yellow. *He fell at least once per week, sometimes every other day. *He had to be careful because he was unsteady. *He explained that he had been told by staff to use his call light to get assistance, but he only used his call light when he wanted to go outside to smoke. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 11/15/24 Brief Interview of Mental Status (BIMS) assessment score was 3 which indicated he was severely cognitively impaired. *His diagnoses included: Tourette's (a disorder involving repetitive movements or unwanted sounds) retention of urine, weakness, urinary tract infection, dehydration, and prostate cancer. *He was found on the floor in his room on 11/20/24, 12/1/24, and 12/8/24. *The documented assessments following each of those falls indicated that he denied hitting his head or having pain. *On 11/19/24 resident 1 was started on an antibiotic for a sore throat. *On 11/19/24 and 11/20/24 it was documented that he had spent most of the time in his bed. *On 11/19/24 and 11/21/24 it was documented that he had no appetite and a small appetite. *On 11/22/24 Resident 1 reported he had left rib pain and staff documented he had increased weakness and needed for assistance with cares. -He stated that he fell into his w/c [wheelchair] yesterday. -An order was received to x-ray his left ribs. *On 11/28/24 resident 1 refused his supper. *On 12/3/24 resident 1 reported he had right rib pain. *On 12/3/24 at 5:02 p.m., it was documented that resident 1 had remained in his room since breakfast. *On 12/4/24 it was documented that resident 1 was asking if he was in the right room and he stated that he was seeing a dog outside. *On 12/4/24 resident 1 went to a clinic appointment, medication changes included: -Discontinue melaxicam, flexiril, and januvia. -start hydrocodone three times a day and continue the as needed order. -start Excedrine ES two tablets in the morning as needed. -Omeprazole 20 mg (milligrams) in the morning. -Naproxyn 500mg at bedtime. -Update in a week on how he [resident 1] responds in one week. *On 12/6/24 resident 1's daughter was informed that his status has declined. *On 12/8/24 resident 1 needed assistance with changing his brief and clothing. *On 12/9/24 resident 1 had episodes of confusion, increased lethargy, and c/o [complaints of] back pain. -He was scheduled for an appointment at the clinic. -He was diagnosed with right rib fractures, dehydration, and a urinary tract infection. *On 12/11/24 labs were rechecked and the antibiotic he was taking by mouth was increased. *On 12/12/24 the clinic called and asked that we push water and fluids for resident 1 as his labs showed he was still slightly dehydrated. Review of resident 1's fluid intake for meals from 12/1/24 through 12/26/24 revealed: *There was no documentation for 18 of 26 breakfasts. *There were three suppers and one lunch that were not documented on. *There were 12 times that 0ml (milliliters) of fluid was documented. *According to the fluid intake documentation, resident 1's average daily fluid intake: -Between 12/1/24 and 12/7/24 it was 557 ml. -Between 12/8/24 and 12/14/24 it was 480 ml. -Between 12/15/25 and 12/21/24 it was 640 ml. -Between 12/22/24 and 12/26/24 it was 980 ml. Review of resident 1's weights from 12/3/24 through 12/24/24 revealed: *On 12/3/24 resident 1 weighed 156 pounds. *On 12/11/24 resident 1 weighed 138 pounds. *On 12/18/24 resident 1 weighed 147.5 pounds. *On 12/24/24 resident 1 weighed 152 pounds. Review Resident 1's 11/19/24 dietary quarterly assessment progress note entered by supervisor, nutrition and food services C revealed: *Resident 1's meal intakes were, breakfast is 76-100%, lunch is mostly 76-100%, and dinner is 50-100%. *His fluid intakes are good and his weights have been steady over the past 6 months. Review of Resident 1's 12/9/24 clinic note revealed: *He had been a little confused and unsteady for the past week or so. *He had some chronic right rib pain. * He had a history of urinary frequency and has a known history of prostate cancer. *He was alert and aware of surroundings but has some slurred speech. -*The right rib fractures were new from 11/22/2024. *His labs indicated that resident 1 was dehydrated and had a significant UTI. *He was dehydrated appearing. *IV fluids and an IV antibiotic were ordered with a plan to start antibiotics by mouth. Review of resident 1's 12/27/24 care plan revealed: *He was at risk of falling. *He had a history of noncompliance with physical therapy recommendations and not calling for help when needed. *He had an identified history of urinary tract infections that was initiated on 8/15/22. -The approach for this indicated staff were to Report signs of UTI (acute confusion, urgency, frequency, bladder spasms, nocturia, burning, pain, difficulty urinating, low back pain/flank pain, malaise, nausea/vomiting, chills, fever, foul odor concentrated urine, blood in urine). * He had an identified potential for nutrition and fluid problems that was initiated on 7/1/22. -The goal was that resident 1 will be well hydrated. -The approaches to achieve this goal included: --Resident 1 will have all meal and fluid intakes recorded daily. --Resident 1 will have fresh water in his room and is capable of drinking on his own. He will be reminded to drink plenty of fluids. --Resident 1 will be weighed weekly with his bath and an increase or decrease of 4# [pounds] or more will be reported to the charge nurse and re-weights will be done according to policy. Interview on 12/27/24 at 8:42 a.m. with cook H revealed: *Resident 1 usually comes out for all meals. *If he would would choose to remain in his room for a meal a meal tray would be provided. *She stated that in her observations, if resident 1 received a meal tray in his room he ate the majority of the meal. *If she noticed a resident's meal intake had decreased, she would notify a nurse or CNA. Interview on 12/27/24 at 8:45 a.m. and 10:40 a.m. with registered nurse (RN) F revealed: *Nursing does not document fluid intake for residents. *Resident 1 usually comes out to the dining room for breakfast. *There was no formal process to alert nursing if there was a decrease in a resident's intake. *She stated that she would expect dietary or a CNA to report to the charge nurse if a decrease in meal intake was seen. *She stated that if there was an identified change in a resident's intake this would be passed on through report (nurse to nurse communication at change of shift). *Supervisor, nutrition and food services C would bring the resident weights printout to nursing weekly. *If there was an increase or decrease of four pounds in a resident's weight from the previous week the resident would be reweighed daily for three days. *She confirmed resident 1 weighed 138 pounds on 12/11/24. *She confirmed this weight was more than a four-pound weight loss from the week prior. *She confirmed there were no daily weights completed after the weight loss was documented. Interview on 12/27/24 at 10:45 a.m. with supervisor, nutrition and food services C revealed: *She printed a weekly weight report on Fridays around noon. *She identified on that report, with a marking, any weight gains, or losses greater than four pounds. *She would give the report to the CNA coordinator, the director of nursing, the minimum data set (MDS) nurse, and the charge nurse for each hallway. *The dietician completed audits on resident intakes. *She audited quarterly when she completes the MDS. *It was her expectation that resident intakes for all meals were to be charted. *She stated that she completed random audits of meal documentation and reports them to quality. *She stated she had not noticed missing documentation. Interview on 12/27/24 at 12:15 p.m. with director of nursing A revealed: *It was her expectation that a neurological check would be completed on every shift for 72 hours with all falls. *Resident weights were to be completed on Mondays, Tuesdays, and Wednesdays. *On Friday, the supervisor, nutrition and food services C printed the weight report, highlighted residents with weight changes and gave it to the DON, MDS coordinator, the CNA coordinator, and the charge nurse for each hallway. *She expected if there was a weight change, the resident who had the weight change would be reweighed for three days. *She indicated that the charge nurse was responsible for initiating the reweights. *The CNA coordinator was responsible for follow-up on the reweights. *The dietician and the MDS coordinator would then be notified if there was a confirmed weight loss unless it was a planned weight loss. *She stated that the resident's representative should be notified of a confirmed weight loss. *She stated that the resident's provider would be notified of a confirmed weight loss if an order for a nutritional supplement was needed. *She stated that the nursing staff did not chart fluid intake unless the resident was on a fluid restriction. *She stated that any fluid consumed during snacks or in the resident's room was not documented. Review of the provider's 4/1/24 Nutrition and Hydration- Food and Nutrition policy revealed: *Identify, implement, monitor and modify interventions (as appropriate) that are consistent with the resident's assessed needs, choices, preferences, goals, and current professional standards of practice to maintain acceptable parameters of nutritional status. *Monitor weight and intake of food and drinks. *Monitor to determine whether the resident is consuming adequate food and fluid for their needs. Fluid includes beverages, foods that are liquid at room temperature and fluid in foods. *A goal of 1,500 mls (ccs) of liquids per day is often recommended. Fluids at snack times will be recorded in PCC-POC [EMR] per care plan. Review of the provider's 10/15/24 Weight and Height policy revealed: *The location will immediately inform the resident, consult with the resident's physician and, if known, notify the resident's legal representative when there is a significant change in the resident's weight, as defined by the RAI [Resident Assessment Instrument] manual. *If weight varies by more than three percent, reweigh resident and document. *The licensed nurse should notify the director of food and nutrition (DFN) within 24 hours regarding any significant weight change. Significant weight change is defined as five percent in 30 days, 7.5 percent in 90 days and 10 percent in 180 days.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (2) who fell , suffered head trauma, and required emergency room treatment, while attempting to sit down on a whirlpool chair when one of one sampled employee (K) failed to ensure the brakes on the whirlpool tub chair were locked. Findings include: 1. Review of the provider's 12/17/24 FRI regarding resident 2 revealed: *She was getting ready to take a bath in the whirlpool tub. *She attempted to sit down on the tub chair. *The tub chair brakes were not locked, and she fell forward landing on her face. -She had supraorbital bruises to both eyes, a skin tear to her right wrist, and she was transferred to the emergency room (ER) for evaluation. Interview and observation on 12/26/24 at 3:05 p.m. with resident 2 revealed: *She stated I look like this is [because] the aide didn't lock brakes on [the] chair. Maybe try: She was going to take a whirlpool bath and when she went to sit down on the tub chair, it slid out from under her, and her face hit the floor. *Her face had purple bruising under both eyes, a greenish-colored raised area above her right eye, and a scabbed area between her eyes on the bridge of her nose. *She now ensured the brakes are locked on the tub chair before attempting to sit down. *She was not willing to share the staff member's name of who did not lock the brakes. -She stated She is a sweet thing and I do not want anything to happen to her. -She indicated she felt the issue was related to lack of staff training rather than an intentional oversight. Interview on 12/27/24 at 8:22 a.m. with licensed practical nurse (LPN) I revealed a certified nursing assistant assisted residents with baths unless the CNA was not of age to operate mechanical equipment. Observation and interview on 12/27/24 at 8:29 a.m. with CNA J in the tub room revealed: *She received education on the use of the whirlpool tub chair in 9/2024 when she took classes to become a CNA. *She knew the wheels on the tub chair needed to be locked to prevent it from sliding when a resident attempted to sit in it. *She indicated there were various signs throughout the tub room with the safety requirements needed to operate and clean the tub appropriately. -No signage indicated the wheels needed to be locked on the tub chair. -She had no knowledge of where the manufacturer's instructions for the operation of the tub chair would have been located. Observation on 12/27/24 at 8:38 a.m. of the whirlpool tub room revealed: *There was a whirlpool tub chair which had four wheels. -The two wheels on the back of the chair were able to be locked to prevent the chair from moving. -All the wheels were functioning as intended. Review of resident 2's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included: arthritis, stroke, history of fall with fracture, and epilepsy. *Review of resident 2's 12/27/24 care plan revealed: *She was identified to be at risk for falls related to a stroke that affected her left side. -Her medications listed on the care plan included: use of antipsychotic, narcotic, antidepressant, antihypertensive, antihistamines, and laxative meds [medications] which can contribute to falls. -She was independent in room and throughout facility with front wheeled walker for stability. -Her bathing performance required Supervision of one staff member for transfer to/from bath. *Review of her nurses progress notes revealed: -On 12/17/24 she was sent to the ER due to a fall from a tub chair that did not have the wheel brakes locked. -On 12/26/24 she still has bruising to the face and some on her arms. Review of resident 2's ER notes revealed: *She was seen on 12/17/24 at 8:05 a.m. for a fall. -She had a skin tear to her right wrist, a skin tear to her right nose, and a hematoma (raised bruised area) above her right eye. -A CAT scan was performed and was negative for any acute intracranial findings. -She was discharged back to the facility on [DATE] at 10:05 a.m. with orders to Ice for next 24-48 hours. Review of CNA K's employment record and training records revealed: *She was hired on 10/29/24. *Her last day of orientation was on 12/14/24. *Her 11/13/24 Safe Resident Handling Equipment Competency Validation Checklist included: -Uses appropriate safety measures and equipment to prevent accidents. -Manufacturer's directions should be followed for use of bathing equipment. *On 12/17/24 following the above incident CNA K was provided immediate education by LPN I to remember to lock the brakes on beds, wheelchairs, and bath chairs. Interview on 12/27/24 at 12:30 p.m. with director of nursing (DON) A, social worker B, and administrative assistant D regarding the use of the tub chair revealed: *DON A stated a staff member could ask management for the manufacturer's instructions for safe use of the tub chair, if they wanted to look at it. *After the above incident with the tub chair, staff had been educated by writing a note on the communication sheet. Review of the provider's 12/15/24 Communication Sheet revealed a handwritten note that read All staff education *make sure breaks are locked on shower/bath chairs. *There was no documentation to support nursing staff had read the form. Review of the provider's 9/3/24 Bathing policy revealed: *Use appropriate safety measures and equipment to prevent accidents. *Manufacturer's directions for operating and maintaining equipment should be followed. Review of the 10/1/09 Manufacturer's Patient Transfer Lift System Safe Operation and Daily Maintenance Instructions revealed: *System Preparation (Before Transferring or Lifting). -Lock the brakes by stepping down on the lock-arm tab located on the back of the rear casters. -WARNING --Failure to lock the caster brakes before the resident is transferred, could result in injury to the operator or patient [resident]. Review of the provider's 8/1/23 Safe Resident Handling Program (SRHP) revealed: *Will include bathing equipment as part of the SRHP. Locations may choose a separate manufacturer for bathing equipment (tub lifts, shower chairs, shower gurney) but must consider safety, training and compliance. *Will provide training and documented competency for all caregivers (including contracted employees with direct care responsibilities) prior to providing resident care with mobility and bathing. Review of the provider's 11/20/24 Nursing Assistant, Certified, job description revealed, Assists the resident in transferring, repositioning, and walking using correct and appropriate transfer techniques and equipment .

