Every finding on record at SD Human Services Center - Geriatric Program

Based on observation, posted staffing review, and interview, the provider failed to ensure the posted nurse staffing information was accessible to residents and visitors at all times and that it included: *The facility's name. *The total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift. 1. Observation on 6/3/25 at 8:00 a.m. revealed the staffing information titled Geriatrics AM Daily Staffing was posted on a central whiteboard near the Spruce 1 unit nurses' station, which was a locked senior care unit. It was not posted in the public area at the front entry of the facility to be accessible to visitors. The unit resident census was posted on a separate sheet of paper on the same whiteboard. 2. Review of the posted staffing data for 6/3/25 revealed: *The posting had the date on the top and Geriatrics AM Daily Staffing as a title. *There were three sections, one for each of the three geriatric units. *Location, worker, position, and shift columns were filled out for each unit. *Nurses were identified as Charge Nurse or RN (registered nurse). *All other staff were identified as Staff. *The total number of nurse staffing hours was not included for each shift. *It did not include the facility's name. 3. Interview on 6/4/25 at 8:45 a.m. with geriatric program director of nursing (DON) B revealed: *The posting format was completed by someone in the administrative offices. *Nursing staff were responsible for filling in the correct staff names and shifts into that format. *Positions listed as staff referred to mental health technicians, who were all certified nurse assistants. *She was not aware the requirements for the posted nurse staffing data included the name of the facility, the resident census and the total hours worked per nursing discipline. *She was not aware of a policy regarding the posting details but updating the whiteboard with the current staff information was on the day and night shift duties checklist. 4. Review of the daily and nightly duties checklist revealed that white board appears on those listed tasks for completion.

Based on observation, interview, record review, and policy review the provider failed to follow food safety standards to ensure:*A process was in place to document sanitation levels in sanitation tubs and water temperatures in the wash tubs for three of three kitchenettes.*Refrigerator temperatures that were out of range had documented interventions for one of one refrigerator in one of three kitchenettes according to the provider's policy.*There was a designated hand washing sink in one of three kitchenettes.*Proper food and equipment handling processes were in place for three of three observed mental health aides (L, P, and X) and one of one therapeutic recreation specialist (R).Findings include:1. Observation on 6/2/25 at 4:44 p.m. in the [NAME] 1 dining area revealed the drinks on the residents' tables were in Styrofoam cups.Interview on 6/3/25 at 10:20 a.m. with mental health assistant (MHA) O revealed:*Styrofoam cups were used for the residents because the glasses on the unit were small, and if those were used, the staff on the unit would have to wash them.*The staff washed the residents' dishes that did not come on the meal trays.*They washed those dishes with dish soap and then sanitized them.Interview on 6/3/25 at 10:52 A.M. with MHA Z revealed:*Adaptive cups that are used by the residents during meals, are hand washed by staff in the kitchenette sink, they do not go back to the kitchen to be washed. -She indicated the adaptive dishes that are used by the residents who live on Spruce two are washed in the kitchenette of the unit they live on. -Dirty dishes are first to be rinsed of any food particles or beverages left in the cups in the first area of the compartment sink. -Clean water and Ajax soap are added to the first compartment of the sink and the dirty dishes are washed there. -Dishes are then rinsed with water in the second compartment of the sink.-The second compartment sink is then filled up with water and one to two Steramine tablets are added to the water.-Dishes are soaked in the water containing the Steramine tablets in the second compartment of the sink.-She had indicated that she was not sure of how the whole process of washing the dishes worked. -She did not state staff were to test the sanitizing solution level with the QAC test strips.*She had indicated that the QAC Fry Oil Saver test strips were for the air fryer.Observation on 6/3/25 at 12:52 of the [NAME] 1 kitchenette revealed:*Plastic glasses were stacked beside the sink on a towel and covered with another towel.*A two-compartment sink that had a dish strainer in one of its compartments.*A wet wadded paper towel was in the drain of the other sink.