Every finding on record at Scotchman Living Center

Based on observation, record review, interview, and policy review, the provider failed to ensure the resident's had a prescription label on their medication bottle and that it matched the physician's order in the resident's electronic medical record (EMR) for one of one observed resident (22) who was administered magnesium glycinate that included a prescribed dose amount indicated on her medication bottle or in her EMR by licensed practical nurse (LPN) (E). 1. Observation and record review on 7/16/26 at 4:50 p.m. in the memory care unit dining room revealed LPN E administered two capsules of magnesium glycinate to resident 22. The prescription label on the magnesium glycinate bottle did not indicate the dosage amount to be administered to resident 22. Resident 22's electronic medication administration record (eMAR) did not indicate the magnesium glycinate's dosage to be administered. 2. Interview and record review on 7/15/26 at 5:03 p.m. with LPN E revealed that the back of resident 22's magnesium glycinate bottle indicated that each capsule as 120 milligrams (mgs). LPN E confirmed that the dosage of that medication was not listed on the prescription label or on the resident's eMAR, and that she administered that medication to resident 22 without confirming the dosage amount. LPN E indicated that the dosage amount should have been checked with the resident's physician before administration of that medication. 3. Review of resident 22's electronic medical record (EMR) revealed that she admitted to the facility on [DATE]. She had a 5/19/26 Brief Interview for Mental Status (BIMS) assessment score of 10, which indicated her cognition was moderately impaired. Resident 22 had a 5/19/26 physician's order for magnesium glycinate oral capsule medication, with the instructions to give two capsules by mouth one time a day for supplement. She had a 5/19/26 physician's order to monitor her for magnesium level yearly for magnesium replacement. Resident 22 had a 5/29/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) that listed a focus area of, the resident has potential nutritional problem r/t [related to] hypomagnesemia [low magnesium levels]. That focus area had the interventions for the staff to administer medications as ordered, to monitor/document for side effects and effectiveness, and to monitor magnesium level yearly for magnesium replacement. 4. Interview on 7/16/26 at 1:31 p.m. with director of nursing (DON) B revealed that she expected the staff to confirm the medication dosage amount before administering any medication to a resident. 5. Review of the provider's 12/5/23 Medication Administration and Documentation policy revealed that before medication administration, the [five] rights of medication delivery must be confirmed, which included the right dose of the medication. The prescribing provider's order is used to verify the correct drug, dose, route, and time.

Based on observation, interview, record review, American Society of Consultant Pharmacist Medications (ASCP) resource review, and policy review, the provider failed to ensure:*An extended-release medication was not crushed by one of one observed registered nurse (RN) (C) who then administered that medication to one of one sampled resident (31).*A laxative documented as administered to one of one sampled resident (31) by one of one observed RN (C) who did not observe that medication was taken. Those findings resulted in a medication error rate of 6.67%. Findings include:1. Observation and interview on 11/20/25 at 8:40 a.m. with RN C while she prepared and administered resident 31's morning medications revealed:Resident 31's November 2025 medication administration record (MAR) revealed a 10/13/25 physician's order that read: Takes medications crushed in applesauce. RN C stated that within the past three months, resident 31 had a decline in her swallowing abilities, which had prompted the physician's order for the resident to have her medications crushed if needed.RN C crushed all of the resident's morning medications, including an extended-release (a type of drug formulation designed to release its active ingredient gradually over a prolonged period, typically 12-24 hours) oxybutynin chloride tablet (a medication used to treat urinary incontinence), placed them inside of a medication cup, added applesauce to the cup, and stirred the mixture together. RN C measured the resident's prescribed polyethylene glycol powder (a laxative) separately from the above medications.Resident 31 was seated at a dining room table in the memory care unit (MCU) (an area where specialized care is provided in a structured, safe, and supportive environment to meet the unique needs of residents with significant memory and cognitive decline). RN C added the polyethylene glycol powder into resident 31's juice, then stirred it to combine the juice and powder. RN C asked the resident to open her mouth, then placed a partial spoonful of the crushed medications into the resident's mouth and verbally prompted her to swallow the mixture. RN C provided the resident with physical assistance to drink several sips of the juice and laxative mixture from her cup. That cup was half full when RN C left the resident's table and documented on the resident's MAR that all of the resident's morning medications, including the laxative mixture, were administered.Continued interview with RC C after the above medication administration revealed she knew that extended-release medications were not supposed to be crushed, but she crushed resident 31's extended-release oxybutynin chloride tablet. She could have contacted the pharmacist regarding an alternate form of that medication, but she had not done that.The facility had an available resource for the licensed nurses and unlicensed medication aides to refer to if it was not known if a medication was appropriate to crush. 2. Random observations on 11/20/25 between 8:45 a.m. and 9:15 a.m. of the MCU dining room revealed activities director (AD) R sat between resident 31 and another resident.AD R provided resident 31 with periodic verbal and physical assistance to eat her breakfast and drink the juice and laxative mixture. At not until 9:15 a.m., that resident 31's juice cup was observed by the surveyor to be empty. 3. Interview on 11/20/25 at 9:20 a.m. with RN C revealed that she had not observed resident 31 consume the juice and laxative mixture she prepared to administer to the resident earlier that morning, and documented that medication as administered.RN C relied on AD R to notify her if resident 31 had not consumed the laxative mixture; otherwise, she assumed that the resident drank the contents of the cup. RN C had not observed resident 31 consume the prescribed laxative. 4. Interview on 11/20/25 at 9:35 a.m. with director of nursing (DON) A and resident care manager (RCM) B regarding resident 31's above medication administration observations revealed they agreed the resident's extended-release oxybutynin chloride tablet should not have been crushed, and an alternative form should have been sought from the resident's physician or the pharmacist. That was a medication error.RN C was expected to observe resident 31 consume the juice and laxative mixture before she documented on the resident's MAR that it was administered. That was a medication error.Review of the provider's revised February 2018 ASCP Medications Not To Be Crushed resource revealed that extended-release oxybutynin tablets were on that do not crush list because of their time-release formulation. The list indicated there were alternate forms of that medication.Review of the provider's 12/5/23 Administering Medication policy revealed: 1. The person who prepares the dose for administration is the person who administers the dose.3.if there is any other reason to question the dosage or [medication] directions, the physician's orders are checked for correct dosage schedule or the attending physician is called for clarification of order.27. Medication tablets may be crushed using the following guidelines: a. Long-acting [extended-release] or enteric coated dosage forms should generally not be crushed; an alternative should be sought.

Based on observation, interview, record review, and policy review, the provider failed to follow infection control practices to ensure: *Three of five observed certified nurse aides (CNA) (E, H, and D) removed their personal protective equipment (PPE) (gowns and gloves ) and performed hand hygiene (HH) (handwashing with soap and water or a hand sanitizer) before exiting two of two sampled residents' rooms (3 and 21) who required transmission-based precautions (infection control measures such as the use of PPE and HH used to prevent the spread of infection (TBP).*Two of two observed CNAs (F and P) performed HH before putting on PPE and providing contact care for one of one sampled resident (31) who required TBP. *One of one observed wound care nurse (O) performed HH before opening new dressing supplies and applying the ordered dressing on one of one sampled resident (3) who required enhanced barrier precautions (EBP) related to a skin wound.*One of one registered nurse (RN) (I) removed her gloves and performed HH before opening new dressing supplies and applying the ordered dressing on one of one sampled resident (6) who required EBP related to a skin wound.Findings include: 1. Observation on 11/18/2025 at 10:50 a.m. outside of resident 3's room revealed there was a PPE supply cabinet and EBP (a type of TBP that requires glove and gown use when providing contact care) signage posted. Wound care nurse O and CNA E performed HH, then put on gloves and a gown before entering resident 3's room. After wound care nurse O completed resident 3's skin treatment, she removed her PPE inside the room, performed HH, and exited the room. CNA E remained in the room and changed the resident's incontinence brief. Then, without removing her PPE and performing HH, CNA E exited resident 3's room, pushed the resident in his wheelchair to the dining room table, walked to the area outside of the resident's room, removed her PPE, and performed HH. Interview on 11/18/25 at 2:06 p.m. with CNA E regarding the above observation revealed that she should have removed her PPE and performed HH before she exited resident 3's room to transport him to the dining room table. Review of resident 3's electronic medical record (EHR) revealed he required EBP related to having chronic skin wounds. 2. Observation and interview on 11/18/25 at 4:30 p.m. outside of resident 21's room with CNA/Activity Assistant (AA) H and CNA D revealed there was a PPE supply cabinet and contact precaution (a type of TBP) signage posted. CNA/AA H and CNA D performed HH, put on gowns and gloves, entered resident 21's room, and assisted the resident with continence personal hygiene care and repositioning. CNA/AA H and CNA D exited the resident's room, removed and discarded their PPE in a trash receptacle across the hallway, and then performed HH. CNA/AA H and CNA D stated their PPE should have been discarded inside resident 21's room, but there was no available trash receptacle near the doorway of that room. Review of resident 21's EMR revealed she required contact precautions related to extended-spectrum beta-lactamase (a type of enzyme that bacteria produce, which is resistant to many common antibiotics, (ESBL) in her urine. 3. Observation and interview on 11/18/25 at 4:45 p.m. with CNA F and CNA P outside of resident 31's room revealed there was a PPE supply cabinet and EBP signage posted. CNA F stated she thought that resident 31 required EBP because of something she had in her saliva. HH was not performed by either CNA F or CNA P before they put on their gowns and gloves to enter resident 31's room. No alcohol-based hand sanitizer (ABHS) was available in or on the PPE supply cabinet for them to use. There was an ABHS bottle on the PPE supply cabinet outside of another resident's room across the hall. CNA F and CNA P entered resident 31's room, checked if the resident's incontinence brief was soiled, and then transferred her from her bed to her wheelchair. They removed their PPE and performed HH using the wall-mounted ABHS inside the room before they exited that room. CNA F and CNA P stated HH was expected to be performed both before putting on PPE and again after removing PPE. Review of resident 31's EMR revealed she required EBP related to chronic skin wounds. 4. Interview on 11/20/25 at 1:25 p.m. with director of nursing (DON) A and resident care manager (RCM) B regarding infection prevention and control practices revealed that they expected HH to be performed by staff before putting on PPE. PPE was expected to be removed inside the resident's room after providing care and before exiting the room. Review of the provider's 4/3/23 Enhanced Barrier Precautions policy revealed: 1. d. Ensure access to alcohol-base hand rub in every resident room is both inside (near the exit) and outside of the room. 1. e. Position trash can inside the resident room and near the exit for discarding PPE. 2. Prior to assisting a resident with high-contact activities [contact care] requiring EBP, the following will be performed: a. Perform Hand Hygiene. 5. Observation on 11/18/2025 at 10:50 a.m. outside of resident 3's room revealed there was a PPE cabinet and sign that indicated the resident was on EBP. After wound care nurse O completed resident 3's ordered dressing change to the open wound on his buttocks, she removed her PPE and performed HH. She then applied clean PPE and then applied the ordered dressing. Review of resident 3's EMR revealed he required EBP related to having open wounds. 6. Observation on 11/19/25 at 9:45 a.m. outside of resident 6's room revealed there was a PPE supply cabinet and signage posted that indicated the resident was on EBP. RN I performed HH, then put on a gown before entering resident 6's room. RN I performed HH put on a pair of gloves and removed the soiled dressing from the resident's buttocks. With those same soiled gloves, she opened a package of a sterile foam dressing and cut it into two pieces with a pair of scissors. She then placed those two pieces of foam dressing to each wound on each of the resident's buttocks. 7. Interview on 11/19/25 at 10:00 a.m. with RN I revealed she should had discarded the soiled dressing into the trash and then removed her soiled gloves. She stated she should have then applied hand sanitizer prior to putting on clean gloves before she applied the clean dressing to resident 6's buttocks. 8. Review of resident 6's EMR revealed he had a diagnosis of malignant neoplasm of the anal canal (cancer in the tissues of the anus or the skin around it) and he required EBP related to burned/denuded (lost) skin from radiation treatments to his buttocks. 9. Interview on 11/20/25 at 1:25 p.m. with DON A and RCM B regarding the above observed infection prevention and control practices revealed that they expected HH to be performed before putting on PPE. Gloves should be removed after handling a soiled dressing. HH should be completed before putting on a new pair of gloves and then placing a clean dressing on a resident's skin wound. Review of resident 6's EMR revealed he had malignant neoplasm of anal canal (cancer that develops in the tissues of the anus or the skin around it). He required EBP related to burn/denuded skin from radiation treatments on his buttocks. 10. Interview on 11/20/25 at 1:25 p.m. with DON A and RCM B regarding infection prevention and control practices revealed that they confirmed HH was expected to be performed before putting on PPE and in-between taking off a soiled dressing and applying a clean dressing. 11. Review of the provider's 10/2022 Wound Care Dressing Change policy revealed: Steps in the Procedure 9. Pull glove over dressing and discard into plastic or biohazard bag. 10. Wash and dry your hands thoroughly. 11. Open new dressing(s) by pulling corners of the exterior wrapping outward, touching only the exterior surface. 12. Label tape or dressing with date, time an initial. Place on clean field. 13. Using clean technique, open other products (i.e. prescribed dressing; dry, clean gauze.) 14. Wash and dry your hands thoroughly. 15. Put on clean gloves. 16. Assess the wound and surrounding skin for edema, redness, drainage, tissue healing process and wound stage. 17. Cleanse the wound with ordered cleanser. If using gauze, use clean gauze for each cleansing stroke. 18. Clean from the least contaminated area to the most contaminated area. 19. Use dry gauze to pat the wound dry. 20. Apply the ordered dressing and secure with tape or bordered dressing per order.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell , suffered head trauma, and required emergency room (ER) treatment when one of one certified nursing assistant (CNA) (B) failed to use a gait belt as directed in the resident's care plan while assisting the resident to the bathroom. Failure to use the gait belt potentially contributed to resident 1's fall which resulted in an injury that required treatment at the ER. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 1/10/25 SD DOH FRI regarding resident 1 revealed: *She was walking with her walker and certified nursing assistant (CNA) B to get dressed for the day. *She did not have a gait belt on. *She fell backward and hit her head on her end table, which caused a laceration to the back of her head. *She was transferred to the emergency room (ER) and her laceration was closed with eight staples. *On 1/10/25 following the above incident CNA B was provided immediate education regarding gait belt use. Resident 1 was out of the facility and not available for observation or interview at the time of the survey. Interview on 1/27/25 at 11:32 a.m. with director of nursing (DON) A revealed: *Resident 1 was impulsive and at times would not wait for CNAs to assist her before she started walking. *It was her expectation that staff were to use a gait belt when ambulating resident 1. *Education on gait belt use had been provided to all staff after the 1/10/25 incident. Interview on 1/27/25 at 12:15 p.m. with registered nurse (RN) C revealed: *Staff had been provided education on gait belt use that included: -When to use a gait belt. -When to put on and take off a gait belt. -The use of gait belts to transfer residents that had fallen. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included: dementia, Parkinson's disease with dyskinesia (involuntary muscle movements) with fluctuations, and abnormalities of gait and mobility. *On her 10/21/24 Fall Risk Evaluation she had a fall risk score of 17, which indicated she had a high risk for falls. *Review of resident 1's 1/27/25 care plan revealed: *She was identified to have a high risk for falls and had fallen multiple times. *She was able to ambulate with the use of a two-wheeled walker, gait belt, and stand-by staff assistance. *She required staff supervision for walking all distances while using her walker. Review of resident 1's ER notes revealed: *She was seen on 1/10/25 at 9:00 a.m. related to her fall. -She had a laceration to the right back side of her head. -She did not have a loss of consciousness. *She was discharged back to the facility on [DATE] at 9:45 a.m. with the following orders: -Staples to be removed in 7 days. -For the next 48 hours perform neuro check every 4 hours x4 [4 times] then every 8 hours along with monitoring vitals-if any changes in pupils, speech, vomiting, etc patient needs to be re-evaluated. Review of CNA B's employment and training records revealed: *She was hired on 7/21/21. *On 1/20/25 she had attended the provider's Team Meeting. Review of the provider's 1/20/25 Team Meeting information revealed: *A portion of that meeting addressed gait belt usage. *It indicated Always use a gait belt with resident transfers and ambulation. Do not take shortcuts! Review of the provider's 9/16/23 Fall and Fall Prevention policy revealed: *Residents who are High Risk [for falls] should utilize a gait belt with transfers and ambulation. -Apply gait belt securely around resident's waist. -One hand should be secured on gait belt with ambulation. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 1/27/25 after record review revealed: *DON A provided immediate education on 1/10/25 to CNA B after the fall regarding resident 1's need for a gait belt with transfers and ambulation. *Education was provided to all nursing care staff on 1/20/25 regarding gait belt use with transfers and ambulation as well as the need to follow residents' individualized care plans. *Staff interviews on 1/27/25 revealed the staff understood the education that had been provided. *Observations on 1/27/25 revealed staff were using gait belts with resident transfers and ambulation. *DON A audited to ensure staff were using gait belts with residents when walking them. *Resident falls and reportable incidents were reviewed through their Quality Assurance program. Based on the above information, non-compliance at F689 occurred on 1/10/25, and based on the provider's implemented corrective actions on 1/20/25 for the deficient practice confirmed on 1/27/25 the non-compliance is considered past non-compliance.