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review the provider failed to ensure one of one sampled resident (1) had neurological checks completed after a fall. Findings include: 51472 1. Review of the provider's submitted SD DOH FRI regarding resident 1 revealed: *On 12/8/24 at 1:41 p.m. resident 1 was found on the floor beside his bed. *He stated that he was trying to get up into his wheelchair. *On 12/9/24 resident 1 complained of back pain and staff documented confusion and lethargy (decreased consciousness, fatigue, drowsiness, or sleepiness). *On 12/9/24 resident 1 was sent to the clinic for an appointment due to the inability to collect a urine sample. -At the clinic appointment he was diagnosed with three rib fractures, a urinary tract infection (UTI), and dehydration. Observation and interview on 12/26/24 at 3:50 p.m. with resident 1 revealed: *He was self-propelling in his wheelchair rapidly. *He fell at least once per week, sometimes every other day. *He had to be careful because he was unsteady. *He explained that he had been told by staff to use his call light to get assistance, but he only used his call light when he wanted to go outside to smoke. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 11/15/24 Brief Interview of Mental Status (BIMS) assessment score was 3 which indicated he was severely cognitively impaired. *His diagnoses included: Tourette's (a disorder involving repetitive movements or unwanted sounds) retention of urine, weakness, urinary tract infection, dehydration, and prostate cancer. *He was found on the floor in his room on 11/20/24, 12/1/24, and 12/8/24. *The documented assessments following each of those falls indicated that he denied hitting his head or having pain. Review of the neurological flow sheet from resident 1's 12/8/24 fall revealed: *The neurological flow sheet indicated that neurological checks were to be completed every 15 minutes x4 [four times], every 1 hour x2 [two times] , every 2 hours x2, and every 4 hours x2 *The neurological checks were not documented as completed on the day shift on 12/9/24 and 12/10/24 or the night shift on 12/9/24. Review of the provider's 3/1/24 Fall Prevention & Follow-Up Reporting-LTC policy revealed: *For any resident with a fall the resident will have vital signs taken each shift for 3 days. *In the event of an unwitnessed fall, open the post fall order set in Matrix for: Fall: With Suspected head trauma- Neuro checks Q [every]15 minutes x 4, then Q1 hour x2, then Q2 hours x2, then Q4 hours x2, then Q shift x3. This order set will apply to all unwitnessed falls regardless of signs of head trauma.

Based on South Dakota Department of Health (SD DOH) 9/25/24 facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to: *Ensure the physical and psychosocial wellbeing for one of one sampled resident (1) with a history of trauma expressed feelings of fear, feeling unsafe, and suicidal thoughts that potentially increased after an unwanted entry into her room and an act of physical aggression made towards her by resident (2) who has cognitive impairment. *Ensure two of two sampled residents (2 and 3) were free from acts of verbal and physical aggression towards each other. Findings include: 1. IMMEDIATE JEOPARDY NOTICE Notice of immediate jeopardy was given verbally and in writing on 10/30/24 at 3:06 p.m. to administrator A and executive assistant K for F600 related to resident 1's fears and expressed suicidal thoughts following unwanted encounters with resident 2, lack of necessary interventions to keep resident 2 from entering other rooms and aggressing and maintaining separation of residents 2 and 3 to minimize verbal and physical aggression towards each other. A plan for removal of the immediacy was requested. 2. Review of the provider's 9/25/24 SD DOH FRI revealed: *Resident 2 entered resident 1's room and a verbal altercation occurred. *Resident 1 became scared due to pass [past] personnel events earlier in her life. *Resident 1 has a trauma history and does not care for this resident [resident 2] who walked into her room. *Regarding resident 2 Medication has been restarted is aware of behaviors with behaviors getting better with medication adjustments. -No other interventions to keep resident 1 safe were included in the FRI. Observation on 10/29/24 at 2:17 p.m. of resident 2 revealed: *He was in the commons area, walking with socks on his feet and no shoes. -He was smiling and laughing, was able to say words, but his statements were nonsensical. Observation on 10/29/24 at 2:43 p.m. of resident 2 revealed: *He was in the kitchenette area and staff were able to redirect him to the commons area. -He agreed to sit on the couch, was assisted to the couch, and then refused to sit down. -He continued to attempt to enter the kitchenette. Interview and observation 10/29/24 at 3:07 p.m. with resident 1 revealed: *There was a mental health therapist who came to the facility, weekly, to counsel her. -She had received counseling from that therapist for many years and felt it was very helpful. -She stated, She has dug me out of a hole more than once. *When asked specifically about other residents she stated that's a hard piece to chew because some of them have hearing and vision deficits. *When asked if she felt safe, she replied no. *She stated resident 2 had tried to strangle me about a month ago, he came from behind and grabbed her neck with both hands and then let go and left. -She demonstrated by placing both of her hands around her neck. -She stated that she had not provoked him. She didn't know what got into his head. *He entered her room again on 9/25/24, she yelled at him, and he left after a short time. -She stated, I was so shaky it caused me to go to the hospital. -She stated that she has been at the hospital before for severe depression, PTSD (Post Traumatic Stress Disorder),anxiety and all that stuff. *She stated, He [resident 2] is still here so I don't think they have done anything and the staff tell her it takes time. *She had been instructed by the staff to push her call button, yell, or scream, when resident 2 came into her room. -He has continued to come into her room, she tells him to leave, and he does. *She stated, I choose to stay in my room because I don't want any contact, I think he needs to go somewhere where he can get the proper attention. Review of the provider's 8/1/24 SD DOH FRI revealed: *On 7/31/24 resident 2 was very agitated. -He had a verbal altercation with resident 3. -Both men were separated into different ways. Recommendation: continue to monitor. -No other interventions were included in the FRI. Review of the provider's 10/15/24 SD DOH FRI revealed: *On 10/15/24 resident 2 entered resident 3's room. -Resident 2 was yelling and swearing at resident 3. -Resident 3 reported resident 2 grabbed his forearms. -There was no visible injury. 3. IMMEDIATE JEOPARDY REMOVAL PLAN On 10/30/24 at 7:11 p.m. administrator A provided the survey team with a final written immediate jeopardy removal plan. The removal plan had been approved by the survey team on 10/31/24 at 8:32 a.m. with guidance from the assistant administrator and long-term care advisor for the South Dakota Department of Health. The provider gave the following acceptable immediate jeopardy removal plan on 10/31/24 at 10:30 a.m. 1. On 10/30/24 at 3:25 p.m. implemented one-to-one staff assistance for resident 2 to ensure his safety and residents 1 and 2's safety. 2. On 10/30/24 updated resident 2's care plan with the new interventions to keep residents 1 and 3 safe. 3. On 10/30/24 at 4:06 p.m. resident 2 was moved to the opposite household to limit interactions between residents 2 and 3. 4. On 10/30/24 at 4:23 p.m. resident 2's primary care physician was notified and an order for Rexulti and a second referral to psychiatric counseling was received. 5. On 10/30/24 at 5:19 p.m. a paper stop sign was placed next to resident 1 and 3's doorways to deter resident 2 from entering their rooms. 6. On 10/30/24 approximately 5:25 p.m. completed immediate education with all staff on duty. 7. On 10/30/24 at 5:34 p.m. emailed all staff resident 2's updated care plan. 8. On 10/30/24 at 6:16 p.m. texted all staff that they needed to read that email and care plan. The immediate jeopardy was removed on 10/31/24 at 10:30 a.m. after the survey team verified the provider had implemented their removal plan. After the removal of the immediate jeopardy, the scope and severity of the citation level was lowered to a G. Current census was 43. 4. Interview on 10/29/24 at 2:20 p.m. with housekeeper I revealed: *She felt resident 1 did not like resident 2 because, He has choked her before a couple of months ago. -Resident 1 went to a psychiatric hospital as she was afraid of resident 2. *Housekeeper I had no training regarding dementia and behaviors of residents. Interview on 10/29/24 at 2:44 p.m. with licensed practical nurse (LPN) F revealed: *He [resident 2] is very busy and he wandered quite a bit. -He wandered into other resident rooms when he was not provided one-to-one assistance from staff. -Other residents would get upset with resident 2. -He would spend most of the day in the social service staff's office. -He often became worked up and anxious. -She indicated that loud noises triggered his behaviors and would set him off. -He had a history of becoming physically abusive to staff. -She was not aware if he had become physically abusive to other residents. -She stated that resident 3 often sets him off. *She identified the following interventions for resident 2's behavior: -Direct him to the social service staff office. -A staff member was to spend one-to-one time with him. -When he was exit seeking, a staff member was to walk with him around the facility. *She knew that on 8/22/24 at 6:30 p.m. there was an incident between resident 2 and resident 1 but had no further knowledge of that incident. Interview on 10/29/24 at 2:50 p.m. with CNA/CMA E revealed: *Resident 2 and resident 3 had gotten into it but were now friends. *Resident 2 would go into other residents rooms. -A staff member would re-direct him out of the room. Interview on 10/29/24 at 3:10 p.m. with activities supervisor H regarding resident 2 revealed: *He had a short attention span. *When she saw he was becoming agitated she would try to redirect him to a different area. *A staff member was to have eyes on him. *Resident 3 likes to antagonize resident 2 to see his reaction. -Resident 3 would call resident 2 names and would say do you want to fight. Interview on 10/30/24 at 8:35 a.m. with RN G regarding resident interactions revealed: *Interventions for keeping resident 1 safe included that she stayed in her room or the activity room and she can remove herself from the situation. -Other interventions had included notes on the doors, and to keep doors closed. --There was no note observed resident 1's door. *Interventions for keeping resident 2 safe were to keep him distracted and keep resident 2 and 3 separated. *Any changes to interventions would be provided to her during nurse-to-nurse report with updated care plans. Interview on 10/30/24 at 8:45 a.m. with CNA D regarding resident interactions revealed: *She was aware of an incident between resident 1 and resident 2. -She made sure resident 2 did not go into resident 1's room. -When resident 2 went towards resident 1's room, she would make sure they were both safe. *Interventions for keeping resident 2 safe were to monitor as able, intervene if needed, re-direct to keep them apart, and resident 3 was easier to redirect. Interview on 10/31/24 at 11:19 a.m. with licensed social worker (LSW) C, administrator A, and director of nursing (DON) B via teleconference revealed: *They had not reviewed the psychiatric hospital notes upon resident 1's return to the facility. -They were not sure if anyone else had reviewed the notes. -They would have expected the nurse on duty at the time of resident 1's return to review the notes and update the resident's EMR. 5. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 8/23/24 Brief Interview of Mental Status (BIMS) assessment score was a 15, which indicated her cognition was intact. *Her diagnoses included cerebral palsy, anxiety, depression, sleep disturbance, and heart disease. Review of resident 1's nurses progress notes revealed: *On 8/22/24 at 6:30 p.m., Resident [1] informed CNA [certified nursing assistant/certified medication aide (CNA/CMA E)] of incident in her room with resident (2) entering her room while she was watching TV [television] and putting his hands on her shoulders by her neck and squeezing tightly. Resident [1] states she has pain but declines pain med [medication]. Resident [1] has no marks on her neck/shoulders at this time. Resident is calm but doesn't want this to happen again and wants to do what she can to make sure. Resident does seem fearful for her safety and the safety of others. *On 8/22/24 at 8:47 p.m., She [resident 1] informed me that she wanted to file a complaint with the city police. RN [registered nurse] did call [out of town] dispatch and police arrived at 2040 [8:40 p.m.] to get statement from resident. *On 8/23/24 resident 1, Stated she was shook but doing ok. She stated she feels safe most of the time just not safe now around the male resident [2]. She stated she avoids coming out of her room at night because of another resident. *On 8/26/24, She [resident 1] then made her own appointment to see her counselor [name] today at 11am [11:00 a.m.] She reported to the CNA that 'her mind is all over the place after what happened last week'. *On 8/30/24, a care conference note indicated she [resident 1] feels staff aren't doing anything about him and getting him out of the facility. [Resident 1] did state will continue to stay in her room until he leaves facility or she is gone. *On 9/4/24, resident 1 wants to find another nursing home to live in because of resident [2]. She voices to staff that she feels like her rights have been taken away from her and that she does not want to be out of her room much. She states that she will go 'anywhere but here'. *On 9/25/24, Resident [1] upset that another resident [2] took a step into her room while walking down the hallway with a CNA. [Resident 2] did not fully go into room. Resident was using bathroom at the time and door was half closed. CNA quickly direct [resident 2] back into the hallway. *On 9/26/24 at 9:11 a.m., Resident 1 reported to Dakota at Home (South Dakota's aging and disability resource center) an incident. This RN spoke with resident [1] who states she was in her bathroom getting ready for bed at and was halfway undressed when resident [2] came into her room. RN asked if resident [1] was physically harmed and she denied but stated she was mentally harmed. Resident [1] states she 'wants the hell out of this place'. Resident [1] stated that she is tired of the run-a-round, that he's [resident 2] is supposed to be on a 24 hour watch and how does he get into her room twice. she stated she feels like she has no rights and that he shouldn't even be here. Resident [1] held up her thumb and fore-finger tightly together and said 'I'm this close to committing suicide.' She said she shouldn't have to stay in her room for 3 weeks. Resident [1] is frustrated and states feels like she isn't important and that she doesn't matter. *On 9/26/24 at 4:09 p.m., resident 1 was transferred to a psychiatric inpatient hospital. This RN talked to resident [1] prior to leaving and resident states she still feels the same urge for suicide and denies having any methods to carry out thoughts. *On 10/10/24 at 4:15 p.m., resident 1 returned to the facility from the psychiatric inpatient hospital. *On 10/21/24, resident 1 reported that [resident 2] had been in her room x2 [two times] this morning. 