*Under the sink there were two brown tubs, a green and white scrub brush, dish soap, and a bottle of Steramine sanitizer tablets.-The tablets were blue.-The bottom of the brown tubs had an unknown sticky substance, flakes of a brown substance, and a black and white substance on them.*There were no test strips to measure the concentration of the sanitizer mixture.*In the upper cupboard to the left of the sink was a stack of clear glasses with handles.*Those glasses had drops of liquid in them.*On the shelf beneath those glasses was a ring of pink liquid.Observation and interview on 6/3/25 at 1:10 p.m. with MHA I in the [NAME] 1 kitchenette revealed:*There was no log of the sanitization mixture concentration levels in the kitchenette.*There was no log of wash water temperatures in the kitchenette.*MHA I stated dirty dishes were brought into the kitchenette and placed in one of the compartments of the two-compartment sink as they were dirtied.*Washing the dishes was an assigned task but any staff member could wash the dishes if they had time.*She washed the dishes with dish soap in one side of the two-compartment sink.*The other side of the two-compartment sink was filled half full of water and she would put one sanitizer tablet in that water.*The dishes were then to be placed to on the dish strainer to dry and then placed in the cupboards.*She agreed there was moisture in the glasses in the cupboard, and a liquid pink ring was under those glasses.*She would test the sanitizer concentration levels by dipping strips into the water that contained the sanitization tablet to determine if the concentration level was adequate to sanitize the residents' dishes.*She stated the last test strip was used after lunch, so more test strips needed to be ordered from supply.*She had not washed the dishes after the lunch meal to be able to verify the last test strip was used at that time.*She did not document the results of the sanitizer concentration levels when she completed the testing.Interview on 6/3/25 at 1:54 p.m. with MHA O in the [NAME] 1 kitchenette revealed:*The dishes were to be washed in the brown tubs that were stored under the sink.*She was not aware there were wet glasses in the cupboard and did not know what the liquid pink ring was under those glasses.*She stated there were no sanitization concentration test strips in the kitchenette because the last one was used by MHA I after breakfast.*The process for washing the dishes was to fill one tub with water and dish soap, and water with the sterilization tablet in it was to be in the second brown tub for rinsing the dishes.*The concentration of the sterilization mixture was one Steramine sanitizer tablet to one gallon of water.*There was no documentation of the sanitizer concentration test results. Interview on 6/4/25 at 11:06 a.m. with mental health aide Y revealed:*The two bags of Ore-Ida Golden Fries belonged to a resident who lived on Spruce 2. -She had indicated that staff at Human Services Center (HSC) had purchased the fries at the store for the resident, but the resident purchased them with his own money. *She had indicated that the red basin under the sink is used to put the dirty dishes in that have been picked up off the tables after the residents are finished eating. -Dirty dishes are first rinsed of any food particles or beverages left in the cups in the first area of the compartment sink. -Clean water and Ajax soap are added to the first compartment of the sink and the dirty dishes are washed there. -Dishes are rinsed with water in the second compartment of the sink.-The second compartment sink is filled up with water and one to two Steramine tablets are added per one gallon of water.-The QAC test strips would then be used to test the solution.-Dishes are soaked in the water containing the Steramine tablets in the second compartment of the sink.Interview on 6/4/25 at 12:38 p.m. with geriatric program director of nursing (DON) B revealed:*Some resident dishes were to be washed by the staff in the kitchenettes.*Sanitization levels were to be tested each time residents' dishes were washed.*There were no logs kept of the tested sanitizer concentration levels.Interview on 6/5/25 at 8:19 a.m. with therapeutic recreational specialist R revealed:*She had washed the dishes after breakfast on 6/5/25.*Staff were to use a three-compartment sink method for washing the dishes.-The first tub was to be filled with soapy water.-The second tub was to be a clean water rinse.-The third tub was to be the sanitization tub where she used four Steramine sanitization tablets to three and one-half gallons of water.*The sanitization concentration was to be between 200 and 400 parts per million (PPM).*The results of the tested sanitizer concentration levels were not documented.