Based on interview, observation, and document review, the provider failed to protect one of one sampled resident's (4) right to be free from neglect by one of one certified nursing assistant (CNA) N who had not followed the resident's care plan related to transferring (moving from one place to another) which resulted in an open wound on her leg. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Interview on 12/17/24 at 3:42 p.m. with resident 4 revealed: *She was talking about her recent dermatology appointment. *When asked if she had any sores or wounds, she pulled up her left pant leg. *She said she got that wound on her leg over a year ago. *She explained that CNA N helped her into bed and her left leg got caught on something. -She got a skin tear from that accident. -CNA N transferred her using the pivot technique rather than with the full-body mechanical lift. -She said that [CNA N] was in a hurry. *She did not blame the CNA for the accident and was very complimentary of the care he provided. 2. Review of resident 4's electronic medical record revealed: *Her care plan included a total of seven interventions that mentioned the use of a Hoyer lift (a band of full-body mechanical lift) and/or a total lift. -Staff are to use [Hoyer] lift with all transfers. Initiated on 12/17/21. Revised on 6/12/23. -DRESSING: .Resident needs assist with staff member and Hoyer lift for dressing abilities. Initiated on 10/23/17. Revised on 4/1/23. -TRANSFER: The resident is fully dependent on staff with [Hoyer] lift for all transfers with two staff at all times. Initiated on 10/23/17. Revised on 11/6/22. -TOILET USE: The resident utilizes a total lift with 2 staff for toileting needs. Initiated on 10/23/17. Revised on 11/6/22. -Resident utilizes Tena products [a brand of incontinence products] to promote ability to toilet with Hoyer lift. Initiated on 6/12/18. Revised on 11/6/22. -Resident uses [Hoyer] lift for transfers, however at times she refuses due to the amount of time it takes to hook up resident and transfer. Initiated on 6/26/19. Revised on 2/27/24. -Tena product utilized for [incontinence] and availability to change product while utilizing a [Hoyer] lift. Initiated on 10/23/17. Revised on 11/6/22. *Her 9/19/24 quarterly Minimum Data Set assessment indicated she had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. *There was a physician's order that read, Wound care to LEFT lower leg: clean w/ wound cleanser. Apply Bacitracin ointment [an antibiotic ointment]. Cover with collagen pad. Secure with bordered gauze. Change QOD [every other day]. [One] time a day on even days change after showering. *Progress note from 2/23/24 at 7:57 a.m. -Staff was transferring resident from her bed into her wheelchair using a pivot transfer, while transferring resident's left leg was cut open. A [four to five-inch] laceration noted to left lower extremity, gauze and paper tape applied to control bleeding. Assessed by wound care nurse, steri strips and mepilex applied. *She had a diagnosis of bullous pemphigoid, an autoimmune skin condition causing large, fluid-filled blisters. *At the time of the survey, the wound was still healing due to blisters forming in the wound area and continually opening per RN skin assessments. 3. Interview on 12/18/24 at 2:33 p.m. with registered nurse (RN) F about resident 4's skin revealed: *She remembered the accident where resident 4's skin on her left leg was torn due to an inappropriate transfer by a CNA. It happened on 2/23/24. *The resident's skin was very fragile due to a rare skin condition. -Her skin was a constant cycle of open and closed. -Resident 4 also had a habit of picking at her skin. *She confirmed that resident 4 was supposed to have been transferred using the full-body mechanical lift rather than with a pivot transfer according to her care plan. 4. Interview on 12/18/24 at 2:59 p.m. with CNA N about the accident with resident 4 revealed: *At the time of the accident, resident 4 was not able to use the toilet in her room. *He was planning on taking resident 4 to the shower room to use the toilet. *He cut corners and transferred her using the pivot technique. -He later admitted the transfer technique he used was not the pivot technique as resident 4 was not able to put her feet on the ground. -Instead, he explained that he assisted her to the edge of her bed, he wrapped his arms around her, lifted her up and transferred her to the wheelchair. *Resident 4's left lower leg got caught on either the bedframe or her wheelchair and caused a skin tear. *There was significant bleeding when that occurred. *Staff brought the resident to the neighboring clinic for treatment of the skin tear. *A large investigation was conducted after the accident. *He received verbal and written reprimands and education about following residents' care plans and how to properly transfer residents. *He knew what he did was wrong and that he should have transferred her according to her care plan. *All staff were reeducated on the importance of following residents' care plans at the February 2024 all-staff meeting. 5. Interview on 12/18/24 at 4:50 p.m. with director of nursing (DON) B revealed: *She confirmed that CNA N had not transferred resident 4 using the full-body mechanical lift on 2/23/24 which resulted in the skin tear to her left lower leg. *The wound was still healing. *Her skin condition made it hard for wounds to heal. *The investigation process included interviewing resident 4 and CNA N to get the whole story related to the accident. *They also interviewed other staff and residents to determine if anyone had concerns with the care that CNA N was providing. *CNA N was reeducated on safe resident transferring and the importance of communicating with coworkers and following residents' care plans. *DON B reeducated all staff at the monthly staff meeting in February 2024. -Those staff who were not in attendance were reeducated prior to their next working shift on accident hazards and following residents' care plans. 6. Random interviews with residents during the survey on 12/17/24, 12/18/24, and 12/19/24 revealed no other residents voiced concerns regarding potential neglect. 7. Observations and interviews during the survey on 12/17/24, 12/18/24, and 12/19/24 with nursing staff throughout the survey revealed appropriate resident transfers according to residents' care plans. 8. Review of staff training records revealed staff were educated about the above resident's accident and re-educated about following residents' care plans on 2/26/24 and 2/28/24. 9. The provider's implemented systemic actions to ensure the deficient practice does not reoccur was confirmed on 12/19/24 after record review revealed the facility had followed their quality assurance process, education was provided to all staff about accident prevention and following resident care plans, and observations and interviews revealed staff understood the education provided regarding those topics. Based on the above information, non-compliance at F600 occurred on 2/23/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 12/19/24, the non-compliance is considered past non-compliance.