6. Review of resident 2's electronic medical record (EMR) revealed: *His diagnoses included: dementia without behavioral disturbances, psychotic disturbance, mood disturbance, and anxiety; Alzheimer's Disease, Parkinson's disease, pain in right shoulder, and conduct disorder. *His 9/4/24 primary care provider progress notes included: -There have been a lot of changes over the past couple months. Per state requirements we took him off all antipsychotic medications as his diagnosis did not meet their recommendations. As a result, the patient's behaviors became significantly worse to the point of threatening physical harm to other residents in long-term care. -A lot of his issues depend on who is working and how they are able to handle him, however, there is some room for improvement as he is not as good as he used to be. Review of resident 2's nurses progress notes included: *On 10/17/24 resident 3 stopped beside resident 2 who was sitting quietly at the nurses station. -Resident 3 stated, I should just smack him now. -Resident 2 yelled at resident 3. -Resident 3 then started punching [resident 2] in the upper left arm. -Resident 2 grabbed at resident 3 and started to swing and punched him in the arm. -Staff intervened and separated the residents. -Resident 2 had no noted injuries. -It was documented that resident 3 stated he did not get hit and denied pain to his fist from hitting resident 2. -He then stated that, I want to hit him again and again as he laughed. -There were no other documented interventions to ensure the safety of resident 2 or resident 3. 7. Review of resident 3's EMR revealed: *His diagnoses included: Tourette's disorder (a chronic nervous system condition that causes people to have involuntary tics, or repetitive movements and sounds, that they cannot control), depression, and nicotine dependence. *His 8/16/24 BIMs score was a 10, which indicated he was cognitively impaired. Review of resident 3's nurses progress notes revealed: *There was no progress note regarding the 7/31/24 altercation with resident 2. *On 8/13/24 he was calling two other residents, Coo-Coo and stated, I don't have to be nice, I pay enough, to live here, and then [they] don't even know/understand I'm [I am] even calling then names. *He had physical altercations with resident 2 on 10/15/24 and on 10/17/24. *His 10/25/24 primary care provider progress note revealed: -He had a history of cognitive impairment. -He is due to see Behavioral Health as he does have some outbursts that are slightly inappropriate at times. Behavior Health is due to see him on 12/4 [12/4/24]. 8. Review of the provider's 6/30/23 Abuse Prevention policy revealed: *Purpose: -To identify, correct, and intervene in situations in which abuse, neglect, or misappropriation of residents' property is more likely to occur. -Physical Abuse: includes, hitting, slapping, pinching, kicking, etc. -Psychosocial Abuse: includes, but is not limited to, humiliation, harassment, threats of punishment, deprivation, restraints, silence, or exposing. -Neglect: a failure, through inattentiveness, carelessness, seclusion, or omission, without a reasonable justification to provide timely, consistent and safe services, treatment and care to a resident. *Procedure: -Administration and Head of Dept. [Department] will provide a plan to correct and intervene in situations identified that abuse is more likely to occur: -The assessment, care planning, and monitoring of the resident needs and behaviors which might lead to conflict or neglect, such as aggressive behaviors, wandering, self-injurious behaviors, communication disorders, and residents requiring high levels of care or are totally dependent. 51472

Based on interview, and policy review, the provider failed to ensure: *One of three sampled residents (1) had been screened for post-traumatic stress disorder (PTSD) upon admission, quarterly, annually, or upon her return from an inpatient psychiatric hospitalization for suicidal ideations. *Two of three sampled residents (2, and 3) had been screened for post-traumatic stress disorder (PTSD) upon admission, quarterly, or annually. Findings include: 1. Interview on 10/30/24 at 3:07 p.m. with resident 1 revealed: *There was a mental health therapist who came to the facility, weekly, to counsel her. -She had received counseling from that therapist for many years and felt it was very helpful. -She stated, She has dug me out of a hole more than once. *She stated she had been hospitalized for severe depression, PTSD, anxiety and all that stuff. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 8/23/24 Brief Interview for Mental Status (BIMs) assessment score was 15, which indicated her cognition was intact. *There was no trauma screen completed upon admission, quarterly, annually, or upon her return from an inpatient psychiatric hospitalization . *She had an inpatient psychiatric hospitalization stay from 9/26/24 through 10/10/24, that record indicated: -She had suicidal ideation with thoughts of stabbing or cutting herself with knives and refusing to leave her room. -She had PTSD related to the abuse her first husband inflected. 2. Review of resident 2's EMR revealed: *He was admitted on [DATE]. *His 9/27/24 BIMs assessment score was 0, which indicated he had severe cognitive impairment. *There was no trauma screen completed, or documentation that he was unable to complete one. 3. Review of resident 3's EMR revealed: *He was admitted on [DATE]. *His 8/16/24 BIMs assessment score was 10, which indicated he was modertately cognitively impaired. *There was no trauma screen completed upon his admission or on a quarterly basis. *A yearly trauma screen had been completed for him on 6/19/23. -There was no yearly trauma screen completed for him for 2024. 4. Interview on 10/31/24 at 11:19 a.m. with licensed social worker (LSW) C regarding trauma screening of residents revealed: *She was responsible to screen all residents for trauma upon their admission, quarterly, annually, and with a significant change. *She confirmed she had not completed a trauma screen for: -Resident 1 upon her admission, quarterly, annually, or from her return from an inpatient psychiatric hospital. -Resident 2 upon his admission, quarterly, or annually. -Resident 3 upon his admission, quarterly, and annually for 2024. 5. Interview on 10/31/24 at 11:25 with director of nursing B regarding resident 1's recent psychiatric hospitalizaiton revealed: *She had not reviewed the hospital notes upon resident 1's return. -The nurse on duty was to have reviewed those notes. 6. Review of the provider's 11/16/23 Trauma Informed Care policy revealed: *Trauma - 'Individual trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or life threatening and that has a lasting adverse effect on the individual's functioning and mental, physical, social, emotional, or spiritual well-being. *Trauma-informed care - 'is a strength-based framework grounded in an understanding of and responsiveness to the impact of trauma, that emphasizes physical, psychological, and emotional safety for both providers and survivors, and that creates opportunities for survivors to rebuild a sense of control and empowerment.' *The Trauma Assessment is required: -a. Within five days of admission for all new residents; -b. PRN [as needed]. *The Trauma Assessment is completed by Social Services while interviewing the resident/representative. *Document how trauma is currently affecting resident. *Individualize Care Plan interventions to avoid re-traumatization; *See Also. -SAMHSA's [Substance Abuse and Mental Health Services Administration] - Concept of Trauma and guidance for a Trauma-Informed Approach. -SASMHSA - Trauma-Informed Care in Behavioral Health Services: Quick Guide for Clinicians Based on Tip 57. Review of the SAMHSA's July 2014 Concept of Trauma and guidance for a Trauma-Informed Approach revealed: *A trauma-informed approach seeks to resist re-traumatization of clients as well as staff. *A trauma-informed approach reflects adherence to six key principles. -1. Safety: Throughout the organization .feel physically and psychologically safe; the physical setting is safe and interpersonal interactions promote a sense of safety. *Trauma screening and assessment are an essential part of the work. Trauma specific interventions are acceptable, effective, and available for individual .seeking services. Review of the SASMHSA's 2014 Trauma-Informed Care in Behavioral Health Services Based Quick Guide for Clinicians Based on Tip 57 revealed: *Create a Safe Environment. *Conduct Universal Routine Trauma Screening. *The most important areas to screen among individuals with trauma histories include: -Trauma-related symptoms. -Depressive symptoms. -Sleep disturbances. -Past and present mental disorders, including trauma-related disorders. -Type and characteristics of trauma. -Substance abuse. -Social support, coping styles, and availability of resources. -Risks for self-harm, suicide, and violence. -Health screenings. *A positive screening calls for further action-an assessment that evaluates presenting struggles to develop an appropriate treatment plan and to make an informed and collaborative decision about treatment placement. *Establish Safety. *Prevent Retraumatization. -Be sensitive to the needs of clients who have experienced trauma; consider behaviors in the treatment setting that might trigger memories of the trauma. *Address Sleep Disturbances and Disorders. 51472

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (24) who eloped (left the facility without staff knowledge) and while he was outside of the building, fell and required evaluation at the emergency department. Findings include: 1. Review of the SD DOH FRI revealed: *On 7/10/24 resident 24 had walked out the front double doors of the building without staff knowledge. 2. Observation on 7/11/24 at 11:16 a.m. of resident 24 in his room revealed: *He had small scabbed-over lacerations to the top of his nose, and his upper and lower lip. *He was smiling, laughing, pleasant, cooperative, and conversive with intermittent garbled and nonsensical speech. 3. Interview on 7/11/24 at 11:27 a.m. with registered nurse (RN) J revealed: *RN J had worked as a permanent staff member for five months and had not worked the previous evening when resident 24 eloped. *Resident 24 moved into the facility a year ago, was ambulatory, and did not use any assistive devices to ambulate. *Residents were assessed for risk of elopement on admission and when newly identified as at risk for elopment. *The social worker was notified when residents were identified as at risk for elopement and obtained orders for a Wander Guard (bracelet door alarm device). *Resident 24 wore a Wander Guard wristwatch, was never known to take his Wander Guard off, had gotten out of the facility the evening prior, and had a history of eloping in the past. *Staff monitored resident 24 closely, but there were no set times or frequencies for rounds (staff checks of resident status and care needs) or documentation of rounds. *Staff communicated at shift change report and he felt the certified nursing assistants (CNAs) were good at reporting to the nurse if residents were observed to have had increased wandering or risk of elopement behaviors. *The Wander Guard was resident 24's primary intervention for his risk of elopement. 4. Interview on 7/11/24 at 11:39 a.m. with CNA K revealed: *She had worked as a permanent staff member for one year and had not worked the previous evening when resident 24 eloped. *She had heard that resident 24 had gone out of the front door, tripped, fell , hit his nose, and was taken to the emergency department. *The resident had a Wander Guard watch, and no residents removed their Wander Guards that she was aware of. *They monitored residents closely, approximately every thirty minutes, when they went up and down the hallways but there were no set times or frequencies or documenting of that. *Staff communicated at shift change report, and in a communication book at the nurse's station. The CNAs reported to the nurse if residents were observed to have had increased wandering or risk of elopement behaviors. 43844 5. Review of resident 24's medical record revealed: *He was admitted on [DATE]. *His diagnoses included dementia with behavioral disturbances and Alzheimer's disease. *His Brief Interview of Mental Status (BIMS) score was a 99, which indicated the interview was not successfully completed. *He had eloped from the facility on 7/10/24. *A 7/10/24 a nurse's progress note indicated: -Noted by activities coordinator that a passerby said someone was lying facedown on the concrete outside the building. CNA staff ran out there and found resident. As I was getting to the resident I could see blood coming from his mouth and nose. He appears to have cut his bottom lip and has a small laceration to the top of his nose. Resident was able to roll with assistance to his side and was sat up right. He was then assisted up and into a wheelchair. The bleeding is minimal. In examining the resident his nose appeared to be misshapen. -Decision made to send to ED [emergency department] for evaluation of this. -On 7/10/24 a follow-up nurse's progress note indicated: --Resident has returned from ED and ruled out fracture or acute head injury. --Of note, it was determined residents fall was witnessed, by the time the CNA's were getting to him to assist him back to the building, he fell then. 6. Review of resident 24's 7/11/24 care plan revealed: *An initiated focus on 11/16/21, and revised on 4/11/24, that he experienced wandering due to his dementia, wandered without a destination or any safety awareness, and had a WanderGuard on his left wrist. -The goal for this focus was that he would wander safely within the specified boundaries. --There were no boundaries specified. -The interventions for this goal included: --Equip resident with a wander guard [WanderGuard] device that alarms when wanders, apply to left wrist. Check for proper functioning of device every night and skin breakdown. --Avoid over-stimulation (e.g., noise, crowding, other physically aggressive residents). --Maintain a calm environment and approach to [resident 24]. --Remove [resident 24] from other resident's rooms and unsafe situations. 7. Review of resident 24's July 2024 treatment administration record revealed: *A 1/4/24 order to monitor for Wander guard [WanderGuard] on at all times (left wrist) with daily activation check at night. *The diagnosis for this treatment was Unspecified dementia with behavioral disturbance. 8. Review of resident 24's 7/10/24 Elopement Risk assessment revealed: *He had wandered in the past 60 days. *His diagnoses included dementia and Alzheimer's disease. *Contributing factors to this elopement were Repeatedly Opening Doors/Setting Off Alarms of Secured Doors and Wandering With No Rational Purposes And Attempting To Open Doors. 9. Interview on 7/11/24 at 2:35 p.m. with director of nursing (DON) B and director of nursing trainer (DONT) M regarding resident 24 revealed: *On 3/1/24 a different resident had alerted staff that resident 24 had exited the building. *On 3/24/24 resident 24 had walked out of the front double doors onto the sidewalk. *On 7/10/24 resident 24 had walked out of the front double doors onto the sidewalk. -He had tripped and fallen while coming back into the building. 10. Interview and review of a video recording on 7/11/24 at 3:40 p.m. with DON B and director of finance N revealed: *At 7:36 p.m. resident 24 held one side of the front double doors for 12 seconds until it opened and walked through the door and exited the building. *At 7:37 p.m. a staff member exited the bathroom in that area, looked through the front double doors, shut off the alarm, and walked around the corner to a different hallway. *At 7:38 p.m. two CNAs ran from the way the staff member above had gone to the front double doors and exited the building. *At 7:40 p.m. a nurse went to the front double doors and exited the building. *At 7:43 p.m. that same nurse returned inside while she talked on her cellphone. *At 7:44 p.m. that same nurse and another CNA exited the building through the front double doors. *At 7:46 p.m. that same nurse, and three CNAs returned with resident 24, seated in a wheelchair back inside the building. 11. Interview on 7/11/24 at 4:10 p.m. with nursing supervisor/wound care nurse (NS/WCN) H, DON B and DONT M regarding resident 24's elopement revealed: *Interventions in place for his elopements included staff were to monitor him during normal rounding every two hours and a Wander Guard was placed on his wrist. -They indicated there were no other interventions in place to prevent him from elopement. 12. Review of the provider's 7/10/24 Security Alert: Missing Person-Elopement policy revealed: *Upon return of the resident to the facility, the following steps will be carried out: -An incident report will be completed. -The person responsible for the resident's care shall initiate an appropriate plan of treatment. -The resident's care plan will be revised to reflect elopement and prevention plan developed. -Elopement assessment will be completed. -Care planning team will meet each week and as needed to investigate any elopements to ensure safety of all residents and to prevent any elopement from reoccurring.