*The temperature of the water was not taken before or during the washing of the dishes.*All the dishes in the kitchenette were washed in the unit.*There was not a designated hand washing sink available for staff to wash their hands in the kitchenette, so staff used the two-compartment sink to wash their hands.*Staff had been provided education about two years ago when the policy for dishwashing in the kitchenettes was put into place.*She stated staff would be educated if there were any changes to the policy, and new staff were educated during the orientation process.2. Observation on 6/5/25 at 8:33 a.m. of MHA J in the [NAME] 1 kitchenette revealed her entering the kitchenette and washing her hands in the sink that the dishes were to be washed.3. Observation on 6/5/25 at 8:34 a.m. of therapeutic recreational specialist R in the [NAME] 1 kitchenette revealed:*She was putting dishes away in the cupboard.*She placed drinking glasses upside down with the drinking rims touching the palm of her hand.*She then placed those glasses in the cupboard.4. Observation and interview on 6/5/25 at 9:06 a.m. of MHA P in the [NAME] 1 kitchenette revealed:*She washed her hands in the sink where the dishes were to be washed.*With her bare hands, she placed bread in the toaster, removed the toasted bread from the toaster, and then buttered the bread.*She stated she was making toast for resident 8.*She served the toast to resident 8, who was seated at the table, and resident 8 ate the toast.*MHA P stated she was a contracted traveling MHA and had been assigned to work at the facility for two years.*The facility had provided her education.*She stated she was provided education on hand washing and glove use, but did not recall having had any food handling education.*She thought because she had washed her hands, she could handle ready to eat food with her bare hands.5. Interview on 6/5/25 at 10:39 a.m. with geriatric program DON B revealed:*The MHA on each unit were responsible for washing the dishes in each unit's kitchenette.*Staff had been provided training on the washing and sanitization of the dishes in 2023 through a required reading session within the computerized training system.*Staff hired since that time had received training during their orientation process.*She expected the dishes to be dry prior to being placed in a cupboard.*Each unit was to have a three-compartment sink process in place using the sink and the brown tubs for washing and sanitizing the dishes.*After the wash, rinse, and sanitization process, the dishes were to be placed on the drying rack to dry, not on towels.*There was no separate handwashing sink available in the kitchenettes for staff to use.*She expected the water for the sanitization process would be tested to ensure the ratio of water to tablets was accurate for proper sanitization of the residents' dishes.*Staff did not take the temperature of the water used to wash dishes.*She expected the sanitization concentration level to be tested each time the residents' dishes were washed.*Staff had not been required to document the concentration levels of the sanitizer on a log.*She agreed there was no documentation process in place to verify staff were measuring the sanitization levels and that the PPM level was sufficient to sanitize the dishes. 18. Observation on 06/03/25 at 10:49 A.M. of the kitchenette on Spruce two revealed:*There were eight unopened 4-packs of Jello Snack Pack cups in a cabinet available for the residents as a snack. -One pack with a expiration date of 9/10/24.-One pack with a expiration date of 9/27/24.-One pack with a expiration date of 10/23/24.-Two packs with a expiration date of 10/25/24.-One pack with a expiration date of 12/3/24.-Two packs with a expiration date of 1/27/25. 19. Observation on 6/04/25 at 10:51 A.M. of the refrigerator and freezer compartment on Spruce two in the kitchenette revealed:*Two unopened Yoplait light vanilla yogurts with a expiration date of 6/2/25.*One unopened garlic butter spray with a expiration date of 9/8/24.20. Interview on 6/4/25 at 11:06 AM. with MHA Y revealed:*The two bags of Ore-Ida Golden Fries belonged to a resident who lived on Spruce two. -She had indicated that staff at Human Services Center (HSC) had purchased the fries at the store for the resident, but the resident purchased them with his own money. *She had indicated that the red basin under the sink is used to put the dirty dishes in that have been picked up off the tables after the residents are finished eating. -Dirty dishes are first rinsed of any food particles or beverages left in the cups in the first area of the compartment sink. -Clean water and Ajax soap are added to the first compartment of the sink and the dirty dishes are washed there. -Dishes are rinsed with water in the second compartment of the sink.