Based on record review, observation, interview, and policy review, the provider failed to adequately treat pressure injuries for one of one sampled resident (11) by not following wound care nurse recommendations, and not notifying the resident's physician, resulting in a non-healing pressure injury. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *He had decreased feeling in his lower legs due to paraplegia (the inability to voluntarily move the lower extremities) from a previous spinal cord injury. *He also had diagnoses of congestive heart failure and dementia. *He had a pressure related injury to his left lateral ankle diagnosed on [DATE]. *His wound care was being managed by wound care registered nurse (RN) G. *RN G assessed his wound once weekly and placed orders for how to care for the pressure injury. 2. Review of resident 11's care plan revealed: *The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] paraplegia. *BATHING/SHOWERING: The resident requires extensive assist with 1 to 2 staff with bed bath 2x [two times] weekly and as necessary. *BED MOBILITY: The resident is able to assist with turning in bed with use of grab bars. Staff assist of 1-2 needed for position changes. *Resident transferred with staff assist of 2 and hoyer lift [mechanical lift that uses a sling] when getting out of bed or obtaining weights. *The resident has potential for pressure ulcers r/t immobility and paraplegia. -Assess/record/monitor wound healing q [every] Week. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [physician]. Revision on: 12/31/2020. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 12/28/2020. -Wash feet daily with warm soap and water, pat dry. Apply silicone cream. Ensure heels and LEFT lateral ankle is floated at all times. Date Initiated: 04/05/2021. Revision on 03/02/2023. -Wound care nurse to assess on Wednesdays. Date Initiated: 07/13/2023. -Heel protectors on while in bed and in wheelchair. Nurse to check skin and placement every shift. Date Initiated: 10/23/2023. -Ensure LEFT lateral ankle is floated [elevated to avoid pressure] with pillow support whenever in bed. Date Initiated: 12/17/2024. 3. Observation on 12/17/24 at 3:16 p.m. of resident 11 revealed the resident laying in his bed with his left ankle not floated, laying directly on a pillow without support under his calf. 4. Observation on 12/18/24 at 2:15 p.m. RN G performing a dressing change on resident 11's left ankle pressure injury revealed: *The dressing was removed, there was a small amount of blood-tinged drainage to the dressing. *A small circular wound to his left outer ankle. *RN G measured the wound, measurements were 0.8 cm (centimeters) x (by) 0.5 cm. *The wound was cleansed with wound cleaner. *New dressing was applied. *Resident 11 did not have complaints of pain. 5. Observation on 12/18/24 at 2:45 p.m. revealed a sign on resident 11's closet door that read, Float Left Outer Ankle. Remove heel protector and use it and a pillow under the calf area. This should float the heel as well, preventing pressure injury to it. Thank you! [RN G]. 6. Observations on 12/18/24 at 5:00 p.m. and 6:23 p.m. revealed the resident laying in his bed with his left ankle not floated, laying directly on a pillow without support under his calf. 7. Observation and interview on 12/19/24 at 11:43 a.m. with RN F of resident 11 in his room revealed: *RN F reported that the wound care RN would see the resident weekly on Wednesdays. -She reported that care instructions would frequently change after the wound care nurse visit, and those instructions usually were not verbalized to nursing staff, but were updated in the resident's care plan. *The resident was sitting up in his wheelchair. *His left ankle was resting on a pillow with no pillow support under his calf to float it. *RN F's definition of floating the resident's ankle would be by placing main support under the resident's calf to avoid pressure on the resident's ankle. -When the surveyor asked if the resident's ankle was floated, RN F replied No. -She agreed that a lack of circulation to the resident's wound could delay wound healing. 8. Interview on 12/19/24 at 11:55 a.m. with resident 11 revealed: *He was unsure of how long he had resided at the facility. *He reported he received good care from the staff. *He was unsure of how long he had the pressure injury to his left ankle. *He had some sensation in his lower extremities, but the pressure injury did not hurt. 9. Interview on 12/19/24 at 10:15 a.m. with director of nursing (DON) B and clinical care coordinator (CCC) C revealed: *Resident 11 could be difficult to provide care for due to his decreased sensation in his lower extremities and his inability to convey his feeling of discomfort to staff. *DON B followed the wound care of resident 11. *DON B expected her staff to follow the orders of the wound care nurse. *DON B reported that it was her impression that resident 11 should only have had his left heel floated when he was in bed. *DON B did not always agree with the care recommendations of the wound care nurse. *When asked if there had been any attempt to consult a physician when the DON was not in agreement with the wound care nurse, she responded that it was difficult to step on toes. 10. Review of resident 11's progress notes documented by wound care RN G related to the left ankle pressure injury revealed: *10/23/24 Skin/Wound note, Outcome: Not progressing-LEFT lateral not floated upon arrival 10/23. *11/20/24 Skin/Wound note, Resident resting in bed upon arrival. Agrees to wound assessment and cares. Ankle not floated upon arrival. Staff education needed. Float instructions hanging above bed., Wound Healing % -166.67. *11/27/24 Skin/Wound note, Wound Healing % 0. *12/4/24 Skin/Wound note, Wound Healing % 0. *12/11/24 Skin/Wound note, Wound is stagnant with little to no progress., Wound Healing % 0. *12/18/24 Skin/Wound note, Wound Healing % -33.33. *There was no documentation that the resident's physician was notified of the lack of healing for the left ankle pressure injury. 11. Review of the providers 12/2019 Pressure Ulcers policy revealed: *10. Pressure ulcers will be treated as ordered by the physician and/or wound care RN and documented in the medical record. *11. No change or deterioration in a pressure ulcer over a 2-4 week period of time will warrant physician notification for evaluation of the current treatment plan.

Based on observation, interview, and document review, the provider failed to properly label foods and discard foods on or before the manufacturer's best-by date, and failed to maintain the following kitchen items in a clean and sanitary manner: *In the kitchenette: -The flattop grill. -The grease trap drawer beneath the flattop grill. -The juice dispenser. -The overhead ventilation hood panels. *In the main kitchen: -The ceiling and ceiling vents throughout the kitchen. -The grease trap drawer beneath the flattop grill. -The deep fat fryer and the spaces in between the fryer and the adjacent equipment. Findings include: 1. Observation on 12/17/24 at 1:27 p.m. in the kitchenette revealed: *The flattop grill was stained with a burnt-on substance. *The grease trap drawer beneath the flattop grill contained a thick brown sludge of burnt food and grease. *There was a layer of dust buildup on the overhead ventilation hood panels. *There was an unidentified white growth inside the grape juice dispenser. 2. Continued observation on 12/17/24 at 1:41 p.m. in the main kitchen revealed: *There was a buildup of dust on the ceiling and ceiling vents throughout the kitchen, including above food preparation areas. *The grease trap drawer underneath the flattop grill was filled with a yellowish oily liquid. There were bits of what appeared to be eggs floating around in that liquid. *The sides of the deep fat fryer were covered in crumbs and grease. -The fryer was situated in between the gas stovetop and the ovens. -There was a buildup of grease and food crumbs on the paneling of the stovetop and the oven, which was a potential fire hazard as the gas stovetop used an open flame to operate. *In one of the reach-in coolers, there were two foods past the manufacturer's best by dates: -One opened jug of lime juice with BEST BEFORE 2024 [DATE]. -One opened container of pesto with BEST IF USED BY: 11.11.2024. *There was a container of orange powder with a handwritten label of Taco Seasoning 6.1.23 - 6.1.24. -A measuring scoop was stored inside that container. *There were two large containers of what appeared to have been sugar and flour. There was no label or date on them. 3. Interview on 12/18/24 at 3:28 p.m. with cook I revealed that the juice machine was supposed to have been taken apart and cleaned weekly. 4. Interview on 12/18/24 at 3:51 p.m. with certified dietary manager (CDM) J revealed: *The overhead ventilation hoods were cleaned professionally every six months. -The hood panels were cleaned as needed by himself or the dietary staff. -He estimated the hood panels in the kitchenette had not been cleaned in approximately a month and a half. -That task was not on the cleaning checklist. *The deep fat fryer was cleaned at least every two weeks, but sometimes more depending on the menu. *Staff were cleaning the fryer that day. *He recently put the protective guards up as another layer of protection between the fryer and the gas stovetop. 5. Interview on 12/18/24 at 4:20 p.m. with cook I revealed: *The grease trap drawers were supposed to have been cleaned daily. *She was not sure why there was so much liquid in the grease trap drawer in the main kitchen. *The flattop grill in the kitchenette was hardly ever used, and she was unsure about when the grill or the grease trap drawer were last cleaned. 6. Interview on 12/18/24 at 4:30 p.m. with dietary aide (DA) H in the kitchenette revealed: *The flattop grill in the kitchenette was not used often as it would take a long time to warm up and clean afterwards. -She did not know when it was last cleaned. *The juice machine was supposed to have been cleaned weekly. -She indicated the juice machine was not always cleaned weekly as it took a long time to drain it, put warm water through it, take it apart, bring it back to the kitchen, wash it, bring it back to the kitchenette area, and put it back together again. 7. Interview on 12/19/24 at 10:28 a.m. with CDM J revealed: *He expected staff to wipe down the ceilings and vents once per week. -He indicated the task on the checklist was to wipe the walls down, but he expected staff to wipe the ceilings as well. -He was aware that task does not always get done. *The grease trap drawer in the main kitchen fills up with liquid daily as they pour large volumes of water and lemon juice onto the grill to clean it. That liquid pours down the drain into the drawer. *He expected the drawers to have been cleaned daily. *He was not aware of the unidentified white growth or sediment in the grape juice dispenser. -He expected the juice dispenser to have been disassembled and cleaned weekly. -He explained that some staff may not take the machine all the way apart because they did not know how to take it apart or put it back together. --He confirmed there are directions to do so on the inside of the juice dispenser door. *He confirmed the food items that were past their best-by dates were thrown away. 8. Review of the provider's Daily [NAME] Cleaning List for the week of 12/8/24 through 12/14/24 revealed all items on the cook's list were initialed off as having been completed. 9. Review of the provider's Weekly Cleaning List from 11/17/24 through 12/14/24 revealed: *Cleaning the deep fat fryer was not included on the list. -Someone had written that the fryer was cleaned the week of 12/1/24 to 12/7/24. *Cleaning the overhead ventilation hood panels was not on the list. *Wiping the ceiling and ceiling vents was not on the list. *Cleaning the flattop grill and the grease trap drawer was not on the list. *Cleaning the juice machine was a weekly task on Fridays. That task was initialed as having been completed each week. 10. Review of the provider's 8/28/23 policy that did not have a title revealed: *POLICY STATEMENT -It is the policy of the Dietary Department that all perishable foods are refrigerated at the appropriate temperature and in an orderly and sanitary manner. *There were no guidelines describing expectations on labeling and storage of bulk items like sugar, flour, and taco seasoning. *There were no guidelines describing expectations on storage of foods past the manufacturer's best-by date.

Based on observation, record review, interview, and policy review, the provider failed to ensure four of sixteen sampled residents (4, 8, 21, and 22) had their care plans updated, and revised promptly to reflect their current status and care needs. Findings include: 1. Observation on 12/17/24 at 3:42 p.m. in resident 4's room revealed: *There was an oxygen concentrator machine next to her sink. *She was using the portable oxygen machine at the time. -The flow rate was set at 2L/min (liters per minute) via nasal cannula. Review of resident 4's electronic medical record revealed: *There were two physician's orders related to her supplemental oxygen: -Oxygen 1-10 liters to be applied PRN [as needed] via NC [nasal cannula] or high flow NC to maintain SPO2 [oxygen saturation] above 90% as needed for hypoxia. Ordered on 6/30/23. -Oxygen 1-10 liters to be applied PRN via NC or high flow NC to maintain SPO2 above 90% three times a day. Ordered on 6/30/23. *Her care plan included the following intervention: -Apply oxygen PRN 1-5L NC to maintain oxygen level above 90%. Date initiated 2/17/20. Revised on 7/12/23. 46453 2. Interview on 12/17/24 at 1:06 p.m. during entrance conference with administrator A, director of nursing (DON) B, and clinical care coordinator/social service director (CCC/SSD) C revealed the facility was a non-smoking facility and there were no residents who smoked. Review of resident 8's medical record revealed: *Her admitted was 11/1/23. *Her diagnosis included: dementia, depression, psychotic disturbance, mood disturbance, anxiety, history of urinary tract infections, history of pulmonary embolism, hearing loss, osterarthritis, wedge compression fracture of first lumbar vertebra, chronic obstructive pulmonary disease and chronic bronchitis. Review of resident 8's care plan revealed: *Monitor location every 2 hours and PRN. Document wandering behavior and attempted diversional interventions in behavior note. -There were no specific diversional interventions listed. *Provide resident with preferred food sources to encourage consumption. -There were no specific preferred foods listed. *An 11/14/23 intervention of Educate the resident/family/caregiver about: ., the adverse effects of tobacco and alcohol, . -The resident 8 did not use tobacco. 3. Review of resident 21's medical record revealed: *He had a diagnosis of dementia. *His Brief Interview of Mental Status score was 4, which indicated he had severe cognitive impairment. *He resided in the memory care unit. *His care plan included he was ambulatory and had a history of wandering. -Interventions for his wandering included: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, and books. --There were no specifically identified pleasant diversions, structured activities, food, conversation, television, books. 4. Observation on 12/17/24 at 4:01 p.m. of resident 22 in her room revealed: *She was awake and lying in bed. *There was an oxygen concentrator in the room that was providing her oxygen through a nasal cannula. Review of resident 22's care plan revealed: *There was a revised 8/14/23 intervention that included Encourage resident to avoid alcohol, smoking, *There was a revised 8/7/23 intervention that included Encourage resident to . stop smoking, . -Resident 22 did not smoke. 5. Interview on 12/18/24 at 5:11 p.m. with Minimum Data Set nurse D, CCC/SSD C, and DON B, regarding the provider's care plan process revealed: *Care plans were reviewed each quarter and with a significant change of condition or status by the interdisciplinary team. -Resident care changes could happen daily. -The interdisciplinary team included the resident, their family or representative, CCC/SSD, DON, dietary manager, activity director, a nurse, therapy staff, a CNA and the resident's medical provider. *Any staff member with appropriate access to the resident's medical record was able to change the resident's care plan. *The facility was a non-tobacco and smoke free facility. *CCC/SSD C confirmed that several areas of resident's care plans were general and were the same care plan interventions for multiple residents that were not person-centered care for each resident. -She confirmed the resident's care plans were not updated or revised in those areas. 6. Review of the provider's 6/2022 Comprehensive Care Plan policy revealed: *The Interdisciplinary Team in conjunction with the resident and his/her family/representative develops and implements a comprehensive, person-centered care plan for each resident. *The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. *Care plan interventions are chosen only after careful data gathering, proper sequencing of events, and careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. *The Interdisciplinary Team must review and update the care plan: -a. When there has been a significant change in the resident's condition -b. When the desired outcome is not met -c. When the resident has been readmitted to the facility from a hospital stay -d. At least quarterly, in conjunction with the required quarterly MDS assessment. 43844