Based on observation, interview, policy review, and reference source review, the provider failed to follow appropriate infection control practices for residents who were on transmission-based precautions with the potential for exposing residents and staff to serious harm including death. On 3/23/21 at 6:15 p.m. an immediate jeopardy was identified when the provider failed to ensure: A. Masks were discarded or changed when staff left a resident's room who were on transmission-based precautions (widespread). B. Goggles and or faceshields were disinfected after contact with residents on transmission-based precautions (widespread). C. Soiled and clean gowns were covered (widespread). D. Staff caring for residents on transmission-based precautions were competent with putting on and taking off personal protective equipment (PPE) (widespread). E. Residents (3, 4, and 20) who were on transmission-based precaution had their doors closed. F. Six out of six staff (G, N, O, Q, R, T) followed infection prevention practices with residents on transmission-based precautions. G. There were separate stations for staff to put on and take off their PPE to prevent cross contamination (widespread). H. Residents (3, 20, and 30) who exhibited COVID-19 like symptoms were tested per policy. I. Resident's and/or family representatives were educated about transmission-based precautions when sharing a room with a resident requiring precautions (widespread). J. Separation of newly admitted or readmitted residents (4 and 142) of unknown status were not cohorted with existing residents that did not require precautions. K. Two of two environmental specialists staff (K and L) followed appropriate cleaning and disinfection of resident's rooms (non-immediate jeopardy finding). L. Two of two certified nursing assistants (M and P) followed appropriate cleaning and disinfection of the two facility whirlpool tubs (non immediate jeopardy finding). These failures have the potential to expose all residents, staff, visiting personnel, and families to illnesses that could lead to serious harm or death. NOTICE: On 3/23/21 at 6:15 p.m. an immediate jeopardy was identified when the provider failed to implement Centers for Medicare & Medicaid Services (CMS) and Centers for Disease Control and Prevention (CDC) recommended practices to prepare for COVID-19 and other contracted illnesses. Notice of Immediate Jeopardy was given verbally to senior director A (attending via phone), director of nursing services (DNS) C, and infection control preventionist (ICP) B. For Specific immediate jeopardy noncompliance, see above findings; A, B, C, D, E, F, G, H, I, and J. At the above time the senior director was asked for an immediate plan of removal to ensure all staff working with residents who were on transmission-based precautions received education and competencies for nationally recognized infection control procedures. On 3/23/21 at 9:10 p.m. senior director A provided a removal plan per email. The removal plan was accepted on 3/24/21 at 5:27 p.m. with agreed upon changes made by the provider while the surveyors verified the plan and the Immediate Jeopardy removed on 3/24/21 at 5:30 p.m. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. 1. Ensure mask worn into resident's rooms who were on transmission-based precautions were discarded or changed after leaving. The masks will discard in the trash can just outside the isolation room. Action: Immediate action was taken. DNS [director of nursing services] and Infection Preventionist began education to staff on discarding of mask after leaving an isolation room and replacing with a new one on 3/23/2021. Education will be provided to all staff to discard their mask after leaving an isolation room and apply a new mask. Directional signage will be placed outside of each isolation room directing staff to remove mask and replace with new mask. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/21. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided to all staff and will be documented by signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI [Quality Assurance Process Improvement] Coordinator or designee will monitor, starting 3/24/2021 by observing 5 exits from an isolation room. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee meeting. 2. Disinfect goggles/face shield after contact with residents on transmission-based precautions. Action: Immediate action was taken. DNS and Infection Preventionist began education to staff on 3/23/2021. Education will be provided to all staff for disinfection of goggles/faceshield, by wiping down with [product name] wipes, upon exiting the isolation room, and the importance of clean/dirty separation. Staff will be education on the process of disinfecting goggles/face shields. Staff will be educated that goggles/faceshield must hang on hooks provided outside of the door for a minimum of three minutes. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided to all staff and will be documented by a signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by observing 5 exits from an isolation room. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee meeting. 3. Soiled and clean gowns will be covered. Action: Immediate action was taken. DNS and Infection Preventionist placed signage on clean gowns and provided education that all clean gowns must be covered. DNS and Infection Preventionist removed overflowing soiled gowns and provided immediate education that soiled gowns could no overflow from soiled linen hamper. Educated staff to change out hamper more frequently. DNS and Infection Preventionist began education to staff on 3/23/2021. Education will be provided to all staff that clean gowns must be covered and marked at all times. Education will be provided to all staff that the soiled linen hamper cannot overflow and should be changed out multiple times throughout the shift. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided to all staff and will be documented by a signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by observing clean gowns and soiled linen hamper daily. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee meeting. 4. Staff caring for residents on transmission-based precautions are aware of proper doffing of PPE and proper use, removal and disinfecting of goggles/ face shields. Action: Immediate action was taken by the DNS and Infection Preventionist on 3/23/21. Staff were educated on proper doffing of PPE, including goggles/faceshields. Education will be provided to all staff on doffing. Donning/doffing competency will be reviewed with all staff. Email sent to all direct care staff on 3/23/21 and to all staff on 3/24/21. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/21. Training will be provided to all staff and will be documented by a signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by observing 5 exits from an isolation room. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee meeting. 5. Transmission-based precaution room doors will be closed. Action: Immediate action was taken. All Isolation doors were closed. DNS and Infection Preventionist began education on 3/23/2021. Education will be provided to all staff that isolation doors must remain closed at all times. If there is a safety concern, clear plastic shower curtains must be used, and staff may reach out to maintenance, administrator, DNS or Infection Preventionist to implement clear shower curtain. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided to all staff and will be documented by signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by observing 5 doors to isolation rooms daily. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee. 6. Infection prevention practices with residents on transmission-based precautions. Action: Immediate action was taken, DNS and Infection Preventionist began education on 3/23/2021. Education will be provided to all staff on proper hand hygiene. A visual aide competency will be provided. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided to all staff and will be documented by a signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/21, by observing 5 hand hygiene opportunities upon entry and exit of a resident room daily. Audits will occur daily for 7 days, weekly for 4 weeks and monthly for 2 months. Results will be reported to the monthly QAPI committee. 7. Separate donning and doffing stations to prevent cross contamination. Action: Immediate action was taken, DNS and Infection Preventionist immediately moved all stations right outside of the isolation room so [product name] wipes can be obtained for cleaning of goggles/faceshields without breaking the clean/dirty barrier. DNS and Infection Preventionist began education on 3/23/2021. Education will be provided to all staff to ensure that clean totes remain with an arms reach outside of the isolation room. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided for all staff and will be documented by a signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by observing 5 exits of isolation room[s] to ensure the clean totes are within reach. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee. 8. Residents who exhibit COVID-19 symptoms will be tested . Action: Immediate action was taken. Residents identified were tested and were negative. All negative results were obtained in [on] 3/23/2021. Education will be provided to all staff on signs and symptoms of COVID-19 and immediate testing when symptoms are present. This includes calling the provider on call for an order. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided for all staff and will be documented by signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by reviewing charts of all residents with COVID-19 symptoms to ensure a test has been obtained. All residents with symptoms are reviewed daily by the care center team. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee. 9. Ensure residents and/or family representatives were notified and educated of roommates' transmission-based precaution status. Action: Immediate action was taken. DNS, Infection Preventionist and Nursing Supervisor/MDS Coordinator called all family and educated resident who were their own decision maker of transmission-based precaution status and sign and symptoms to watch for. DNS and Infection Preventionist began education on 3/23/2021. Education will be provided to all staff on calling family representative and educating residents who are their own decision maker of transmission-based precaution status and signs and symptoms to watch for. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided for all staff and will be documented by signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by reviewing charts of all residents on transmission-based precautions who have roommates to ensure notification has occurred. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee. 10. Ensure separation of newly admitted residents of unknown status were not cohorted with existing residents. Action: New admit residents who are not fully vaccinated are placed on quarantine in a private room for 14 days or until considered fully vaccinated. Education will be provided to all staff on new admission requirements. Email sent to all direct care staff on 3/23/2021 and to all staff on 3/24/2021. All staff will review education and sign with a witness prior to the start of their next shift. Training was started on 3/23/2021. Training will be provided to all staff and will be documented by signature of staff and witness on competency validation. All staff will review education and sign with a witness prior to the start of their next shift. QAPI Coordinator or designee will monitor, starting 3/24/2021, by reviewing separation/isolation setup of all new admit residents upon admission. Audits will occur daily for 7 days, weekly for 4 weeks and then monthly for 2 months. Results will be reported to the monthly QAPI committee. As of 3/24/2021 at 3:15 p.m., the above items have been implemented. Findings include: A. Interview on 3/23/21 at 11:15 a.m. with facility staff including senior director A, DNS C, and ICP B revealed: *They had two residents on quarantine. One was a new admission and the other was a re-admission to the facility. *They had two residents on isolation due to gastrointestinal (GI) symptoms. *It was their expectation for staff to wear gown, goggles, and surgical mask into the isolation and quarantine rooms. -Staff also signed a sheet of paper when they had entered the room, for tracking purposes. *ICP B stated that staff did not change their surgical mask or clean their goggles in between quarantine, isolation rooms, and non-quarantine rooms. -She stated this was because they were in reuse status. Observation on 3/23/21 on at 11:48 a.m. of the 100 hallway revealed: *room [ROOM NUMBER] was resident 3 and 28's shared room and had an enhanced barrier precautions sign outside of the door. *The door was open. *There was a container with a lid that stated clean gowns outside the door. *There was a small 3 drawer white container also outside the door. *There was an open container inside the room with what looked like discarded gowns. *Resident 3 was on transmission-based precautions, resident 28 was not. Observation on 3/23/21 at 11:49 a.m. revealed: *room [ROOM NUMBER] was resident 4 and 39's room and had a droplet precautions sign outside the door. *There was also a staff sign in sheet that was hanging on the wall that had not been filled out yet. *Their door was also open. *There was a small 3 drawer white container outside the door. *There was a clean gown container outside the door that was partially covered by a towel. *Resident 4 was observed coming out of the door of the shared bathroom, and went back to his side of the room. B. Observation and interview on 3/23/21 at 11:58 a.m. of activities director R revealed: *She went into resident 3 and 28's room, without a face shield or goggles. *The door had remained open. *She walked outside of the room in the hallway and removed her gown. *She placed her gown in the clean gown bin, instead of the dirty gown bin which was inside the room. *She had not removed her surgical mask. *She had removed her soiled gloves and placed them both in her left hand. *She had not performed hand hygiene. *Registered nurse (RN) T informed the Activities director that resident 3 was on isolation due to GI symptoms. *Resident 3 had spiked a fever, vomiting and loose stools. -RN T thought that resident 3 may have had Clostridioides difficile (C. Diff). Surveyor : Observation and interview on 3/23/21 at 12:00 p.m. with activities director R entering and exiting resident 3 and resident 28's shared room revealed: *There was an isolation station set up outside of the room. *No sanitizing wipes or hand sanitizer were observed on the cart. *The door to the room remained open. *Activities director R: -Entered the room wearing a surgical mask and after donning a cloth gown, and gloves. -Gave resident 28 his mail, spoke with him behind the closed curtain by his bed for a few minutes and then exited the room without closing the door. -Had not washed her hands or performed hand hygiene. -Had taken off her cloth gown and placed it into a linen bin marked clean gowns outside of the room in the hallway and closed the lid. -Continued to wear the same surgical mask. -Confirmed she forgot to wear eye protection into the room and should have. -Removed her gloves and kept them in her hand. -Thought resident three was the resident on transmission-based precautions because he had readmitted . -She walked away after RN T came up to explain the transmission-based precautions for resident 3 when she overheard the conversation. -Activities director R was observed to carry those same gloves with her while she walked away down the hallway and around the corner. Surveyor : Further observation on 3/23/21 at 12:02 p.m. revealed: *RN T went into resident 3 and 28's room. -She put on a gown and went inside room [ROOM NUMBER]'s open doorway. *She had checked resident 3's blood glucose level. *She had reached in her pocket with her soiled gloves. *She had removed her gown inside the room with the door open. -The soiled gowns were overflowing onto resident 3 and 28's floor. *She had performed hand hygiene with alcohol based hand rub (ABHR). *She had brought the dirty glucometer back down to the nurses station to disinfect it. *The door had remained open. Surveyor : C. Observation and interview on 3/23/21 at 12:05 p.m. with RN T after she exited resident 3 and 28's shared room revealed: *She removed her cloth gown inside of the room and had placed into an uncovered container next to the doorway that was overflowing with gowns. *RN T had not sanitized her goggles when she exited the room. *She had not changed her surgical mask. *She had not washed her hands and hand hygiene was not observed to be done. *Resident 3 had been on precautions because of a gastro-intestinal (GI) issue that had been going around the facility. *He had loose stools and a fever. *They did not think he had COVID-19 and he had not been tested for it. Surveyor : Observation on 3/23/21 at 12:10 p.m. of the rest of the 100 hallway revealed: *There was isolation container outside of room [ROOM NUMBER] and 111. *room [ROOM NUMBER] had residents 10 and 20 in a shared room, the door was open. *room [ROOM NUMBER] had resident 30 in a room, the door was closed. D. Observation on 3/23/21 at 12:16 p.m. of the 200 hallway revealed: *room [ROOM NUMBER], which was resident 32 and 142's shared room. *There was a container that had clean gowns, which was partially covered with a towel. *There was a white three-drawer container outside the door. *Sign by the door stated contact/droplet precautions. *The door was closed. Further observation on 3/23/21 at 12:21 p.m. on the 100 hallway revealed: *Staff were passing room trays to residents in their rooms. *Nurse aide (NA) O, went into room [ROOM NUMBER] to deliver a tray to resident 28. -She did not put a gown, gloves, and did not take off her surgical mask. --She also did not perform hand hygiene when she left the room. *RN T then put on a gown to deliver a room tray to resident 3 in room [ROOM NUMBER]. *RN T was overheard telling resident 3 that his blood work and urine came back ok, he probably just had a GI bug that was going around. -When she left the room she did not remove her surgical mask or disinfect her goggles, the door remained open. *CNA Q went into room [ROOM NUMBER] to deliver a room tray to resident 4. *She did not have a gown on, or goggles. -When she left she did not perform hand hygiene. *RN T, NA O, and CNA Q also went into non-quarantine and non-isolation rooms with the same surgical mask that they wore into the rooms of residents who were on transmission-based precautions. Surveyor : E. Interview on 3/23/21 at 12:30 p.m. with NA O after observation of her entering and exiting resident rooms on transmission-based precautions revealed she: *Was in training to become a CNA and had been scheduled to take the test later in the week on Thursday. *Had been scheduled to train with a CNA each day and worked with CNA Q that day. *Wore a surgical mask and had touched it several times to keep it over her nose. *Stated she had already completed dietary training and infection control classes online. *Reported the hand sanitizer had been removed from the hallways because of a problem with a resident getting into it. *Pointed to a small hand sanitizer bottle attached to her lanyard and stated she used hand sanitizer when exiting resident rooms or would walk down and wash her hands in the dining room or kitchen. *Had not been observed to use hand sanitizer when entering or exiting rooms or to wash hands. *Stated resident 4 was on precautions because he on a home visit and resident 3 was on precautions because he had been vomiting. *The doors to resident 3 and 4's rooms remained open. Observation on 3/23/21 at 12:40 p.m. with CNA Q after exiting resident 4 and 39's shared room with transmission based precautions revealed: *The door to the room was open. *She carried a cup of water into the room. *She had not put on gloves or a gown. *She had not changed her surgical mask after exit. *She had not sanitized her eye protection after leaving the room. *She had not performed hand hygiene or washed her hands. Surveyor : F. Interview on 3/23/21 at 12:42 p.m. with CNA Q revealed she: *She was a temporary CNA hired through a temp agency. *Had been working in the facility for 8 months. *Was providing training with NA O that day. *Stated staff were supposed to wear a gown, goggles, and surgical masks into quarantine and isolation rooms. *Did not have an answer for why she did not wear a gown into those rooms. G. Observation and Interview on 3/23/21 at 1:14 p.m. of the 200 hallway revealed: *Resident 32 was being brought back to his shared room [ROOM NUMBER] with resident 142. *Resident 142 was a newly admitted resident to the facility. -He was on contact/droplet precautions. *Resident 32 was in the main dining room eating with other residents. -He was not wearing a mask. *RN G put on a gown to help CNA's N and E. *She went into resident 32 and 142's room with goggles on the top of her head. *RN T came over from the 100 hall and reached in the door and grabbed keys from RN G. *RN G came out of room [ROOM NUMBER] did not clean off her goggles or change her surgical mask. *Clean linen container remained partially uncovered with a towel. *CNA N stated resident 142 was on COVID-19 precautions because he is a new admit. *She said they were supposed to wear a gown, gloves, goggles, and surgical mask. *She said they were not supposed to clean off their goggles or change their surgical mask. *CNA N stated they were supposed to sign the sign in sheet when they went into the room that way if resident 142 developed COVID-19, they will know who had been in contact with him. -CNA N had signed the sheet earlier that day. --CNA E did not sign the sign in sheet. *RN G was not sure why resident 32 had been placed with resident 142, they did have an open room available. Review of the sign in sheet by resident 32 and 142's door revealed: *The date on the sheet stated 3/15/21 *There were four people that have signed into the room in eight days: -One staff member on 3/15/21. -One staff member on 3/18/21. -One staff member on 3/22/21. -One staff member on 3/23/21. H. Interview on 3/23/21 at 3:28 p.m. with DNS C and ICP B revealed: *ICP B had been in her role for [AGE] years at the facility. *DNS C had been at the facility for [AGE] years, but had been the DNS for 5 weeks. -She previously worked as a charge nurse in the facility. *They leave it up to the Physician regarding testing residents for COVID-19. *Resident's 3, 20, and 30 were having GI symptoms, including low grade temperatures. *They did not know if they had standing orders or prn (as needed) orders for COVID testing. *Staff were expected to wear gown, gloves, goggles, and masks for contact/droplet precautions. *Staff were expected to remove gown before leaving the room. *ICP B stated staff are not required to change their masks because they are currently in conservation status at the facility. *Conservation status came from the corporate level. -ICP B had not known when they were told they were in conservation status. *Nursing staff are given a new mask daily. *Office staff get a new mask every five days. -They have had a hard time getting masks. *Surveyors asked if they had reached out to the South Dakota Department of Health (SD DOH) for supplies. -ICP B stated they did a long time ago, she did not know when they last submitted a request for PPE. *For residents on droplet/contact precautions it is preferred that their door is closed. -At times the doors are left open for safety reasons. *Cohorting residents had been challenge. -They have not had a cohort zone. *They believed resident's roommates were informed and educated on being roomed with someone on transmission-based precautions. -If so, it would have been documented in the electronic health record (EHR). *Nurses have been fit-tested for N95 masks. *They are able to fit test other staff if needed. *ICP B stated they are not changing masks because the policy said if using a face shield they do not need to change masks. *ICP B and DNS C agreed staff have been wearing goggles and should change their masks. *ICP B and DNS C agreed if staff needed to reuse surgical masks then their policy stated they need to fold them and store them in a paper bag outside of the resident's room. Surveyor : Interview on 3/23/21 at 4:47 p.m. with CNA E on disinfecting her goggles after exiting a resident's room who was on transmission based precautions revealed she: *Wiped her goggles with a paper towel in the residents room if they were soiled. *Agreed the goggles could be contaminated. *Did not know she needed to disinfect the goggles. *Did not know where or how to disinfect the goggles. Interview on 3/23/21 at 4:48 p.m. with CNA F on disinfecting her face shield after exiting a resident's room who was on transmission based precautions revealed she would walk to the nurses station and use the disinfecting wipes kept in the cupboard to disinfect her face shield or goggles. There had not been disinfecting wipes available outside resident rooms. Surveyor : Further interview on 3/23/21 at 4:49 p.m. with ICP B and DNS C revealed: *Family and resident notification on cohorting quarantine residents and non quarantine residents has not been done. *All residents do have a standing order for COVID-19 testing. -Some of the newer residents have not had the EHR updated yet. Entered the facility on 3/24/21 at 7:15 a.m. surveyors were informed that there were additional residents with GI symptoms. There was now a total of six residents. I. Observation and interview on 3/24/21 at 10:01 a.m. with environmental specialist (EVS) personnel K revealed she: *Has worked in her current role in the facility for two years. *Went into resident 36's room, wearing a pair of gloves. *Had taken the trash out of the resident's bathroom, bedroom, and grabbed an almost empty toilet paper roll. *Had left the resident room, to go to the housekeeping cart where she: -Put the resident's trash in the waste receptacle. -Grabbed a new roll of toilet paper. *Using the same gloves she originally put on she: -Grabbed all of the resident's soiled linens that were on the floor. -Placed them in soiled linen hamper. -Reached into her house keeping cart with the same soiled gloves to grab her disinfecting chemical and a toilet cleaning brush. *She said the chemical she uses is a [product company name] disinfectant. *She squirted the chemical on the toilet brush then she: -Cleaned the inside of the resident's toilet bowl. -With that same brush she cleaned off the rim of the toilet, underneath the seat, and on top of the seat. *With the same soiled gloves she went back to the housekeeping cart. *She grabbed a clean towel out of the clean linen bag. *She went back into the resident's room and wiped off his bedside table. -With the same gloves she moved his coffee mug to wipe underneath it. *She wiped off his dresser. *She then removed a piece of chewed bubblegum from the resident's bedside rail. -She took the gum back to the cart to throw it away. -She did not change her gloves. *She then grabbed her mop and mopped the resident's bathroom. *Then vacuumed his room. *She did not clean any high touch surfaces such as door knobs, hand rails, light switches, or remotes. *Surveyor asked if she knew the contact time for the disinfectant that they use. -She wasn't sur

Based on observation, record review, and interview, the provider failed to implement interventions prior to and after the development of a pressure ulcer for one of three sampled residents (3) who acquired a pressure ulcer while in the facility. Findings include: 1. Multiple random observations on 9/25/17 from 2:15 p.m. through 5:30 p.m. of resident 3 while she had been in her room revealed she was sitting in her chair. She had been wearing blue pants, a purple flowered shirt, and a black plaid flannel jacket. Review of resident 3's medical record revealed she had a pressure ulcer on her left buttocks that had been identified on 8/12/17. Observation on 9/26/17 at 7:30 a.m. of resident 3 revealed she was sitting in the chair in her room eating breakfast. She was wearing the same blue pants, the purple flowered shirt, and a black plaid flannel jacket as on 9/25/17. Observation on 9/26/17 at 9:30 a.m. of resident 3 revealed she remained sitting in the chair in her room. Interview on 9/26/17 at 11:00 a.m. with resident 3 revealed she: *Stayed in her room and sat in the chair all of the time. -That was where she wanted to be. *Wanted to sit upright, so she could breathe easier. *Reclined in the chair about two hours per night. *Sat upright the rest of the time. *Stated: -She did not walk in the halls. -She walked to the bathroom a couple times a day. -The chair belonged to the nursing home. -Sometimes she was a little bit damp from perspiration on her buttocks and tailbone area. -She was aware she had a pressure ulcer on her right buttock. -No one had talked to her about ways she could help the healing of her pressure ulcer. -She did not have a pressure reducing device in her chair or on her bed. -No one had offered her a pressure reducing device for her chair or bed. -Again she did not sleep in her bed. -She had a lift chair at home that was bigger than the chair she was sitting in. -She did not think the lift chair would fit in the room. -Did not know she could rearrange the furniture in her room to accommodate a lift chair. -Did not want to bring that chair to the nursing home to sit in. I do not want to be a bother. -She slept in her clothes every night and changed them two times a week when she bathed. -That had been what she wanted to do, because she did not want to bother anyone. -She had no space between her upper thighs and the chair. She fit tightly in the chair but that was all right according to her. -She did not want to bother anyone. -No one from the facility had offered her a different chair or place to sit. Interview on 9/26/17 at 4:25 p.m. with certified nurse aide M revealed resident 3: *Never used her call light. *Ate her meals in her room. *Always sat in her chair. *Slept in the chair with her clothes on. *Did not recline her chair. *Had not been seen walking in the hall. Review of resident 3's resident progress notes revealed: *On 12/01/16 a progress note written by staff member L stated the resident could benefit from a lift chair and refused to sleep in her bed. -There had been no further documentation regarding a lift chair in the resident progress notes. *On 8/12/17 a note by registered nurse (RN) J stated Staff reported resident has small open area to coccyx area. resident in chair at the time and when asked if could look at area, she stated she would let staff or call for nurse. Staff reported no drainage or odor to area. Resident does sit in chair most of day, does ambulate in hallway per PT (physical therapy) recommendation and to toilet. *On 8/17/17, 8/22/17, 8/31/17, 9/7/17, 9/14/17, and 9/21/17 notations by licensed practical nurse (LPN) K stated weekly skin assessment, and to see the observation. *Clinical documentation-Skin Integrity Conditions forms that had been completed by LPN K stated on the following: -8/17/17, 1 centimeter (cm) open area, filling in with white tissue, depth is shallow, RN J reports it looks much better that last week, has healed approx. by half. Granulation tissue. Pressure reducing device for chair. Pressure ulcer care. [MEDICATION NAME] placed over site with tape to secure it. -8/22/17, 0.5 x 1 cm shallow open area. [MEDICATION NAME] Tissue. Pressure reducing device for chair. [MEDICATION NAME] and tape placed over open area on R buttock. -8/31/17, 1x05 cm shallow open area. [MEDICATION NAME] Tissue. Pressure reducing device for chair. -9/7/17, [MEDICAL CONDITION] cm. [MEDICATION NAME] Tissue. Pressure reducing device for chair. [MEDICATION NAME] with small piece of [MEDICATION NAME] applied with Steadier to hold it in place, area is a little moist and tape does not want to stay in place. -9/14/17, 1cm [MEDICAL CONDITION] small open area, today also has an area directly below the open sore that is reddened and moist. Granulation Tissue. Pressure reducing device for chair. Pressure reducing device for bed. -9/21/17, R Buttock, 2 areas now open, 1st one is sm with granulation tissue filling in, 2nd one is directly below the first one and is very small. 1)[MEDICAL CONDITION]. 2)superficial pinpoint open area. Pressure reducing device for chair. Pressure reducing device for bed. [MEDICATION NAME] and [MEDICATION NAME] applied to both areas. Review of all resident 3's physician's orders [REDACTED]. Review of resident 3's last revised 8/10/17 care plan revealed: *No dietary problem, approach, or goal related to the resident's pressure ulcer. *A problem that stated the resident Has a potential for pressure ulcers related to occasional incontinence, decreased mobility, and does not utilize the bed, spending most of time in recliner, and obesity. -On 8/17/17 the pressure ulcer had been added. -A goal to heal without complication. -A treatment to the right buttock of Safegel and [MEDICATION NAME] had been added on 8/17/17. *No mention of management of pressure relief for the right buttock ulcer such as gel cushion for chair. *A problem for ADL Functional/Rehabilitation Potential with an approach to Encourage (resident name) to amb (ambulate) in hall at least 6x(times)/day. -Resident does not ambulate in the hallway. Interview on 9/27/17 at 9:00 a.m. with the Minimum Data Set coordinator regarding resident 3 revealed she stated she: *Had visited with the resident in the past about a different chair but had not documented it. -Had been unsure how long ago that had been. *Agreed there had not been interventions in place for the resident to prevent and relieve pressure from her right buttock. *Thought the resident was getting enough protein and nourishment from her usual diet. *Had not requested a dietary consultation. *Did not think there were wound care orders for the resident. *We usually like to have orders for all wound care but I don't think we do for resident 3. Interview on 9/27/17 at 10:25 a.m. with the interim director of nurses (IDON) about resident 3 revealed she agreed there had not been interventions in place to prevent the facility acquired pressure ulcer from developing. On 9/27/17 at 9:00 a.m. a policy for the prevention of and management of pressure ulcers was requested from the IDON. At 1:30 p.m. she stated they did not have anything specific to the requested policy.