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (21) who eloped (left the facility without staff knowledge) when a visitor exited the building. This citation is considered past-noncompliance based on review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's submitted SD DOH FRI regarding resident 21 revealed: *On 10/29/24 at 2:10 p.m., resident 21 followed an unidentified visitor out the front door of the facility. *The visitor had used a key fob to unlock the door and once in the parking lot the visitor realized resident 21 was a resident. *The visitor assisted the resident back into the lobby of the facility where staff were present. -Upon his return, the resident was assessed with no injuries and was dressed appropriately for the weather that day. -At the time of the elopement, resident 21 was in the main lobby of the facility attending a birthday party. *The facility was considered a locked unit, all exterior doors of the building were locked, and the front door had a delay of ten seconds before closure after it was opened. Review of resident 21's medical record revealed: *He had a diagnosis of dementia *His Brief Interview of Mental Status score was 4, which indicated he had severe cognitive impairment. *He resided in the memory care unit. *His care plan included he was ambulatory and had a history of wandering. -Interventions for his wandering included: -Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. -Monitor the resident's location every fifteen minutes. -Offer diversion activities when resident begins talking about leaving facility. -Provide structured activities: toileting, walking inside and outside, reorientation strategies including signs, pictures, and memory boxes. The provider implemented systemic actions to ensure the deficient practice does not reoccur by having: *Notified families in the monthly newsletter and posted signage at the facility's exits that there are residents who wander and not to let residents out of the facility without staff knowledge. *Provided education to staff members regarding the elopement policy. *A practice elopement drill was conducted. *Ensured their FRI's were presented at the next Quality Assurance meeting. *An exit door in the memory care unit had been frosted, which maintains the natural light but obscures the view of the exit. *There have been no other elopements. *Visitors have been monitored to ensure they are following instructions and ensuring residents do not follow them out. The provider's implemented systemic actions to ensure the deficient practice does not reoccur was confirmed on 12/19/24 after record review revealed the facility had followed their quality assurance process, education was provided to all staff about the resident's elopement, and observations and interviews revealed staff understood the education provided regarding those topics. Based on the above information, non-compliance at F689 occurred on 10/29/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 12/19/24, the non-compliance is considered past-noncompliance. 51816

Based on observation, record review, interview, and policy review, the provider failed to follow their Resident Weight policy and notify the registered dietitian (RD) and begin follow-up for one of one sampled resident (34) who experienced a significant weight loss. Findings include: 1. Observation on 12/17/24 at 3:37 p.m. revealed resident 34: *Was asleep in a group/activity room recliner with a hat and glasses on. *His clothes were loose-fitting. 2. A review of resident 34's medical record revealed: *He was admitted on [DATE]. *His 10/18/24 Brief Interview of Mental Status (BIMS) assessment score was 99, indicating he had not participated or was unable to participate in the assessment. *His diagnoses included vascular dementia (a type of dementia caused by reduced blood flow to the brain) with anxiety, cerebral infarction (stroke), and depression. *Review of the resident's weight records revealed: -On 10/10/24, he weighed 186.4 pounds. -On 11/2/24, he weighed 185.4 pounds. On 11/9/24, he weighed 178.6 pounds. --A loss of 6.8 pounds in one week. -On 12/13/24, he weighed 170.6 pounds which was an 8.5% weight loss since his admission. *His care plan interventions for his weight included: -To Monitor/document/report PRN [as needed] any signs/symptoms of dysphagia [difficulty swallowing]: Pocketing [when someone holds food in their mouth rather than swallowing], Choking, Coughing, Drooling, Holding food in mouth, Several attempts at swallowing, Refusing to eat, Appears concerned during meals initiated on 10/24/24. -RD [registered dietician] to evaluate and make diet change recommendations PRN [as needed] initiated on 10/24/24. *On 11/15/2024, the resident had an outpatient dentist appointment to check his denture fit. -The dentist's progress note indicated: --He had not seen any sore spots. --The resident was not able to wear his dentures predictably due to dementia. --Please use soft foods- patient is not likely to keep dentures in. ---The progress note was acknowledged by a nurse in his chart, and the note was entered into his electronic medical record (EMR). *On 12/12/24, the registered dietician (RD) performed a significant weight change assessment on the resident and recommended continuing his current diet order and added a Magic Cup (a nutritional supplement) once a day. -She did not change the resident's regular diet to a soft diet. *His dietary orders included: -Regular diet, regular consistency, large portions at meals. These were ordered on 10/10/24 on admission. --The diet orders had not been changed related to the dentist's 11/15/24 diet recommendation. -Magic Cup one time a day at noon, ordered on 12/13/24. *On 12/18/24 at 2:10 p.m., a nurse's note indicated that he had refused to wear his dentures that morning. 3. Interview on 12/18/24 at 3:59 p.m. with RD (M) regarding resident 34 revealed: *She had reviewed the resident's weight last week while performing a significant weight loss assessment and started an intervention of adding a nutritional supplement. -She was unaware of the dentist's 11/15/24 recommendation for a soft diet until 12/18/24. Interview on 12/18/24 at 4:17 p.m. with dietary department manager J regarding resident 34 revealed: *He was not aware resident 34 was to have a soft diet until 12/18/24. *He stated the speech therapist emailed him on 12/18/24 of the diet change. -He was unable to find a soft diet order in the resident's current orders. 4. A review of the provider's 5/15/23 Resident Weight policy revealed: *Weight Assessment - 3. Any weight change of 5 lbs more or less since the last weight assessment is retaken the next day for confirmation. --a. If the weight is verified, nursing will immediately notify the dietician in writing. *Evaluation - 1. Undesirable weight change is evaluated by the treatment team whether or not the criteria for significant weight change has been met. The evaluation includes: --c. the relationship between current medical condition or clinical situation and recent fluctuations in weight - 2. The physician and the multidisciplinary team identify conditions and medications that may be causing anorexia, weight loss or increasing risk of weight loss.

Based on observation, interview, record review, and policy review, the provider failed to follow their policy related to oxygen administration for two of five sampled residents (4 and 12) who received oxygen therapy: *Resident 4's oxygen tubing was not dated. *Resident 12's oxygen tubing was not changed monthly per facility policy. *Resident 4's nasal cannula was observed on the floor during one of three observations. *Resident 4's foam filter on the back of the oxygen concentrator machine had a buildup of dust. Findings include: 1. Observation and interview on 12/17/24 at 3:42 p.m. with resident 4 in her room revealed: *She was wearing a nasal cannula and using a portable oxygen tank. That tubing was not dated. *There was an oxygen concentrator machine next to her sink. -The foam filter on the back of the machine had a buildup of dust and fuzz. -The nasal cannula for that machine was on the floor. 2. Observation on 12/18/24 at 9:39 a.m. in resident 12's room revealed: *There was a section of extension tubing from the oxygen concentrator machine to the water chamber with a handwritten date of 9/28 on it. *The water chamber had a handwritten date of 12/13/24 on it. 3. Interview on 12/18/24 at 2:28 p.m. with registered nurse (RN) F revealed: *They previously used plastic baggies to store the residents' oxygen tubing when not in use. Residents did not like these baggies and would throw them in the trash. *They now used hooks that were adhered to the side of the concentrator machines to wrap the oxygen tubing around when not in use to keep it off the floor. *She expected staff to replace a nasal cannula if it was found on the floor. *The reason why resident 12's oxygen extension tubing had not been replaced was due to supply issues. -They did not have that particular tubing in stock. -The employee in charge of ordering supplies went on medical leave for approximately two months, and the backup person was not aware of that specific type of extension tubing to ensure it was ordered and available. *She indicated that sometimes cleaning the filter each week does not get done like it should. 4. Observation on 12/18/24 at 2:50 p.m. in resident 4's room revealed: *The nasal cannula was stored wrapped up and tucked under the handle of the oxygen concentrator machine. The nasal cannula was not on the floor. *There was no indication to note if the nasal cannula had been replaced or not. *The foam filter was still dusty. 5. Interview on 12/18/24 at 2:59 p.m. with certified nurse assistant (CNA) N about oxygen tubing revealed: *The nurses changed the residents' oxygen tubing weekly. *If he found a nasal cannula on the floor, he would have wiped it off with an alcohol wipe, wrapped the tubing up, and tucked it under the handle of the oxygen concentrator machine. 6. Interview on 12/18/24 at 4:45 p.m. and again on 12/19/24 at 8:12 a.m. with director of nursing (DON) B revealed: *She expected the residents' oxygen tubing to be changed monthly. *The backup supply person may not have known about that style of extension tubing to be able to order it. *She expected the foam filters on the oxygen concentrators to be cleaned weekly. *RN F was usually responsible for ordering the oxygen tubing supplies for residents. -She indicated that RN F was probably waiting for [the employee in charge of ordering supplies] to get back to order that part. *She confirmed that oxygen extension tubing was about two months overdue for changing. 7. Review of resident 4's physician orders revealed: *Change O2 [oxygen] tubing on concentrator/tank Q month [every month]. -That order was scheduled one time a day every 14 day(s). *Clean O2 concentrator filter Q week [every week] one time a day every 7 day(s). *Those orders were placed on 6/6/23. 8. Review of resident 4's December Treatment Administration Record revealed that the filter was documented as having been cleaned on 12/5/24 and 12/12/24. 9. Review of the provider's 9/23 Oxygen Administration policy revealed: *Maintenance: -1. Oxygen tubing is to be changed monthly. -2. Concentrator filters are to be cleaned and checked monthly. -3. Humidifier containers are to be cleaned weekly with a 1:1 [1 to 1] vinegar/water solution or as per manufacturer recommendations. *Documentation: -1. After completing the oxygen set up or adjustment, the following information should be documented in PCC [PointClickCare]. --a. The date and time the oxygen was applied . *Reporting: - .2. Report other information in accordance with facility policy and professional standards of practice.

Based on review of the South Dakota Department of Health (SD DOH) complaint online report, interview, and policy review, the provider failed to protect one of one sampled resident (20) from mistreatment while receiving care from staff. Findings include: 1. Review of the SD DOH complaint online report revealed the following: *On 2/8/24 at 12:30 p.m. certified nursing assistant (CNA) C reported to registered nurse (RN) B that while providing care in the morning for resident 20, resident 20 had grabbed the back of CNA D's arm and twisted it. -That caused three open abrasions and redness on CNA D's arm. -CNA D had put resident 20's hands between her legs and put her weight on top of resident 20. -Resident 20 began yelling, You're going to break my arm. -CNA D stated, You're going to get dressed, and you're not going to hit me anymore. -CNA C told CNA D to ease up [on resident 20], and called out for help from other staff members. -CNA E came into the room and saw that CNA D to be straddling on top of resident 20 with the resident's arms crossed and the resident yelling get off me, you're going to break my arms. -CNA E then had assisted in helping resident 20 stand up and walk to the dining room. -RN F came to the room as CNA E was walking the resident out of the room. Observation on 3/6/24 at 10:27 a.m. of resident 20 in her room revealed she was in her bed, laying on her left side, with her eyes closed. Observation on 3/6/24 at 11:30 a.m. of resident 20 in the dining room revealed: *Her noon meal was served on a red plate. -She had pushed that plate into the middle of the table. *When asked open-ended questions, she had shaken her head no to each one of those questions with no other response. Review of resident 20's medical record revealed: *She was admitted on [DATE]. *Her 12/7/23 Brief Interview of Mental Status score was a 99 indicating she was unable to be interviewed. *Her diagnoses included dementia with behavioral disturbances and visual loss. *Her 3/6/24 care plan included the following: -Allow sufficient time for dressing and undressing. -She requires substantial assistance by 1 [one] staff [member] to dress. -At times will refuse morning cares due to preference of sleeping in. -She was resistive to care. --Give clear explanation of care activities prior to an as they occur during each contact. --If resident resists with ADL's [activities of daily living], reassure resident, leave and return 5-10 minutes later and try again. --The resident is verbally aggressive with staff. --The resident has impaired visual function r/t visual loss. Confidential interview with an employee who wished to remain anonymous regarding the above incident revealed: *She heard a staff call for help from resident 20's room. *She went to resident 20's room, and heard yelling that was not unusual, knocked and entered the room. *She heard CNA D state, She is not going to [profanity] hit me again. *CNA C had looked at her and stated quietly to her, I don't know what to do. *Resident 20 was on the bed lying on her side. -CNA D was lying over the top of resident 20. -Resident 20's arms were crossed and underneath of her. -CNA D stated, You are not getting up, she isn't going to hit me again. -The anonymous employee, during the interview, that the tone of resident 20's voice stating, Don't hurt me made her ill. -CNA C and the anonymous employee intervened and assisted resident 20 to stand up. -CNA D left the room. -RN F came into the room, looked around, and then left the room. *As resident 20 walked down the hallway, she stated Where is the ghost? -The employee asked resident 20 who the ghost was and resident 20 responded, That is what I am going to call that mean lady, a ghost. *On 2/8/24 after the above incident there was an emergency staff meeting held for all staff regarding abuse and neglect, proper restraining of residents, and how to handle residents with behaviors. Confidential interview with a second employee who wished to remain anonymous regarding the above incident revealed the following: *She heard a call for assistance in resident 20's room. -When she went into the room, CNAs C and D were assisting resident 20 to stand up, and assisting her pulling up her pants. *Regarding CNA D the anonymous employee stated that CNA D had a short fuse. Interview on 3/6/24 at 11:54 with RN B regarding the above incident revealed: *The incident happened at around 10:00 a.m. while staff were assisting resident 20 in getting up for the day. *She was notified of the incident around noon time from CNA C. *She contacted director of nursing (DON) A, who was not in the facility at that time. *The investigation was started. -CNA D was suspended on 2/8/24 at 1:16 p.m. -The investigation was completed and was substantiated that abuse had occurred. -CNA D's employment was terminated on 2/14/24. *Education regarding abuse and neglect, retaliation, and dementia care was provided to every staff member after the incident on 2/8/24 and before their next working shift. -Additional education for those same topics was provided to all staff members on February 28, 2024. Interview on 3/6/24 at 12:06 p.m. with DON A regarding the above incident revealed: *She was notified on 2/8/24 of the above incident. -She came to the facility and started educating staff members on abuse and neglect. -Education was provided to staff members in their monthly meeting. *Events that were reportable to the SD DOH were included in the monthly Quality Assurance Process Improvement (QAPI) meeting for review. Review of the provider's revised February 2024 Abuse policy revealed: *Subject: Freedom from abuse, neglect and exploitation & [and] reporting *Purpose: To ensure the facility has followed all the required stops for recognizing and for appropriate reporting and follow up in cases of suspected resident/patient abuse. *Policy: Each resident/patient has the right to be free from abuse, neglect, misappropriation of resident/patient property .Residents/Patients must not be subjected to abuse by anyone, including, but not limited to, facility staff ,other residents/patients, consultants or volunteers, staff or other agencies serving the resident/patient, family members or legal guardians, friends, or other individuals. -C. To assist our facility's staff members in recognizing incidents of abuse, the following definitions are provided: -Physical Abuse includes but is not limited to hitting, pinching, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. -Mistreatment means inappropriate treatment or exploitation of resident/patient -Person Centered Care is care that is individualized by being talored [tailored] to all relevant considerations for that individual, including physical, functional and psychosocial aspects. -Physical restraint as [is] any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: --is attached or adjacent to the resident's/patient's body --can not be removed easily by the resident/patient. --restricts the residents/patients freedom of movement or normal access to his/her body. *Subject: Prevention *Purpose: to prevent abuse by providing residents/patients, families, and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The leadership will assess the needs of the residents/patients in the facility to be able to identify concerns in order to prevent potential abuse. *Subject: Abuse/Neglect Inservice Training *Purpose: To provide periodic inservice [in-service] training for employees/volunteers on resident/patient rights and our facility's abuse/neglect prevention program. *Procedure: -5. Dementia training is offered throughout the year via [computerized training system] and staff meeting education, which addresses behavioral issues and approaches. Substantial compliance was confirmed on 2/14/24, after: *Staff member interviews confirmed education regarding dementia, abuse and neglect had occurred. *Review of documented dementia, abuse and neglect education for all staff members. *Termination of CNA D's employment. *SD DOH reports were reviewed during the QAPI meetings.

Based on observation, interview, record review, review of the 8/29/23 Required Healthcare Facility Event Reporting form, and policy review, the provider failed to investigate and report in a timely manner an injury of unknown origin for one of one sampled resident (32). Findings include: 1. Observation and interview on 8/29/23 at 11:15 a.m. with certified nurse aide (CNA) E and CNA F and resident 32 in her room revealed: *The resident was lying in bed. -There were bilateral side rails on her bed, one fall mat on the floor next to one side of her bed, and a second fall mat on the floor at the foot of her bed. *A sign near the head of her bed indicated she was at risk for falls. *CNAs E and F transferred the resident with a mechanical lift from her bed to her wheelchair. -The staff stated the wheelchair was new to the resident. *The resident's left hand was wrapped with a gauze dressing. -A portion of the skin that was visible on her left thumb appeared black-colored and dry-looking. *CNA F confirmed the resident had injured her left hand a few weeks earlier but was not certain what happened to have caused that injury. *The resident stated she had been injured after falling out of an airplane. *Staff placed the resident's left arm in a sling after she was transferred to her wheelchair. -The resident had a stroke in the past and was unable to control the movement of that arm. Review of resident 32's medical record revealed the following nurse progress notes: *On 8/12/23 at 6:21 a.m.: Around 5:30 AM 8/12/23 resident rolled out of their bed. Resident was found laying on fall mat with pillow under head. Resident was assisted back into bed, injury assessment done, and vitals taken. No new injuries found. Fluid pockets found on left hand. *On 8/12/23 at noon: Resident's vital signs and LOC [level of consciousness] seem to be WNL [within normal limits] s/p [status post] fall earlier this morning. Large bruise found on L [left] elbow and resident does c/o [complain of] pain at this site. No other bruising or signs of injury on head or elsewhere noted. Of note, there are 3 large fluid pocket/blisters on L outer thumb as well as one small fluid blister on outer 5th digit. Review of the physician's 8/15/23 progress note regarding resident 32's left-hand skin injury revealed: *They [nursing home staff] are not sure how that happened [the hand injury] just on her left hand which is a side that is affected from her stroke. Not sure if she laid on the hand or got pinched in between something. *Multiple blisters [on the] left hand most likely secondary to some sort of friction injury on her affected stroke side . Observation and interview on 8/29/23 at 10:30 a.m. with registered nurse (RN) D in resident 32's room revealed: *There were multiple areas of impaired skin integrity that varied in size and shape that were observed after RN D removed the dressing from the resident's left hand. *The areas observed were: -On the top of the resident's hand near her knuckles and near where her hand and wrist met. -On either side of the base of the palm of her hand and on the center of her wrist just below the palm. -On her thumb, index and pinky fingers. *The areas were dark red or black colored, dry looking in appearance, and none of the areas were fluid-filled. *RN D confirmed those areas on the left hand had initially presented as two to three fluid-filled blisters when they were first observed after the resident's 8/12/23 fall. *She had not known the cause of those blisters but thought the resident had a reaction to something. Interview on 8/30/23 at 3:15 p.m. with director of nursing (DON) B regarding resident 32's post-fall injury referred to above revealed: *It was presumed the left-hand blisters referred to above had occurred as a result of the 8/12/23 fall. -That was when those blisters had first been noticed by the staff. *The development of blisters was not a common injury associated with falls. -Bruising and skin tears were more often seen with falls. *Resident 32's 8/12/23 injury of unknown origin should have been reported to the South Dakota Department of Health-Office of Licensure and Certification (SD DOH-OLC) within 24 hours of its occurrence. -That notification had not been made until 8/29/23. *It was DON B's responsibility to ensure that notification occurred in a timely manner. Review at that same time of the Required Healthcare Facility Event Reporting form submitted by the provider on 8/29/23 to the SD DOH-OLC regarding the injury of unknown origin referred to above revealed DON B agreed: *The information documented by the provider in the Explanation of Event section and the Conclusionary Summary Statement of the Facility Investigation section of that form were the same. -The Investigation section of that form had not included any information explaining possible causes for that hand injury or what interventions had been put in place to prevent a re-occurrence of that injury. *There was no documentation to support the following: -The resident's environment had been assessed after the fall for possible causes of that injury such as the side rails on her bed, her new wheelchair, the mechanical lift, or the arm sling she had worn. -Interviews with other staff members regarding what may have caused or contributed to those injuries. -Potential causes of the hand injury referred to in the physician's 8/15/23 progress note were not investigated. *DON B agreed it was her responsibility to ensure a thorough, documented investigation was completed following the unwitnessed fall that had resulted in resident 32's injuries of unknown origin. Review of the revised April 2023 Abuse policy revealed: *Injuries of unknown origin that had not resulted in serious bodily injury to a resident were expected to have been reported to the SD DOH-OLC no later than 24 hours following the event. *The completed investigation of that event was to have been submitted to the SD DOH-OLC within five working days. -The report was expected to have included pertinent information such as the steps the facility had taken to protect the resident and a description of preventative measures that had been implemented to try to prevent a recurrence of that event.

Based on observation, interview, record review, and policy review, the provider failed to ensure the following: *Care-specific details regarding one of one sampled resident's (32) skin condition and skin treatment had been documented in that resident's medical record. *One of one registered nurse (RN) C had not implemented a discontinued physician-ordered skin treatment for one of one sampled resident (32). *One of one sampled resident's (32) physician had been notified of her worsening skin condition. Findings include: 1. Observation and interview on 8/29/23 at 10:30 a.m. with RN D in resident 32's room revealed: *There were multiple areas of impaired skin integrity that varied in size and shape that were observed after RN D removed the dressing on the resident's left hand. *The areas observed were: -On the top of the resident's hand near her knuckles and near where the top of her hand and wrist had met. -On either side of the base of the palm of her hand and at the center of her wrist just below the palm. -On her thumb, index and pinky fingers. *The individual areas varied in size and shape: -Round, slightly larger than the eraser at the end of a pencil to quarter size. -Approximately one-inch square. -Oval-shaped and about one and a half inches by a half-inch. *Each of those areas varied in color from dark red to black in color and were dry-looking. *RN D confirmed those areas referred to above on the resident's left hand had initially presented as two to three fluid-filled blisters when they were first observed after the resident's 8/12/23 fall. Review of resident 32's medical record documentation between 8/12/23 and 8/30/23 related to her left-hand skin condition referred to above included the following: *Three progress notes: -On 8/12/23 at 6:21 a.m. the resident had been found on the floor lying on a fall mat beside her bed. An injury assessment had been completed and fluid pockets found on [the] left hand. -On 8/12/23 at 12:00 noon there are 3 large pockets/blisters on L [left] outer thumb as well as one small fluid blister on [the] outer 5th digit [finger]. -On 8/14/23 at 4:03 p.m. the left hand dressing had been removed from the resident's hand and several fluid filled blisters had been observed. One to her pinky finger, one at the base of her thumb two to her inner hand. Not open at this time. *An 8/15/23 physician's progress note that indicated the resident had multiple fluid-filled blisters to her left hand. *Two weekly skin assessments: -On 8/16/23: Resident has scattered bruising throughout her entire body. Several large blister on her left hand/wrist that is wrapped in Kerlex. [Kerlix] -On 8/23/23: On the palm of the resident's left hand Two large sanguineous (clear fluid) filled blisters. Little finger with blister as well. Applied iodine and put dressing over hand to protect site. *One monthly resident summary: -Skin Summary documentation on 8/18/23: The resident's skin was normal and intact. Comments included blisters to left hand. *No additional documentation related to the status of resident 32's left hand had been documented since 8/23/23. 2. Review of resident 32's August 2023 Treatment Administration Record (TAR) revealed: -A physician's skin treatment order for Iodine to L hand blisters, then wrap with Kerlex [Kerlix] one time day. That order had been started on 8/15/23 and was discontinued on 8/16/23. -An updated physician's skin treatment order initiated on 8/16/23 to Monitor L hand blisters, then wrap with Kerlex [Kerlix] one time a day. *RN C signed the TAR on 8/23/23 indicating she had completed resident 32's physician-ordered skin treatment that day. -The resident's weekly skin assessment completed on that same date by RN C revealed she had applied iodine and put dressing over hand to protect site. -RN C had implemented a physician-ordered skin treatment for resident 32 that had been discontinued on 8/16/23. Observation of resident 32's unwrapped left hand and interview at that same time with director of nursing (DON) B on 8/30/23 at 3:30 p.m. revealed she: *Agreed the condition of the resident's hand was much worse since the last time she had observed it. *Between the time of the last documented left hand skin assessment on 8/23/23 and today's skin observation: -The number of affected areas on the resident's left hand had increased from three located on two parts of her hand to approximately ten separate areas affecting multiple fingers, the top and palm of her hand and the top and inside of her wrist. -The blisters had opened, the skin was dry-looking, and the black-colored areas might have been necrotic or dead skin. *DON B expected: -Resident 32's skin assessments should have been comprehensive and included wound characteristics such as: wound edges, undermining and/or tunneling, drainage type, drainage amount, drainage odor, signs and symptoms of infection, the skin surrounding the wound, edema, pulses, temperature, texture, turgor, and color. -The nursing staff used that assessment information to document in their progress notes the resident's skin condition and any changes observed following the resident's daily skin treatments. -RN C had not implemented the discontinued physician ordered skin care treatment for resident 32. -The nursing staff had notified the resident's physician of her worsened skin condition. Review of the 12/21/20 Charting and Documentation policy revealed: *Policy Statement: All services provided to the resident, progress toward the care plan goals, or any changes in the resident's medical, physical, functional or psychosocial condition, shall be documented in the resident's medical record. *Policy Interpretation and Implementation: -Information expected to have been documented in the resident's medical record included the following: treatments or services performed; changes in the resident's condition, and events; and incidents or accidents involving the resident. *7.c. Documentation of procedures and treatments will include care-specific details, including the assessment data and/or any unusual findings obtained during the procedure/treatment;