Based on observation, record review, interview, and policy review, the provider failed to implement interventions for one of one sampled resident (1) who eloped twelve times and demonstrated behaviors related to a history of smoking. Findings include: 1. Review of resident 1's medical record revealed: *An admission date of [DATE]. *Her 12/24/16 Brief Interview for Mental Status (BIMS) assessment score was a fifteen. -A score of thirteen to fifteen meant she was cognitively intact. *Her [DIAGNOSES REDACTED]. Review of resident 1's SafetyZone Portal reports from 1/24/17 through 2/16/17 revealed: *She had left the building twelve times without staff knowledge. *On 1/24/17 at 6:37 p.m. she had left without being seen. -Resident called phone to be let in. -Resident was out smoking. -RN (registered nurse) did not let her out and had not known she (was) out smoking. -The director of nursing (DON) follow-up on 1/26/17 had not included any interventions. *On 1/26/17 at 7:45 p.m. she had went out front door independently. -While in her wheelchair independently pushed open front door and went outside. -Staff responded to see her sitting there smoking a cigarette. -The DON follow-up on 1/27/17 had been: Resident stated she was going to be good and start using her tool again such as reading her bible, coding her anger, writing in a journal, breathing, all the things that are recommended for her to do for her coping skills. *On 1/29/17 at 8:06 p.m. she had left the building. -She had gone out the front door. -Staff heard the alarm shortly after due to staff being in resident's rooms. -Staff went out and brought the resident back into the facility. -The DON follow-up on 2/6/17 had been: Resident states that she just got mad and wanted outside. Reminded resident to use her coping mechanisms when she is mad and she agreed to this. *On 1/30/17 at 5:25 a.m. she had left the building. -She had waited until all staff were doing 5:00 a.m. rounds and exited out the front door. -Staff heard the alarm upon entering the hallway and chased after her. -The DON follow-up on 2/6/17 had been: Resident educated on how unsafe this is for her to be going outside unattended. *On 1/31/17 at 6:00 p.m. she had left without being seen. -She had gone through the doors between the hospital and nursing home setting off the alarm. -The resident was outside on the road. -It took two staff to bring her in. -The DON follow-up on 2/2/17 had been: She stated she just gets mad at stuff and wants to go out feels like a prisoner. Reminded (resident name) that she can go outside but needs to be dressed appropriately and use the proper channels to go outside. She needs to ask a staff member to go with her but can not smoke unless she leaves the grounds with her family. *On 2/2/17 at 4:05 p.m. she had left the building without proper supervision or clothing. -Two staff members redirected her back into the facility. -She was uncooperative and cursing at staff. -She wanted a cigarette. -She stated she hated it there and wanted to leave. -The DON follow-up on 2/6/17 had been: She stated she just gets mad at stuff and wants to go out feels like a prisoner. Reminded (resident name) that she can go outside but needs to be dressed appropriately and use the proper channels to go outside. She needs to ask a staff member to go with her but can not smoke unless she leaves the grounds with her family. --That had been the same note from 1/31/17. *On 2/2/17 at 5:45 p.m. she had left the building. -The resident had gotten outside and was in the parking lot in a wheelchair, without a coat or hat. -She had two cigarette butts in her hand that she disposed of on the ground. -The nurse assisted the resident back into the facility with no problem. -The DON follow-up on 2/6/17 had been: She stated she just gets mad at stuff and wants to go out feels like a prisoner. Reminded (resident name) that she can go outside but needs to be dressed appropriately and use the proper channels to go outside. She needs to ask a staff member to go with her but can not smoke unless she leaves the grounds with her family. --That had been the same note from 1/31/17 and earlier on 2/2/17. *On 2/3/17 at 8:05 p.m. she had left the building without being seen. -Staff had heard the hospital door alarm going off. -She had gone out the front hospital doors in her wheelchair and was heading across the parking lot. -She was uncooperative and had to be pulled backwards into the facility. -The DON follow-up on 2/6/17 had been: Resident stated she was upset wanted to leave go home she did not care about her pain meds she wants to smoke. Reminded resident that the doctor thinks it's best that she in here in the care center that we have to come up with something more agreeable to everyone and use her book to code her anger and to write in her journal and read her bible. Resident states that she will try. *On 2/3/17 at 10:30 p.m. she had left the building. -She had gone out the front hospital doors in her wheelchair. -The nurse and certified nursing assistant (CNA) had responded by running across the parking lot the into road. -She was briskly self propelling with head down and not looking what was ahead of her endangering herself and staff that was chasing her to the possibility of someone driving a vehicle rushing to ER hitting us. She was brought back in despite her not being uncooperative (cooperative). -The DON follow-up on 2/6/17 had been: Resident stated she was upset wanted to leave go home she did not care about her pain meds she wants to smoke. Reminded resident that the doctor thinks it's best that she in here in the care center that we have to come up with something more agreeable to everyone and use her book to code her anger and to write in her journal and read her bible. Resident states that she will try. --That had been the same note as the earlier note on 2/3/17. *On 2/15/17 at 8:00 p.m. she had left the building without being seen. -The resident had followed the activities staff member out of the facility. -RN A and two CNAs went to get the resident. -RN A informed the resident she could not be outside without family as it was not safe. -The DON follow-up on 2/22/17 had been: Staff educated that no one can take (resident name) out except her family to smoke, staff can take (resident name) out for a walk when appropriate. Staff is not to let (resident name) out by herself and in with their badge. Educated (resident name) that staff is not to take her out to smoke only family can, staff is not to let her outside by herself unless it is in the courtyard and at the appropriate time and weather. (Resident name) stated that they said she could and (resident name) was educated that staff had also (been) re-educated on this mark and that we should all be on the same page again. (Resident name was tearful and said ok. --There had been no explanation of what appropriate time and weather was. *On 2/15/17 at 8:40 p.m. she had left the building. -She independently pushed open the front door and went outside. -She was briskly self propelling her wheelchair out through parking lot and down the middle of the road as she was smoking a cigarette. -Staff brought her back in against her will. -There had been no DON follow-up comments. *On 2/16/17 at 1:00 a.m. she had left the building without being seen. -She had gone out the hospital doors after refusing her 2:00 a.m. pain pill and trying to involve the ER nurse. -Staff had told her prior to exiting the facility the police would be called to bring her back. -When outside she attempted to light a cigarette and was throwing stones (not pebbles) at CNA. -This nurse told CNA to go in and call police. -Nurse then grabbed handles of her wheelchair and turned her around and was pushing her back into the building. -She kept saying 'Why are you doing this to me?' repeatedly and nurse simply replied by repeating 'Why are YOU doing this to me?' -She then says 'All I wanted was my medicine.' -Nurse replied 'You did not want to take your pills so I could see you take them and I was not going to leave them with you. Any time you are ready to take them so I can see you take them you can have them.' -Finally (2 a.m.) she said 'I want all of them now and I will take them so you can see me take them'. -The report had been completed by the LSW -The nurses and CNAs had not been identified. -The DON follow-up on 2/22/17 had been: Reminded (resident name) of her care plan and that she needed to use her coping mechanisms and if she gets upset instead of going out to maybe go to her room and just tell staff that she is upset and needs time alone. (Resident name) agreed to this behavior. Review of resident 1's 12/29/16 care plan revealed: *A problem area for medication started on 10/6/16 with the following underneath it: -(Resident name) has a history of smoking and is attempting smoking cessation. She states she had less pain and feels better since she is not smoking. -(Resident name) continues to sneak out of facility and tries to smoke on facility grounds. -Smoking on facility grounds sneaking out and getting cigarette and lighters from niece. Tries to get cigarettes from other visitors and residents. -9/8/16 started low dose nicotine patch per request but continues to attempt smoking frequently and patch is removed. -Smoking risk: 16 potential risk. -10/6 restarted [MEDICATION NAME]. *Approaches for that problem area were: -Assist (resident name) to review the important reasons she has to stop smoking, such as: smell on clothing, health improvement, less pain per her statement. -If she is having difficulty wanting to smoke have her drink a full glass of water and help divert her attention to other activity to assist her thru. -Nicotine patch will be administered per Dr. orders. Change patches every 24 hours. To be removed if (resident name) is smoking. -Other ideas (resident name) states helps her when she has smoking urges: find a word puzzle, riding the nu-step, reading books, eating ice cream and working on crafts. -(Resident name) is not to go outside unattended and has a wanderguard on. -(Resident name) is not to go with staff to smoke and can not smoke on facility ground per policy. She is aware of policy and was reviewed on this date. 12/26/16. -(Resident name) may go with niece for short ride off facility grounds to have a cigarette. Reinforced information related to NO smoking on campus. Have discussed with family and niece smoking policy. Niece continues to bring cigarettes, lighters, and helps outside to smoke on facility grounds. -(Resident name) must alert the nurse related to going with niece to smoke prior to leaving and upon returning. -She may be accompanied by staff to go outside for walk making (sure) she is appropriately dressed for weather BUT NOT TO SMOKE. --All of those above approaches had been started on 10/6/16. --None of the above mentioned elopements had been identified on the care plan. --No new interventions had been attempted following any of the above mentioned elopements. *A problem area for behavioral symptoms with a start date of 11/20/15: -(Resident name) has been verbal abusive towards others. *Approaches for that problem area were: -Explore with resident previous effective and ineffective coping mechanisms. -Maintain a calm environment and approach to the resident. -(Resident name) does have talk therapy with (therapist name) scheduled to see (therapist's name) on 10/17/16 at 2:00 p.m. --All of those above approaches had been started on 11/20/15. --No new interventions had been attempted following any of the above mentioned elopements and her behaviors. *A problem area for mood state with a start date of 11/20/15: -Resident has signs and symptoms of mood distress as evidenced by verbalizing feeling down, depressed, or hopeless and anxiety. *Approaches for that problem area were: -Monitor depression and anxiety each shift daily and record on mood/behavior record. -Monitor for side effects and effectiveness monthly and PRN (as needed) review/assessment charting per charge nurse. -Obtain a psych consult/psychosocial therapy with (therapist name) per residents request. -Quarterly [MEDICAL CONDITION] medications eval with assessment and PRN. -Wanderguard on wheelchair to alert staff if going out of doors or heading to the ER without staff. -Elopement risk assessment will be completed quarterly. -Keep (resident name) involved in activities, crafts and decorating. -Likes to play bingo. --All of those above approaches had been started on 11/20/15. --No new interventions had been attempted following any of the above mentioned elopements and her behaviors. Observation and interview on 2/22/17 at 9:20 a.m. with resident 1 revealed: *There are not enough activities on weekends, only television and puzzles. *I get bored. *She liked to do crafts and take care of plants. *She Feels like a prisoner. *Staff come in from smoking and smell like smoke and it makes me want to smoke. *I like to be outside. *She stated that staff had given her bruises on her arms when they held her from going outside. *She had moved from other hallway but could not recall the date. Interview on 2/22/17 at 11 :15 a.m. with CNA G regarding resident 1 revealed she: *Had been employed for about seven months. *Had no problems with the resident. *Knew other CNAs had issues with her, but it usually revolved around her wanting to go outside to smoke. *Was unsure if it was care planned for the resident to go outside. Interview on 2/22/17 at 2:30 p.m. with CNA C revealed she: *Had been employed for about 2.5 years. *Knew resident 1 had been there for a while. *Had never had any problems with the resident. *Had heard about her having problems, but it was more during the overnight. She did not work that shift. *Stated there was a gentleman down the other hall that smoked. Interview on 2/22/17 at 3:35 p.m. with CNA B revealed she: *Had been employed for about one year. *Used to take resident 1 out to smoke when she was first hired, but she had been told she could not do that anymore. *Stated We cannot take her outside. *Was not aware of what was care planned or what interventions to use when she got agitated. Interview on 2/22/17 at 4:00 p.m. with RN A regarding resident 1 revealed: *The resident usually tried to get outside during the night. -That contradicted the above incident reports and the time of events. *They were not to let her go outside and smoke. *Her behaviors got worse when she wanted to smoke. *She was unaware of what interventions to use with the resident when she wanted to go outside except to contact the family, so they could take her to smoke. Interview on 2/22/17 at 4:50 p.m. with the administrator and licensed social worker (LSW) regarding resident 1 revealed: *They administrator stated she had never been allowed to smoke since her admission into the facility. *They were a tobacco free campus. *She denied that a gentleman from the other hallway smoked. *Appropriate weather and time had not been defined. *There had been no documentation they had educated the resident on proper clothing. *She stated staff could take her outside and was unsure why staff would say they could not take her outside. *There had been no interventions for staff to stay with her outside when she was upset to help calm her down. *They did not get the mental health practitioner's notes or recommendations to review. *The resident recently used her walker and walked the hallway. -She informed the LSW she was very tired that night and slept really good. -They had not implemented that as an intervention. *They had no other documentation of interventions implemented to assist in her well being. Review of the provider's revised 5/6/16 Care Planning in the Nursing Home policy for Social Services revealed: *The Social Services Designee/Social Worker will complete sections A, B, C, D, E, F0400, F0600, F0700, Q and S on the MDH 3.0 and complete corresponding RAPS as needed. *There was no mention what should have been included on a resident's care plan, who updated it, and how often. Review of the provider's revised Documentation System policy revealed: *The Plan of Care is to be initiated within the first 24 hours and updated throughout the stay as needed. Interdisciplinary Team (IDT) members consulted will update the Plan of Care within 24 hours of the first visit when an IDT problem is identified. *For initiating a Plan of Care Determine interventions which will help the patient (resident) progress toward the outcome(s) identified . A policy on resident behavior and interventions had been requested from the administrator, but what she provided only addressed employee misconduct. Review of the provider's 10/26/16 Tobacco Free Campus Enterprise policy had not addressed residents who smoked. Review of the provider's undated Resident Information packet provided at the time of admission revealed: *Residents have the right to be free from verbal, sexual, physical or mental abuse. *Residents have a right to be cared for in a manner and in an environment that promotes maintenance or enhancement of each resident's quality of life, dignity, and respect in full recognition of his/her individuality. *The staff of the facility will show an appreciation for and make every attempt to promote each resident's self-worth. *Staff will enhance resident's self-image and worth by helping them to be dressed and groomed neatly and by respecting resident's rights to private space and property. *Staff will speak respectfully, listen carefully and address residents in the way he/she wishes. *The resident has the right to make choices about aspects of his or her life in the facility that is significant to the resident.

Based on record review, interview, and policy review, the provider failed to: *Thoroughly investigate incidents for abuse or neglect for five of five sampled residents (1, 2, 3, 4, and 5). *Report an incident with injury to the South Dakota Department of Health (SD DOH) for one of one sampled resident (4). Findings include: 1. Review of resident 1's incident reports revealed she had left the building without staff knowledge twelve times from 1/24/17 through 2/16/17. She liked to be outside and had been a smoker. The provider had not implemented interventions regarding her wanting to go outside. Refer to F319, finding 1. Review of resident 1's medical record revealed: *An admission date of [DATE]. *Her 12/24/16 Brief Interview for Mental Status (BIMS) assessment score was a fifteen. -A score of thirteen to fifteen meant she was cognitively intact. -On 1/23/17 she had reported to the director of nursing (DON) she had received bruises on her right forearm and her left upper inner arm from staff. Review of resident 1's 1/23/17 initial report sent to the SD DOH revealed: *On 1/23/16 (2017) at 1600 (4:00 p.m.) (resident name) came to the director of nursing office to show bruising on her right forearm and her left upper inner arm and stated 'I don't know who did this to me.' I asked (resident name) what had happened, she stated that when '(Registered nurse (RN) A), and them were pulling me back, I don't know who did this.' (Resident name) gave me the names of (RN A, CNA (certified nursing assistant) B, CNA E, and CNA D). Investigation started. *Law enforcement had not been notified. *South Dakota Department of Social Services (SD DSS) and SD DOH had been notified on 1/23/17. Review of resident 1's 2/6/17 final report with the conclusion of the investigation sent to the SD DOH revealed: *The incident in question had occurred on 1/18/17 and not 1/23/17. *RN A, and CNAs B, D, and E were involved. *All staff involved with incident were interviewed. -That contradicted what was said in the interviews below with CNA B and RN A. *The documented interview with RN A had actually been the nursing note that had been documented on 1/18/17 and per that documentation: -The resident had refused to take her evening medication and became aggressive with staff and attempted to go outside. -RN (A) had grabbed the back of her wheel chair, RN did not touch resident. *The conclusion had been No abuse substantiated bruises were left due to CNA D holding residents arms down from hitting at the nurse attempting to harm staff. -That information of CNA D holding the resident's arms down had not been included in the written statements made by RN A, and CNAs B, D, or E. -It was unclear where they had obtained that information. *After the incident, staff had been educated on using the resident's care plan to diffuse a situation, MOAB (Management of Aggressive Behavior) training, and if they were able to leave the resident to let her calm down and return to her later. -That contradicted what was said in the interviews below with CNA B and RN A. *Law enforcement had not been notified. *Action taken by the facility was Personnel education. -That contradicted what was said in the interviews below with CNA B and RN A. -They had not marked: equipment repaired/removed, personnel reprimanded, personnel terminated, staff levels reviewed/revised, facility procedures reviewed/revised, leadership reviewed/revised, restitution made, or other. *There had been no documentation regarding why no one had reported the incident on 1/18/17. *It had been submitted to the SD DOH four times for final approval as it had to be sent back for more information each time. Review of resident 1's interdisciplinary nursing notes revealed: *On 1/18/17 at 11:22 p.m. RN A had documented the following: -Resident went into activity room, RN and CNA followed resident to watch. -Resident then went to the hospital doors and tried opening them. -RN and CNA right behind resident and stopped her. -RN wheeled resident back and told her to knock it off. -RN put resident back into her room and told her if she keeps it up she was going to sit with us the rest of the night. -Resident weepy. *On 1/19/17 at 4:23 a.m. that note had been edited to include: -0130 (1:30 a.m.) RN and resident in dining room, helping resident decorate. Resident apologized. -0300 (3:00 a.m.) resident in bed asleep. *On 1/24/17 at 1:16 a.m. the note had been edited to read: -Resident went into activity room, RN and CNA (B) followed resident to watch and make sure resident did not leave. -Resident then went to hospital doors and tried opening them. -RN and CNA right behind resident and stopped her, RN grabbed the back of residents wheel chair so she would not leave the facility. -Resident tried swinging her arms and fists behind her to hit RN. -RN put resident back into her room and left her be. -Resident weepy. -0130 (1:30 a.m.) RN and resident in dining room, helping resident decorate. Resident apologized. -0300 (3:00 a.m.) resident in bed asleep. *Those notes had not been included in the 1/18/17 SafetyZone Portal report or the above investigation. Interview on 2/22/17 at 3:35 p.m. with CNA B regarding resident 1 revealed: *She had been asked by the director of nursing (DON) to write up a statement regarding the incident on 1/18/17. -The DON had informed her the resident had told them they had caused her bruises. -The DON had stated to CNA B she did not think it really happened. *She had not been interviewed regarding the incident. -That contradicted what was in the above investigation report. *The resident was trying to go outside and had become aggressive. *No one held her down or touched her. -That contradicted what was in the above investigation report. *She had not witnessed RN A push the resident back into her room. -That contradicted what RN A had stated below. *She had heard RN A tell the resident her behavior was unacceptable. *She had not been instructed on interventions to use with the resident when she had become agitated. *She had MOAB training in the past but not related to this incident. -That contradicted what was in the above investigation report. *She had not been re-educated or reprimanded regarding this incident. -That contradicted what was in the above investigation report. Interview on 2/22/17 at 4:00 p.m. with RN A regarding resident 1's above incident revealed: *She was asked to write down a statement regarding the incident on 1/18/17. *She had not been interviewed by the DON or anyone regarding the incident. -That contradicted what was in the above investigation report. *She had to follow-up with the DON, because she had not heard anything after she turned her statement in on 1/23/17. -The DON had told her everything was fine. -She informed RN A at that time she had reported it to the state agency. -Nothing else was said about the incident. *She was worried about her license. *She stated This place is scary. *I don't feel supported. I even called my contact at the staffing agency and asked them who is supposed to have my back. *The resident had refused to take her medication in the evening on 1/18/17. *She had become agitated and aggressive. *RN A was frustrated and unsure of how to handle her. *CNAs B, D, and E were present when the resident was trying to go outside. *She wanted to go outside and smoke, but they were not supposed to let her go outside. *She had grabbed the back of her wheelchair and pushed her back to her room, told her to stay there, and told her the behaviors were unacceptable. *She had notified the DON of the incident and thought she had entered it into the SafetyZone portal. -The SafetyZone portal was a database where staff entered all incidents. *She had not been instructed on interventions to use with the resident when she had become agitated. -That contradicted what was in the above investigation report. *CNAs B, D, and E saw her push the resident back into her room. -That contradicted what CNA B stated above. *No one had touched the resident. -That contradicted what was in the above investigation report. *She had edited the notes, because she wanted them to be more accurate. *She agreed putting the resident back in her room and telling her to knock it off had been inappropriate. CNA D was unavailable to be interviewed as she had not been at work due to an injury. An interview was attempted with CNA E, but she had not returned to work on 2/22/17 until after the interviews had been conducted. Interview on 2/22/17 at 4:50 p.m. with the administrator and licensed social worker (LSW) regarding resident 1's 1/18/17 incident revealed: *The bruising was caused by CNA D giving the resident a bear hug from behind when trying to keep her from hitting out. -They had observed that on a video tape of the night in question. -She was not aware that had not been included in the investigation. *They would not answer if they were aware that CNA D had not admitted to holding down the resident's arms in her statement. *The administrator had stated all four staff members RN A, CNA B, CNA D, and CNA E named in the allegation had been reprimanded. -They had been told if it happened again they would be let go. -She had not been involved in any of those meetings. -That had not been marked on the final report as having been done. *The administrator and LSW were not aware the staff in question had not been interviewed as stated in the investigation. -The administrator's expectation was they would have been interviewed. *The DON had taken care of all of the above. *They had thought she had interviewed the staff, given them education, and reprimanded them. *They were unable to provide any documentation the staff had been talked to, reprimanded, or that education had been done. *They had not addressed the fact that none of the above staff reported the incident of CNA D holding the resident's arms down on 1/18/17, and that it was the resident who had gone to the DON. Interview on 2/22/17 at 5:45 p.m. with the DON regarding resident 1's above investigation revealed: *She had entered the SafetyZone portal incident report on 1/19/17 for the 1/18/17 event. -She would not answer how she had been informed of the incident. *She had not started an investigation until 1/23/17 after the resident came to her regarding the bruises. *She had not reported the incident to the police. *She had asked the staff to write statements. *She thought she had interviewed CNA B, but she was not sure if she had interviewed RN A. *She thought CNA D had admitted to holding the resident's arms down in her statement. -That had not been included in CNA D's written statement. *They had watched the video and saw CNA D hold down the resident's arms. -Watching the video had not been included in the final investigation. *She agreed the investigation had not been documented or completed thoroughly. Review of resident 1's 1/18/17 SafetyZone Portal document revealed: *The event date had been 1/18/17. *It had been entered on 1/19/17 by the DON. *It had first been reviewed on 1/23/17. *The DON follow-up had been documented on 1/26/17. *On 2/14/17 the quality assurance staff member had documented the following: -An officer had been at the facility to investigate missing money for resident 1. -Upon investigation, (resident name) also told (officer name) of alleged assault that occurred on 1/18/16 (2017). On 2/14, (officer name) watched the video along with (operations personnel, DON name) and myself. Our perception from (officer name) is that he didn't feel (resident name) was assaulted. A police report will be filed and (DON name) will request a copy on Monday. RM has been updated. 2. Review of resident 2's medical record revealed: *An admission date of [DATE]. *His 1/20/17 BIMS assessment score was a five. -A score of zero to seven meant his cognitive ability was severely impaired. Review of resident 2's 2/16/17 initial report sent to the SD DOH revealed: *On 2/16/17 (resident name) reported that one night this past week one black woman was rough with him assisting him to the restroom. (Resident name) stated that the black woman seemed unhappy about having to help him and that 'she slammed me in there, was not gentle and scared me to death.' (Resident name) also stated that another night a black woman was rough with him in his room. He stated 'that she had I don't give a damn attitude. She also did not provide tender loving care.' (Resident name) was unable to recall either of the staff members names. Investigation started and a switch in staffing assessment (assignment). *Law enforcement had not been notified. *SD DSS and SD DOH had been notified on 2/16/17. Review of resident 2's 2/20/17 final report sent to the SD DOH revealed: *We showed him pictures of staff members and he was not able to recall staff that was involved in the incident by the photos or names. (Resident name) also stated 'that he would like white person to take care of him and won't stand for these 2 negroes to work with me.' 2/16/17 visited with (licensed practical nurse (LPN) F) that was working the night of 2/15/17. (LPN F) stated that she was standing in the doorway and observed that CNA assisting (resident name) in the bathroom and did not see the CNA being rough with him during cares. On 2/17/17 (resident name) requested the nurse to give him a suppository because he has not had a bowel movement. The nurse explained that she could give him prune juice due to him having 5 bowel movements in the last three days. (Resident name) then became upset and pointing his finger in the nurse face and yelling. He drank the prune juice then demanded that the CNA tell him when it will work. (Resident name) stated that 'you on not being civil in her, tell me when it will work, haven't you take it before? I want to know how long.' Later that morning (resident name) became upset at breakfast, the nurse provide(d) comfort and he yelled at her to get away from him. (Resident name) was noted to be paranoid, swearing and crying. (Resident name) had a dose of [MEDICATION NAME] the night before related to increased anxiety. (Resident's wife) stated that he doesn't handle this medication well, it makes him confused, angry and paranoid. Order received from physician to discontinue the [MEDICATION NAME]. 2/17/17 visited with CNA, she stated that she helped (resident name) in the bathroom (there was no date). (CNA name) stated that he believed that she was the nurse and (resident name) stated that the (CNA name) that 'they were not civil.' (CNA name) asked him what he meant and (resident name) stated that he wanted to know how long before the prune juice would help him have a bowel movement. (CNA name) explained that everyone is different. (Resident name) also stated to (CNA name) that everyone does not care about him including his family. Educated (education) to the staff was to have two people providing cares. There was no evidence of abuse, (LPN F) witnessed no abuse in bathroom, (resident name) could not identify anyone by name or picture, no bruising or injury noted, could not prove abuse/neglect. *The 2/17/17 note regarding the suppository had been copied from the nurse's documentation. -That had not been an interview. *The documentation on 2/17/17 had occurred after the resident had made his report. *There had been no documentation the schedule had been reviewed to determine who had been working in the past week. *There had been no other documentation regarding the investigation into the allegation. Interview on 2/22/17 at 4:50 p.m. with the administrator and LSW regarding resident 2's 2/16/17 incident revealed they agreed the investigation had not been complete and thorough. They had not reviewed the schedule to see who had been working. They had not conducted any other interviews. They were unsure what the 2/17/17 documentation would have had to do with the reported concern. 