Based on observation, interview, and policy review the provider failed to ensure: *A protective barrier was placed under a wound prior to a dressing change for one of two sampled residents (15). *A clean brief had been applied after dressing change for one of two sampled residents (12). 1. Observation and interview on 10/26/22 at 10:45 a.m. of resident 15's dressing change with registered nurse (RN) E revealed: *The resident laid on top of his bedspread. *Registered nurse E had not placed a barrier between the bedspread and his legs. *RN E confirmed after the dressing change she should have placed a barrier between resident 15's legs and the bedspread. 2. Observation and interview on 10/26/22 at noon of resident 12's dressing change with RN E revealed: *The resident was laying on her right side with a brief on. *RN E opened the left side of residents brief and lowered it below the coccyx area and folded the brief over onto itself and exposed an open wound with no dressing on it. -She applied a clean dressing to the wound, unfolded the brief and reapplied it. -She confirmed she should have changed resident 12's brief. Interview on 10/26/22 at 12:30 p.m. with RN E revealed she should have changed resident 12's brief. Interview on 10/27/22 at 10:30 a.m. with director of nursing B regarding the above dressing change she confirmed: *Resident 15 should have had a barrier placed between his legs and the bedspread. *Resident 12 should have had a clean brief placed on after the dressing change. Review of the revised December 2019 Wound Care Protocol revealed All wound care will be performed, at a minimum, using clean technique to prevent cross-contamination.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (2) with a fall resulting in an injury had: *Completed a thorough investigation of the fall with injury. *Notified the South Dakota Department of Health (SD DOH) of a reportable incident. Findings included: 1. Observation and interview on 10/25/22 at 12:04 p.m. in resident 2's room revealed she: *Was sitting in her wheelchair leaning to the right side. *Had a soft wrist splint on her right wrist. *She had asked the certified nursing assistant (CNA) to put her earrings on. *She stated: -Her arthritis made it difficult for her to put her earrings in. -She had numerous falls. --One of the falls caused her to end up in the hospital with a broken hip. -She was unable to stand or walk because of her broken hip and right knee. --They were using a mechanical lift to transfer her. -She had fallen and broken her right wrist which was why she was wearing a wrist splint. Review of resident 2's medical record revealed: *An admitted [DATE]. *She had diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *She had falls documented on 4/4/22, 6/2/22, and on 6/24/22. -The 4/4/22 fall resulted in a hospitalization with a distal femur [thigh bone] fracture with a fracture extending to the previous knee replacement. *There were no further falls documented since 6/24/22. *There was a 10/20/22 physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 2's 10/17/22 quarterly Minimum Data Set (MDS) assessment revealed: *A Brief Interview for Mental Status examination score of fifteen indicating she was cognitive. *She required extensive assistance of two staff for bed mobility, transfer, and toilet use. *She: -Used a wheelchair for locomotion. -Had fallen in the past month and the past two to six months. -Had a fracture in the past six months from a fall. -Was on a restorative nursing program. Review of resident 2's 8/10/22 care plan revealed: *She had a high risk for falls related to limited mobility and desire for independence. *The goal was to have no major injuries from falls. *Interventions included: -Call light within reach and encourage the resident to use it. -Fall risk evaluation completed upon admission and then quarterly or with any significant change in Status. -PT (physical therapy)/OT (occupational therapy) screen will be sent after any fall. --Staff to conduct hourly rounds monitoring the 4Ps-Pain-Potty-Position-Possessions. *There were no interventions on the care plan related to her right wrist splint. *Staff to use Hoyer lift with all transfers. If resident refuses, she may self-transfer with no staff assist. Review of resident 2's 10/19/22 Fall Risk Evaluation revealed she had not been coded as having any falls in the past 90 days. Interview on 10/26/22 at 2:20 p.m. with MDS nurse K regarding resident 2's falls and right wrist injury revealed: *They didn't know if or when resident 2 had fallen because she could not have gotten up by herself. *There was no documentation or staff reports she had fallen. *They were surprised she had a ligament tear on her right wrist. Interview on 10/27/22 at 2:00 p.m. with director of nursing B regarding resident 2's falls and right wrist injury revealed: *They were unaware of how the injury occurred to her right wrist. *There was no documentation of what had happened. *After she had read the physician's report, she was surprised about resident 2's right wrist injury. *She confirmed resident 2's right wrist injury: -Was an injury of unknown origin. -Had not been reported to the SD DOH. -Should have been reported to the SD DOH. Interview on 10/27/22 at 3:00 p.m. with physician L regarding resident 2's right wrist injury revealed due to her multiple falls and arthritis the right wrist injury had arthritis with progressive deformity with a tear. Review of the provider's July 2021 Accidents and Incidents Investigation and Reporting policy and procedure revealed: *Policy: -All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. *Procedure: -1. The Nurse Supervisor/Charge Nurse and/or the department director or shift supervisor shall promptly initiate and document the investigation of accident. *It had not included the process on reporting to the SD DOH. Review of the provider's September 2019 Fall Prevention and Management policy revealed If resident has a significant injury notify the SD DOH.

Based on observation, interview, record review, and policy review, the provider failed to ensure one-on-one activities were provided for one of two sampled residents (5) who was in bed between meals. Findings include: 1. Random observations on 1/21/20 from 2:00 p.m. through 5:00 p.m. three times, 1/22/20 from 8:30 a.m. through 5:00 p.m. six times, and 1/23/20 from 8:30 a.m. through 3:00 p.m. three times of resident 5 in her room revealed: *She had been in bed and laying on her back or her left side. *She had a neck pillow and a blanket covering her. Sometimes she was awake and sometimes her eyes were shut. *There was no staff one-on-one visits, activities, music, or television observed during the above times. Review of resident 5's 10/24/19 annual Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status score was three. That score indicated a severe cognitive impairment. *She required the assistance of one to transfer, and ambulate in her room, and in the halls. *Listening to music and religious services had been very important to her. *It had been somewhat important to her to have books, newspapers, keep up with the news, and be around pets. Review of resident 5's revised 11/4/19 care plan revealed: *A focus area stated: Resident is frequently unable to attend the entire duration of the activity d/t (due to) pain. Interventions included: -Music and memory program is being introduced in the facility. Daughter (name) consents to try it with (name). -Resident enjoys country western music and church hymns. She used to play the guitar but hasn't since her fingers have gotten crippled. She has a CD player at bedside and enjoys listening to music. -Resident was a cook in her earlier years. -Resident enjoys church. She would prefer the minister visit her in her room as her pain is too high if she is up too long. -Resident also enjoys reading country western books and watching country western shows on TV. Review of resident 5's activity 1:1's Nursing Home documentation revealed: *November 2019: -Thirteen times she had refused activities. -One time she participated in a 1:1 activity. -There was no mention of music, TV, reading, books, or religious activities that had been identified on her current MDS activity assessment and care plan. *December 2019: -Fourteen times she had refused activities. -Four times she had participated in 1:1 activity. -There was no mention of music, TV, reading, books, or religious activities that had been identified on her current MDS activity assessment and care plan. *January 1-18, 2020: -Five times she had refused activities. -Two times she had participated in a 1:1 activity. -There was no mention of music, TV, reading, books, or religious activities that had been identified on her current MDS activity assessment and care plan. Interview on 1/23/20 at 11:45 a.m. with the activity director revealed: *The resident often refused group activities. *She agreed they had not implemented any of the in room activities the resident stated she had liked. *She agreed: -The resident had not always been a sleep when she was in bed. -She laid down due to pain. -She might have enjoyed music, TV, reading, or books, during the times she laid down. Review of the provider's revised 4/2018 Individual Activities policy revealed: *Individual activities will be provided for those residents whose physical disabilities prohibit movement to other types of activities, and to those who do not wish to attend group activities. *Some residents are unable or do don't wish to attend group activities. *Suitable activities are provided for those residents unable to leave their room.

Based on observation, interview, record review, testing, and policy review, the provider failed to ensure: *One of one commercial mixer did nt have sticky white substances by the beater insertion sites or on the outside of the mixer. *One of one food grinder did not have debris by the hook insertion site and on the top of the grinder. *One of one white pipe under the three compartment sink did not have debris on it. *The dishwasher, dishwashing area counters, and supporting counter legs, were not rusty. Findings include: 1. Observations and interviews on 1/21/20 from 5:00 p.m. through 6:00 p.m., 1/22/20 from 10:00 a.m. through11:00 a.m., and on1/23/20 from 9:45 a.m. through 10:15 a.m., with the certified dietary manager (CDM) revealed: *One of one commercial mixer was not clean. There had been sticky white substances by the beater insertion sites. There had been a white sticky substance around the outside of the mixer where the bowl attached and on the bottom by the legs. *One of one food grinder was not clean. There had been white, tan, and yellow debris by the hook insertion site and on the top of the grinder. *One of one pipe under the three compartment sink was not clean. There had been multiple black, red, yellow, and brown, particles of debris on it. When swiped with a finger that area became white. *One of one dishwasher, dishwashing counters and legs had been uncleanable: -The dishwasher had rust: --Over approximately one-third of the top of it. The CDM stated it would not scrub off anymore. --On the exterior of all four edges of the dishwasher door there was rust build-up. When the dishwasher door closed that build-up ran from the top of each corner to the bottom. It was one-half to two inches wide. -There was rust under the front corner of the dirty dishwashing counter. That area was approximately four inches by six inches. -The supporting counter legs and lower shelves under the dirty dishwashing area were worn and uncleanable. They were at least seventy-five percent covered with rust. On most of those areas the finish had peeled off. Those peeling and rusty areas were uncleanable. *Interview with the CDM during all of the above observations confirmed the above findings. Review of the provider's undated Daily Cook Cleaning List revealed: Sanitize all equipment and handles. Review of the provider's undated Daily Aide Cleaning List revealed: Delime dishwasher (Sundays & Wednesdays). Review of the provider's undated Weekly Cleaning List revealed: *Aides: -Clean shelf under dish machine. -Deep clean mixers.

Based on observation, interview, and policy review, the provider failed to ensure thorough investigation and follow up for reported loss of clothing items for one of one sampled resident (6). Findings include: 1. Review of resident 6's medical record revealed: *She had been admitted on [DATE]. *Her Brief Interview for Mental Status was thirteen, that indicated she was cognizant. Observation and interview on 1/22/20 at 8:46 a.m. and on 1/23/20 at 9:57 a.m. with resident 6 revealed: *She was clean, well dressed, and well groomed. *She liked to look nice. *She stated that since admission she had several items of her clothing that had gone missing after being sent to laundry. -She didn't recall exactly how many items went missing. -Many of the items had been her favorites, that made her feel bad. *She had reported the lost clothing to staff, but they could not locate her clothing. -Some of her clothing had been found, while other items had not. *She had at times found other resident's clothing in her closet. -She had worn some of those clothes so she would have choice. *Interview with on 1/22/20 at 10:30 a.m. with LPN [NAME] regarding resident 6's missing clothing revealed: *She had been at facility 3 years and was familiar with resident 6. *She confirmed that clothing items lost when sent to laundry had been an issue at this facility. *She was not surprised that resident was missing clothing items. *When they are notified about missing clothing items, they are to search for them. *The laundry department was supposed to group resident clothes by initials located inside clothing. Interview on 1/22/20 at 11:15 a.m. and again on 1/23/20 at 1:55 p.m. with the director of nursing (DON) regarding resident 6's missing clothing revealed: *She was aware there was an issue with missing clothing. *Her investigation and process review had been triggered by the missing clothing report of another resident approximately two months ago. *She was not able to determine where the problem was with the process during that investigation. *She had not documented the review or investigation of missing clothing. *There was no tracking system or policy in place to adequately address missing clothing. *Some of the resident's clothes were never found. *They could have done more to resolve the issue of missing clothing. Interview on 01/23/20 at 10:51 a.m. with housekeeping/laundry personnel F and G, regarding resident 6's missing clothing revealed: *When a resident had reported a missing item they would check any unmarked items. * During the laundry cycle they would keep an eye out for the item. *After two or three days any unclaimed, unmarked clothing was sent to the activities department. -The activities department was responsible for locating the owner of the unmarked, unclaimed clothing item. *They were not aware of any policy or procedure about resident missing clothing. Interview on 01/23/20 at 11:24 a.m. with activities director and activity assistant D regarding resident 6's missing clothing revealed: *They usually received the unmarked, unclaimed clothing items. -The items were kept in the office closet for an undetermined time. *There was no tracking system for missing clothing items. *Staff did not communicate with each other about missing clothing items. -They were not advised when items were or were not located and therefore did not continue attempts to locate the missing clothing items. *There was no system in place to replace missing items. Interview on 01/23/20 at 2:45 p.m. with resident 6's son revealed: *He was aware through conversations with his mother some of her clothing had gone missing. -He was not sure how many items had gone missing. -Some clothing items had been found and some had not. *He had never been notified by the facility when clothing had gone missing. *His mother knew her clothing very well. Review of the provider's (MONTH) (YEAR) Personal Property of Residents Policy revealed: *The resident's personal belongings and clothing shall be inventoried and documented upon admission and as such items are replenished. *The facility will promptly investigate any complaints of misappropriation or mistreatment of [REDACTED].

Based on observation, interview, record review, and policy review the provider failed to ensure one of four residents (19) had adequate pain control. Findings include: 1. Review of resident 19's medical record revealed: *He had been admitted on [DATE]. *He had multiple [DIAGNOSES REDACTED]. Review of resident 19's 12/12/19 Minimum Data Set (MDS) revealed: *He had frequent pain. He rated his pain at a six on a scale of zero to ten, with zero meaning no pain and ten meaning the worst pain ever experienced. *His Brief Interview of Mental Status score was seven, indicating the resident had severe cognition impairment. *His MDS had indicated he had been able to make his needs and wants known. 2. Observation and interview with the resident on 1/22/2020 at 10:00 a.m. revealed: *The nurses (RN A and RN B) had been changing a dressing to his sacral area and providing wound care to excoriated areas over his buttocks. *He was notably uncomfortable during procedure as was noted by his facial grimacing and by his yelling at the nurses, especially when he had been assisted to roll over and during wound cares. *He had hollered out loudly to the nurses during that time. *He received pain medication when he asked staff. Interview with resident 19 on 1/23/20 at 10:44 a.m. revealed: *He stated he had pain in his right shoulder and hand with dressing change. *He had not asked for the medication because he didn't want to wear the nurses out. *He did not feel like his pain was controlled . *He would have liked his pain medications scheduled. *The Tylenol was ineffective. *The [MEDICATION NAME] was effective to control his pain. *He did not like to ask for pain medications. 3. Review of resident 19's (MONTH) 2020 Medication Administration Record [REDACTED] *Tylenol 1000 milligrams (mg) was given four times. *Pain rating was documented at five to nine on a scale of zero-ten, with zero meaning no pain and ten meaning the worst pain ever experienced. *On (MONTH) 20, 2020 Tylenol 1000 mg was administered at 6:30 a.m. by medication aide and follow-up documentation at 7:35 a.m. was documented as ineffective. -No further pain medication was administered. *The medication aide was not available for an interview. *[MEDICATION NAME]/[MEDICATION NAME] 5-325 mg was ordered-one tablet every four hours as needed for pain and the resident had been given five doses. -Pain rating had been documented at seven to nine on a scale of zero to ten. *Resident had not received any pain medication prior to the dressing change and wound care. 4. Interview on 1/23/20 at 9:11 a.m. with certified nursing assistant C regarding resident 19 revealed: *She had been familiar with resident 19's care. *He did not like caregivers to touch or pull on his right arm and shoulder. *He preferred to move his right arm as much as he could independently to assist with positioning. *If he showed signs or symptoms of pain or reported pain while she was caring for him, she would have notified the nurse or medication aide and they would have given him a pain pill. Interview on 01/23/20 at 09:20 a.m. with RN A, resident care manager regarding resident 19 and the 1/22/2020 10:00 a.m. dressing change revealed: *He had pain medications that were administered on an as needed basis. *[MEDICATION NAME] had been recently changed to [MEDICATION NAME] and that had helped. *He was repositioned every two hours. *She had assisted with the dressing change and resident 19 experienced pain when cleaning the wound area. *He liked to be independent with repositioning because it caused him less pain. *He did not like to have his right shoulder touched. *She did not perceive him to be in pain during dressing change. *She would have expected the medication aide to inform the nurse when his pain medication was ineffective on 1/20/20 and the nurse should have followed up with the resident. *She agreed it may have been good if his pain medication was scheduled. Interview on 1/23/20 at 9:39 a.m. with director of nursing regarding resident 19 revealed: *He had chronic pain with position changes. *He had a bad right shoulder. *Pain was monitored based on care and what he told the CNAs or nurses. *Pain assessments were done weekly when taking vital signs and prior to adminstering pain medication. *If the pain medication was not effective, she would expect the nurses to follow-up and consult the physician. *She agreed he would not put his call light on to ask for a pain medication. *She also agreed it would have been a good plan to schedule the resident's pain medication. 5. Review of resident 19's 12/19/19 care plan revealed: *There was no documentation of right shoulder/arm pain. *The resident has chronic low back pain related to spinal stenosis, past history of lumbar fracture, and post-laminectomy syndrome. *Resident will verbalize adequate relief of pain or ability to cope with incompletely relieved pain through the next review date. *The resident's pain is aggravated by: wound care treatment and repositioning. *The resident's pain is alleviated/relieved by: pain medications and repositioning for comfort in bed. *Administer pain medication per provider's orders: [MEDICATION NAME]/Acet ([MEDICATION NAME]) 5/325mg tab by mouth every four hours as needed for pain (PRN); [MEDICATION NAME] 10mg three times a day; [MEDICATION NAME] 1000mg every six hours PRN. Monitor and report effectiveness and adverse side effects. *Evaluate the effectiveness of pain interventions. *Monitor for and document side effects of pain medications. *Monitor/record/report to nurse any signs/symptoms of non-verbal pain. *Notify physician if interventions are unsuccessful or if current complaint is a significant change from resident's past pain experience. *Resident is able to: ask for medication and tell you how much pain is experienced. Review of the provider's (MONTH) 2019 Pain management policy revealed: *To monitor and achieve the most tolerable level of pain available for the resident/s through a course of monitoring and reassessing pain. *The physician and staff will identify individuals who have pain or are at risk for having pain. *The nursing staff will assess each individual for pain upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is new onset of pain or worsening of existing pain. *The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example-wound care, ambulation, or repositioning. *Staff will evaluate and report how much and how often the individual asks for PRN medication. *The staff will reassess the individual's pain and related consequences at regular intervals; at least once each shift for acute pain or significant changes in level of pain and at least weekly in stable chronic pain.