3. Review of resident 3's medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. *His 2/4/17 BIMS score was fifteen that indicated he was cognitively intact. Review of resident 3's 1/29/17 initial event report to the SD DOH revealed: *The event occurred on 1/28/17 at 7:40 p.m. *The brief explanation was: -1/29/2017 11:04 am At approximately 1940 (7:40 p.m.) on 1/28/2017 resident (name) was taking a shower and was assisted by (CNA D). The night nurse (name) overheard (resident name) being repeatedly verbally abusing to staff cursing and calling names using the F word. (Nurse) also then did hear the f word used by (CNA D). (Nurse) intervened educated (CNA D) not to be using that kind of language, and when frustrated and resident is safe to walk away. (Nurse) then also moved (CNA D) to the other hall. (Nurse) checked with the resident and resident denied anything being said or had happened in the shower room. Investigation started. Review of resident 3's 2/2/17 final event report to the SD DOH revealed:*The same event time and brief explanation as the initial report above. *The conclusionary summary was the same as the brief explanation and the following additional information: -1/29/17 Interview with (nurse) at approximately 1940 (7:40 p.m.) with patient (name) was taken into the shower area on Hamilton (unit) by staff (CNA D). (Nurse) was outside of the door passing meds and cart was parked in front of another residents door and heard loud interactions coming from the shower area of patient (name) calling names and cussing at staff (CNA D) more than once, staff (CNA D) was trying to talk to patient (resident) and he continued to cuss and name call to her. (Nurse) did hear a cuss word in a different tone and when they exited the bathroom and staff (CNA D) was done with patient (nurse) spoke with (CNA D) and educated her on speaking with patient's and walking away from difficult situations and getting nurse. Education completed with no concerns. (Nurse) then spoke with (resident) who denied anything being said or happening in shower room. (Nurse) did see (resident's) aunt arrive shortly after shower and left within 5 minutes, not speaking to (nurse) but to staff (CNA D) and asked who had gave (resident) his shower? (CNA D) stated she did and was there anything or concerns the aunt stated no thank you we will discuss on Monday. DON was notified and (CNA D) then went to the other hall working at this time. (Resident) still states nothing was said and has no idea when (nurse) was talking about. -1/29/2017 interview with (CNA D) on the night of Saturday 1/28/17 about 7pm I was giving resident (room number) a shower for the first time, and he started off in a good mood but then begin to be rude and sarcastic everything thing I did was not right or am doing it to hold then when I was dying (drying) the off and his feet and residents called me an ignorant stupid F*** so by the time I had took as much as I could and told the resident that I did not give a F*** and if he wanted respect he had to give respect too. He said ok Sorry I said ok sorry I dressed resident and took him back to the room the nurse that was on heard what happened educated me on my language and let me work on the other hall. When the resident's aunt then came to the side that I was on asked who gave residents his bath and I said me can I help you she said no I will take care of it Monday in a voice that I felt threatened. -1/29/2017 this writer and (social worker) interviewed (resident). (Resident) had no other complaints or concerns at this time. -Actions taken: CNA moved to other household, education provided educated her on speaking with patient's and walking away from difficult situations and getting nurse when able. DON educated (CNA D) by telling her that we do not speak that way to the residents and (CNA D) has read and took a quiz for competency on abuse and neglect. *The brief explanation indicated the nurse had intervened and educated the CNA, but the conclusionary statement indicated the nurse waited until the CNA and resident exited the shower room until she intervened and educated. *There was no mention of: -Any further follow-up with CNA D related to her behavior. -Follow-up with the resident's aunt. -Why the nurse had not intervened right away when she heard CNA D talk inappropriately to the resident nor why she waited until they exited the shower room. *It was unclear: -Who conducted the interviews with the nurse and CNA D. -When those interviews were completed. Review of resident 3's interdisciplinary progress notes revealed no mention the 1/28/17 event had occurred. Interview on 2/22/17 at 4:50 p.m. with the administrator and licensed social worker regarding the above event revealed: *They confirmed the investigation was not clear related to: -Who completed the interviews and when they had been done. -If there was any follow-up with the resident's aunt. -Why the nurse had not intervened promptly when she had overheard the CNA D talk inappropriately to the resident. *The investigation was not documented thoroughly and completely and should have been. *Investigations should have been documented in the progress notes, safety zone event reports, or on the SD DOH report forms. Review of the reports sent to the SD DOH revealed CNA D had been involved in the above incident regarding resident 1. 4. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *Her 1/28/17 annual Minimum Data Set (MDS) assessment indicated: -Her BIMS examination was unable to be completed by interview. -Staff assessment of her cognition revealed she was severely cognitively impaired. -She was dependent on staff for care and activities of daily living. -She had impaired range of motion to both upper and lower extremities. -She did not display any behaviors. *She required assistance from two staff and a mechanical lift for transfers. Review of resident 4's Safety Zone Portal event reports revealed: a. On 12/10/16 at 9:30 a.m. an event included the following details: *The description from the nurse was Called into resident's room around 0930 (9:30 a.m.). Two CNA's were transferring resident into bath bed when she was incontinent of a large bowel movement. CNA states when changing the sling underneath they noticed 'a lot of blood.' There was a pool of blood on ground and large skin tear to the right arm near the elbow. Called RN, applied steri-strips, cleansed with sterile saline and applied bulky gauze dressing. Called ER, spoke to (practitioner name) and advised we felt that resident should be seen. Resident referred to ER and left facility around 1000 (10:00 a.m.). Returned around noon. *The DON follow-up note was not until 12/19/16 and stated Resident has steri-strips in place with dressing over steri-strips, resident has some redness swelling and warm to touch, resident will have apt (appointment) at clinic today, resident is on ASAP (aspirin) regime daily. Resident also has a bruise related to this incident with the sling noted in a later Safety Zone. will continue to monitor. *The event was listed as not reportable to the SD DOH. *There were no investigation details related to the possible cause of the injury or who the two CNAs were that had been involved. b. On 12/17/16 at 10:00 a.m. an event included the following details: *The description from the nurse was Found bruise on right thigh same area as scrape from when ST (skin tear) to R (right) elbow. *The DON follow-up note was not until 12/19/16 and stated Bruise in line where sling would be placed related to ST when transferring for a shower, resident does have a ASAP regime daily and will be going to the clinic today. *The event was listed as not reportable to the DOH. *There were no investigation details related to the possible cause of the injury or if any staff were involved. c. On 12/18/16 at 1:28 a.m. an event included the following details: *It was an infection report related to [MEDICAL CONDITION]/soft tissue/wound infection. *An antibiotic was ordered. *A culture had been ordered for her right arm wound that grew out multiple organisms. *The comments included: received skin tear to right arm near elbow on 12/10/16. Was taken to ED and had wound cleaned and dressed and On 12/18/16 staff noted redness, swelling, warmth and by 12/19/16 noted serosanguinous drainage. culture done with presence of 4 organisms . *There was no DON follow-up note. *The event was listed as not reportable to the SD DOH. d. For the above event reports the investigations were not documented to indicate investigations had occurred, and the resident had not been abused or neglected. Review of resident 4's progress notes revealed: *On 12/10/16 at 9:30 a.m. the nurse's note was the same as the event description in the above Safety Zone report. *On 12/10/16 at 6:58 p.m. there was another nurse's note that stated small scrapes on outer side of right thigh and on right buttocks. -There was no mention of how those injuries had happened. -There was no safety zone event note for them. *On 12/17/16 at 1:08 p.m. .Noted blue/purple bruise to back of right thigh. -There was no mention of how that bruise had happened. -It had not matched the safety zone event note for that date. Interview on 2/22/17 at 4:50 p.m. with the administrator and LSW regarding resident 4 confirmed: *She was dependent on staff for care and was cognitively impaired. *Her above skin tear and injuries had not been investigated and documented thoroughly. and they should have been. *Since it was an unknown injury and she had required treatment in the emergency room for the skin tear they should have reported that event to the SD DOH. *Her skin tear had become infected and later required treatment with an antibiotic. *They were unsure why the scrapes on her thigh and buttocks from the 12/10/16 nurse's note had not had an event report completed. -There should have been an event report and investigation for those injuries. Interview on 2/22/17 at 5:45 p.m. with the DON regarding resident 4's above injuries revealed:*She was unsure why they decided not to report her skin tear to the SD DOH. *She agreed the investigations had not been thorough or documented completely related to her injuries, and they should have been. *There was no mention of which two CNAs had been involved with the 12/10/16 incident, if they had followed the resident's care plan, nor if they had been interviewed related to the event. 5. Review of resident 5's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *Her 1/7/17 annual MDS assessment indicated: -Her BIMS examination was unable to be completed by interview. -Staff assessment of her cognition revealed she was moderately, cognitively impaired. -She was dependent on staff for care and activities of daily living. -She had impaired range of motion to both upper and lower extremities. -She did not display any behaviors. *She required assistance from two staff and a mechanical lift for transfers. Review of resident 5's Safety Zone Portal event reports revealed: *On 12/11/16 at 9:00 a.m. an event included the following details: -The description from the nurse was Bruise to Left FA (forearm) reported following bath this morning. -The DON follow-up note was on 12/12/16 and stated (resident) is a hoyer lift and on an aspirin regime, education will be given to staff to make sure arms are crossed across the body in transfers and not on the sides of the sling during transfer. -There was no indication the bruise had occurred from a transfer in the notes. -There were no notes indicating a thorough investigation into the bruise had a occurred. *On 12/21/16 at 5:00 p.m. an event included the following details: -The description from the nurse was resident received a small approximate 1 cm (centimeter) V shaped skin tear to her (R) buttock. -The DON follow-up note was not until 12/28/16 and stated education on proper placement of sling, and trying different size brief to help keep snugness off of that area. Resident does lay down twice a day to be repositioned off of bottom. -There was no documentation that indicated the skin tear had occurred from the brief or sling. -There were no notes to indicate a thorough investigation into the skin tear had occurred. Review of resident 5's progress notes revealed:*On 12/11/16 at 6:45 p.m. Noted after bath that CNA saw bruise to Left FA (forearm) blue/black in color does not look new to this writer approx. 4 cm by 3 cm in half moon shape. Daughter in facility aware of bruise. *On 12/21/16 at 5:18 p.m. CNA noted a small skin tear to resident's (R) buttock, approximate 1cm V shaped. Small amount of active bleeding to the area. Barrier cream applied after cleansing. *Neither of the above notes had included potential causes nor investigation into the causes of those injuries. Interview on 2/22/17 at 4:50 p.m. with the administrator and LSW regarding resident 5 confirmed: *She was dependent on staff for care and was cognitively impaired. *Her above injuries had not been investigated and documented thoroughly. and they should have been to rule out abuse or neglect. 6. Review of the provider's revised 1/14/16 Reporting Abuse or Neglect Alleged or Suspected policy revealed:* .Suspected elder or disabled adult abuse or neglect will be reported to the Department of Social Services or other legal authorities as soon as possible.*Elder or Disabled Adult Abuse will be reported to the local law enforcement agency, Office of Adult Services and Aging of the Department of Social Services or the county States of Attorney in which the older adult resides or received medical treatment as soon as possible. *Documentation in all kinds of abuse should include the following:' -A written description of all injuries, including drawings to show location and shape, if appropriate. -A complete history of the injury or neglect. When possible this should be related by the patient and parent, guardian, or caregiver independently. This should be documented as stated, identifying the historian. Use the patient's (resident) and/or caregivers own words when possible. -Document patient's affect and emotional response.-The medical record must include documentation of treatment given, instructions for follow-up care, contacts made to referral agencies, and reports made to legal authorities. *Physical abuse may have included holding, tying down, or restraining.*Emotional or psychological abuse may have included threats of harm, physical and social isolation, intimidation, degradation and humiliation, or calling another names and constantly criticizing, insulting, and belittling. *Elder or disabled adult abuse might have included: -Physical abuse such as fractures, burns, lacerations, or different stages of healing bruises. -Psychological abuse such as verbal assault by name calling or isolation from others. Review of the provider's revised 1/14/16 Abuse Prevention policy revealed: *All staff will have input as to identifying situations in which abuse is more likely to happen. It will be the responsibility of the Head of Dept. to intervene and correct. *Administration and Head of Dept. will provide a plan to correct and intervene in situations identified that abuse is more likely to occur.*Supervision of the staff to identify inappropriate behaviors. Review of the provider's revised 1/14/16 Abuse Reporting and Response policy revealed: *3.1 Any staff must report any event that may constitute as abuse to t