Based on observation, interview, record review, and policy review, the provider failed to: *Reposition one of three sampled residents (3) with pressure ulcers according to her care plan, physician's orders [REDACTED]. *Follow the physician's orders [REDACTED]. *Implement interventions to promote healing and prevent reoccurring pressure ulcers from developing for one of three sampled residents (3). *Have registered nurses (RN) conduct wound assessments for three of three sampled residents with pressure sores (3, 4, and 6). Findings include: 1. Random observations and interviews on 7/11/16 from 1:50 p.m. through 6:15 p.m. of resident 3 revealed she: *Was in her bed. *Did not leave her room. *Required assistance of two staff members to reposition in bed. *Needed one staff member to assist her with eating and drinking. *Was repositioned at 4:50 p.m. During that repositioning: -Certified nursing assistants (CNA) F and G assisted her to move up in the bed. -They stated she had pressure sores, a pressure relieving mattress, and staff repositioned her every two hours. -She had two dressings in place to her buttocks area that the nurses took care of. -She had a urinary catheter to drain her urine. *She had a room tray for supper and was assisted by CNA G. -Her meal included a carton of whole milk, a glass of water, corn bread casserole, three-bean salad, and strawberries. -There were no supplements or additional protein included in that meal. -She consumed 75% of the food and drank the milk. Review of resident 3's medical record revealed: *She had originally been admitted in December 2011. *Her most recent re-admission from the hospital was on 3/30/14. *Her [DIAGNOSES REDACTED]. *On 11/16/15, 2/16/16, and 5/16/16 her Braden pressure ulcer risk assessment score was 11. That indicated she was a high risk for developing pressure ulcers. *She had a history of [REDACTED]. *She was on bed rest due to her history of fractures and left buttock wound. *She currently had three areas the nurses had been treating. Those were on her: -Left buttock, surgical wound. -Coccyx, pressure ulcer. -Left lower leg, pressure ulcer. Review of resident 3's physician's orders [REDACTED]. *Her most recent physician visit was on 6/29/16 with the following orders: -Stage 3 wound - left buttock wound .Size & Stage wound Q (every) week. -Stage 2 wound - left lower leg wound .Size and Stage wounds Q week. -Foot pillows to bilateral feet to prevent pressure on heels while in bed, foot board to bed to prevent pressure on toes, position change Q 1-2 hrs . -Diet as tolerated - push fluids - special plate. *On 7/10/16 treatment was started to her coccyx pressure sore. That order stated: -To cleanse the area daily with Saf-clens (wound cleaner). -Apply SSD 1% ([MEDICATION NAME]) cream. -No dressing or tape since it was contraindicated due to moisture and location. Review of resident 3's 5/19/16 care plan regarding her skin and pressure ulcers revealed: *She had: -A potential for pressure ulcer development related to her history of them and immobility. -An old surgical wound and various rash areas from bed confinement. -A stage 2 open ulcer on the backside of her lower left leg, and redness of her underarms and abdominal fold skin breakdown. *The goal was for the resident to have intact skin, free of redness, blisters, or discoloration by the next review date on 11/16/16. *Interventions had been initiated on 11/16/15 and included the following: -The resident requires the bed as flat as possible to reduce shear. The resident prefers to be repositioned with at least 2 people and needs repositioned Q 2 hours. Lift used for all transfers. -Administer skin treatments as ordered and monitor for effectiveness. -Administer medications as ordered. Monitor/document side effects and effectiveness. -Assess/record/monitor wound healing weekly. Measure length, width and depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD. -Continue with Foley catheter to keep skin free from further excess moisture. Turn and reposition and check and change as necessary for skin integrity. Use TENA products. -Pressure relieving mattress placed on bed. Gel cushion in w/c. *On 2/22/16 there was a handwritten intervention for See Tx record for pressure & skin tears & surgical wounds. *There was no mention of an air mattress, additional wound healing interventions, or additional nutritional interventions to promote wound healing. Review of resident 3's wound care measurement and assessment forms from June 2016 through 7/12/16 revealed: *On 6/3/16: -A stage 2 pressure ulcer to her left ankle. -A stage 2 surgical ulcer to her left buttock. *On 6/11/16: -Three stage 2 pressure ulcers to her left ankle. -The surgical area to her left buttock had no stage listed. *On 6/18/16: -A stage 2 left outer calf pressure ulcer. -A stage 3 coccyx pressure ulcer. -There was no assessment for the long-term left buttock surgical area. *On 6/26/16 there were new stage 2 left lower buttock and right lower buttock pressure ulcers. *On 6/27/16: -The long-term left buttock surgical area had no stage listed. -A stage 2 pressure ulcer to her left lower leg. -There was no mention of the coccyx pressure ulcer. *On 7/3/16: -A stage 1 pressure ulcer to her left lower leg. -A stage 2 right buttock ulcer and there was no mention of the left buttock ulcer from 6/26/16. -There were no assessments for the long-term left buttock surgical area or the coccyx pressure ulcer. *On 7/10/16: -The stage 3 long-term left buttock surgical area. -The stage 2 coccyx pressure ulcer. -The stage 2 left lower leg pressure ulcer. -There was no mention of the right buttock pressure ulcer. *Of those above assessments the following dates had been completed by LPNs and not RNs: -6/18/16. -6/26/16. -7/3/16. -7/10/16. Review of resident 3's nurses notes from 2/15/16 through 7/12/16 revealed: *A 2/15/16 LPN note stated .Skin is intact with exceptions of surgical wound on left buttocks and stage II wound on back of lower left leg. Sore to left upper post thigh, right lower buttocks, right upper buttocks, and skin tear to coccyx. All areas treated per wound care protocol with PCP (primary care physician) orders. All areas are assessed daily with dressing change and staged and sized weekly . *A 2/16/16 RN note stated .Needs extensive to total assist of two staff to accomplish ADLs (activities of daily living) .resident continues to receive dressing changes daily for old surgical wound on L buttock. Has developed stage III pressure ulcer to LL leg .has pressure reducing mattress on bed and cushion in w/c. Also, is on turning/repositioning program to help prevent further pressure ulcers . *A 3/18/16 registered dietitian note stated Dietary - (resident name) continues to receive regular diet. Eats in her room - appetite often poor. Current weight is 127# (down arrow) 5% for the quarter. BMI is 23. Treatment continues to L buttock wound and L ankle. She does not receive adequate nutrition to foster skin healing per her choice. She can have any foods she may request. Family requests comfort care. -There was no mention of trying different interventions for nutrition for wound healing, such as vitamins, supplements, increasing protein, or changes or additions to her diet, meals, or snacks. *A 3/18/16 RN note stated Resident is confused most of the time. Oriented to self only .Remains in bed and only occ gets up (once weekly for tub baths). Extensive assist needed for eating, will occ pick up something and eat it. Dependent on staff totally for other ADLs .Has slowly healing surgical wound to L buttocks and also open area to L leg. Buttocks area red daily and Nutrashield is applied. *A 5/16/16 dietary manager note stated Resident is on a DAT (diet as tolerates) diet and takes all meals in room. Resident is unable to feed herself. Appetite is poor, usually eats 25% of meals, unable to obtain weight do to pain while moving .Will continue to monitor and provide special requests. -There was no mention of trying different interventions for nutrition to promote wound healing. *A 5/16/16 LPN/RN note stated .Is usually in bed 24/7 except for use of bath chair when given a tub bath .Needs extensive assistance .Is checked and changed Q (every) 2 hours .Has an old surgical wound on L buttocks et a stage II sore on LLE. Buttocks et peri-area has MASD (moisture associated skin damage) et is treated per MD orders. Mattress on bed is pressure reducing . *A 6/3/16 RN note stated skin assessment done with bath. Red area under L breast and L arm pit. Wound remains to L buttock. L leg wound OTA (open to air). *A 6/11/16 RN note stated Open area to L leg noted. This is same area that was recently resolved. Size and staged. See wound care sheet . *A 6/27/16 RN note stated Two small open areas found buttocks on R side. Skin fragile. Will apply SSD 1% cream and not put dry dsg as this will cause more damage with tape. Will F/U with next shift. *A 7/10/16 LPN note stated Verified with previous nurse skin to buttocks R and L lower buttocks are healed. D/C (discontinue) wound assessment. Size/stage wound areas completed to Lt buttocks, Lt calf/leg. New wound care measurement & assessment noted to the coccyx area stage II. Approx 3 cm X 1 cm. Cleansed with NS & SSD 1% cream applied. Unable to keep a dry drsg to this area contraindicated, i.e. moisture will continue to monitor & report any further changes . *There was no mention of other interventions they had implemented or tried to promote healing and prevent further pressure sores from developing. Interview on 7/12/16 at 9:00 a.m. with RN E regarding resident 3's wound assessments revealed: *Her pressure sores were scheduled to be sized, staged, and assessed by the nurse weekly. *Sometimes the charge nurse was an LPN. *If the wound assessments were scheduled for a day that an LPN was the charge nurse then they would have completed it. Observation, interview, and TAR review, on 7/12/16 from 1:15 p.m. through 1:40 p.m. with RN E during resident 3's dressing changes and repositioning revealed: *CNA H assisted her with repositioning the resident. *She completed dressing changes to her left lower leg sore, left buttock surgical sore, and her coccyx pressure ulcer. *During the dressing change to her coccyx ulcer: -She did not use Saf-clens to clean the area. -Applied the SSD cream. -Applied a gauze dressing to cover the area. -Used tape around all four edges to secure the gauze. -The Saf-clens was available and sitting on the bedside table with the other supplies. *When asked about the gauze dressing and using the tape she stated the area needed to be covered to protect it. *She confirmed she had not: -Followed the physician's orders [REDACTED]. -Performed the coccyx dressing change properly. *RN E confirmed: -The resident was on a pressure reducing mattress. -She had an air mattress at one time but was unsure what had happened to it. -She was high risk for pressure ulcers. -She had some pressure areas resolve, and she continued to develop new pressure ulcer at times too. -Staff were to reposition her at least every two hours. *After they completed the dressing changes they assisted her onto her back in bed, positioned pillows under her lower legs, assisted to position her blankets, and then left the room. Interview on 7/12/16 at 2:55 p.m. and again on 7/13/16 at 8:50 a.m. with RN/nurse manager B regarding resident 3 revealed: *She had been a resident in the facility for years. *They had been treating the left buttock surgical wound for years, and it was improving. *She continued to develop other pressure ulcers at times. *She had an air mattress at one time and was unsure why she did not have one now. -She felt that could have benefited her. *She confirmed the resident was a high risk for developing pressure ulcers and needed to be repositioned more often because of that. *The minimum repositioning should have occurred at least every two hours. *She was on comfort care per her family's request. *Even though she was on comfort care they should have continued to heal her current pressure ulcers and attempted to prevent future pressure ulcers from developing. *She confirmed wound assessments should have been completed by an RN and not an LPN. *They had a wound certified nurse available to help them with pressure ulcers and skin issues. -That wound nurse did not have designated hours or times she was available since she also worked in the hospital. *She thought the resident had been on nutritional supplements and had dietary interventions to promote wound healing in the past, but that had been quite awhile ago. -Now she received a regular diet as tolerated. *She confirmed the resident's Turn and Reposition sheet for July 2016 had minimal documentation by the staff. -That sheet did not prove she had been turned at least every two hours. Observations on 7/12/16 at 2:45 p.m., at 3:15 p.m., and at 4:10 p.m. revealed resident 3 was in the same position on her back in her bed as she had been when RN E and CNA H had left her during the treatment above at 1:40 p.m. Observation, interview, and review of the Turn and Reposition sheet for July 2016 on 7/12/16 at 4:40 p.m. with CNA A in resident 3's room revealed: *The resident was laying in her bed on her back in the same position from the above observation with CNA H and RN E. *CNA A stated the resident was always in bed and should have been repositioned every two hours by staff. *Her shift had started at 2:00 p.m., and she had not been told when her last repositioning had been done or when it was due. *She had not repositioned the resident yet since her shift had started. *She referenced and reviewed the resident's Turn and Reposition sheet that was hung on the wall in her bathroom. She confirmed there was no documentation she had been repositioned since 7/10/16 at 1:00 p.m. *She agreed the sheet had a minimal number of staff initials and did not prove repositioning had occurred every two hours. *She thought staff had not documented all the times they had repositioned her, and they should have. Interview on 7/13/16 at 10:10 a.m. with the director of nursing regarding resident 3 revealed: *RNs not LPNs should have done or overseen all the wound assessments. *Dressing changes should have been completed as ordered by the physician. *The resident used to be on an air mattress for pressure relief. It had broken down, and they had not replaced it. *Her repositioning should have been completed at least every two hours due to her current pressure sores and high risk for developing new pressure sores. *The wound certified nurse worked in the hospital and did not have scheduled time in the facility to oversee the wounds. *She agreed: -The wound assessments lacked consistency due to several nurses completing them. -It was difficult to track an area from the time it started until it healed, because the nurses had labeled, measured, and sized them differently. -They had not implemented nutritional interventions to promote healing. -Overall they could have done more to prevent new pressure ulcers from developing. Phone interview on 7/13/16 at 1:13 p.m. with the consultant registered dietitian regarding resident 3 revealed: *All her documentation would have been in the nurses notes. *She confirmed her last assessment and documentation for the resident had been on 3/18/16. *The resident was on comfort care. *They had not gotten any weights on her since March 2016, so she had not done any further assessments. *She was not aware of her recent open area to her coccyx. *The facility did not contact her in-between her monthly visits. -They could have notified her of new pressure sores or weight changes when they occurred instead of waiting for her monthly visit. *She would not have known about resident 3's other pressure sores without reviewing her record herself on her monthly visits. *She confirmed they had not tried recent diet changes or nutritional interventions to promote wound healing in quite awhile. *Even though the resident was on comfort care they could have utilized interventions such as supplements or increased protein items to promote wound healing. -Those types of interventions had not been recommended or started. 2. Review of resident 6 complete medical chart revealed: *The resident's initial sizing and staging and assessment of the ulcer on his buttock on 7/9/16 had been completed by a LPN. -His wound had been assessed as a stage two on 7/9/16. -On 7/12/16 a registered nurse had noted the wound was healed and a reddened area remained. Observation on 7/12/16 at 10:30 a.m. with RN E and resident 6 revealed he had a wound that was intact and the area appeared to be red in color. 3. Review of resident 4's complete medical record revealed initial sizing and staging of his ulcer on his buttock was a stage two on 7/9/16. That assessment had been completed by a LPN. Observation on 7/12/16 at 10:40 a.m. with RN E with resident 4 revealed he had a wound that was intact and the area appeared to be red in color. Interview on 7/13/16 at 11:15 a.m. with the director of nursing revealed she did not expect a licensed practical nurse (LPN) to complete an initial assessment on pressure ulcers. Interview on 7/13/16 at 1:10 p.m. with registered nurse B revealed she agreed the initial assessment included the sizing and staging of the wound should not have been done by a LPN. Surveyor: 4. Review of the provider's revised April 2010 Pressure Ulcers policy revealed: *Residents will be assessed for risk of pressure ulcers upon admission and ongoing throughout their stay. *Based on assessment findings, interventions will be implemented to reduce and/or prevent the risk of pressure ulcer development. *The residents care plan will be updated to identify if they are at risk for pressure ulcers, interventions and treatment. *Interventions to reduce pressure ulcers will be implemented and may include but not limited to: -Nutrition. -Hydration. -Repositioning. -Support surfaces. -Pressure redistribution. -Resident education. *Pressure ulcers will be treated as ordered by the physician and documented in the medical record. Measurements and wound characteristics will be documented weekly . Review of the provider's wound care resource book available at the nursing station had a January 2015 article from American Medical Technologies titled Pressure Ulcers at Previous Pressure Ulcer Sites - Staging and Prevention that revealed: * .persons with closed full-thickness pressure ulcers, or any wound on a pressure bearing area, remain at risk for future pressure ulcers due to the reduced tensile strength of scar tissue . *Patient's/resident's circumstances such as immobility, inadequate offloading or pressure redistribution techniques, inadequate nutrition, the presence of medical comorbidities such as diabetes, medications and lifestyle choices such as smoking all impact the likelihood of reoccurrence. *Scars are weaker on previously wounded tissues, therefore it is critical that strategies be implemented (or put in place) to protect newly closed wounds, flaps and grafts. *An overview of prevention strategies for persons at risk for pressure ulcers includes, but it not limited to the following: -Individuals at-risk for pressure ulcers should be placed on a pressure redistribution surface. -Schedule regular repositioning and turning for bed and chair bound patients taking into consideration the support surface in use, the individual's tissue tolerance, level of activity and mobility, general medical condition, overall treatment objectives, and assessments of the individual's skin condition. Review of the South Dakota Board of Nursing administrative rules 20:48:04:01 regarding the nursing scope of practice revealed: *(a) The registered nurse shall utilize the following recurring nursing process: -(i) Make nursing assessments regarding the health status of the client; -(ii) Make nursing [DIAGNOSES REDACTED]. -(iii) Develop a plan of care based on assessment and nursing diagnosis; -(iv) Implement nursing care; and -(v) Evaluate responses to nursing interventions; *(b) The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01. *(a) The licensed practical nurse shall assist the registered nurse or physician in the recurring nursing process as follows: -(i) Contribute to the nursing assessment; -(ii) Participate in the development of the nursing diagnoses; -(iii) Participate in care planning; -(iv) Participate in the implementation of nursing interventions; -(v) Contribute to the evaluation of responses to nursing interventions; *(b) The licensed practical nurse may practice as follows in two general settings: -(i) With at least minimal supervision when providing nursing care in a stable nursing situation; and -(ii) With direct supervision when providing nursing care in a complex nursing situation. Review of the provider's undated registered nurse job description revealed they had the responsibility to perform comprehensive physical, functional and psychosocial assessments of the residents. Review of the provider's undated licensed practical nurse job description revealed they should have contributed to the ongoing assessments of assigned residents.