-The second compartment sink is filled up with water and one to two Steramine tablets are added per one gallon of water.-The QAC test strips would then be used to test the solution.-Dishes are soaked in the water containing the Steramine tablets in the second compartment of the sink.21. Interview on 6/4/25 at 11:23 A.M. with Geriatric Program DON B revealed:*She was not aware there were outdated food items in the kitchenette. *Her expectation is staff should be monitoring the expiration date of all food items in the kitchenette. -Inspections of the kitchenette are to be done by staff every week and by a charge nurse every month. -The MHAs are to be putting all new food items received from the kitchen behind or underneath any previous items that were already in the kitchenette. 22. Interview on 6/5/25 at 11:02 A.M. with Food Service Supervisor BB revealed:*Food is distributed from the main kitchen and then to each unit with issued dates and expiration dates. *Dietary staff do not monitor the kitchenettes in the units. *Unit staff on the units monitor the issue and expiration dates of food in their kitchenettes. 23. Review of the provider's October 2022 Manual Warewashing policy revealed:*All cookware, dishware, and serviceware that is not processed through the dish machine will be manually washed and sanitized.*Wash temperature at no less than 100 [degrees] F [Fahrenheit].*Appropriate test strips will be utilized to measure the concentration of the sanitizer solution. Results will be recorded on the Three-Compartment Sink Log.Review of the provider's undated Cleaning of Kitchen Appliances, Equipment, and Utensils policy revealed:*Storage and handling of kitchen equipment and utensils:-Clean cups, glasses, plates, and bowels shall be handled by their bases, so as to prevent fingers and thumbs from contacting inside surfaces or lip contact surfaces.-Clean equipment and utensils shall be stored above the floor in a clean dry location in an area which protects them from splash, dust, and other contaminations.-Clean equipment and utensils shall be thoroughly dry prior to storing.*Daily cleaning/sanitization of soiled kitchen equipment, utensils, and assistive eating devices:-A three-compartment since (one permanent compartment and two portable compartments) must be provided for manually washing, rinsing, and sanitizing equipment and utensils. Sink compartments must be large enough to accommodate immersion of the largest equipment and utensils.Note: One permanent sink compartment shall be designated for handwashing and may not be used for washing, rinsing, or sanitizing equipment and utensils.-Drain boards and racks must be provided for holding washed, rinsed, and sanitized equipment and utensils to air dry.-Manual washing, rinsing, and sanitizing must be done in the following manner:a) Obtain needed supplies from designated storage area:--Portable Sink (2)--Drain board and Rack--Dishwashing Detergent--Quaternary sanitizing tablet(s)b) Sinks must be thoroughly cleaned before each use.c) Equipment and utensils must be thoroughly washed in the first compartment of the three-compartment sink with a hot detergent solution that is kept clean. The detergent must be used according to the manufacturer's label directions.d) Equipment and utensils must be rinsed free from detergent with clean water in the second compartment of the sink.e) Equipment and utensils must be sanitized in the third compartment of the sink by immersing them in warm water (1 gallon) and one quaternary sanitizing tablet(s) (use one tablet per 1 gallon of water- allow several minutes for tablet(s) to dissolve prior to immersing). Immerse items for at least one (1) minute.f) Equipment and utensils must be air-dried after sanitization using a rack and drain board.Review of the provider's 9/30/24 New Employee Orientation Checklist revealed:*Dishwashing-Dishes washed on the unit are required to be washed using the 3-compartment sink method.-Additional tubs should be located under the kitchen sink.-Sanitizer and testing strips should be utilized.*Food Handling-Wear gloves when preparing or serving patient food.*Fridge [refrigerator] Temps [temperatures]-Complete daily fridge temp log-Ensure the temperature is safe for food storage-Immediately report concerns to [the] nurse.*Food Storage-Date and label with date items are received and opened.-Food should be rotated and disposed of in accordance with safe storage, expiration dates and handling guidelines.Review of the provider's May and June 2025 [NAME] Shift Duties Checklist revealed Check fridge temp was marked completed each day starting on 5/1/25 through 6/4/25.Review of the provider's undated Food Storage policy revealed:*All refrigerators and freezer temperatures are to be monitored and logged on a DAILY basis. Completed forms are forwarded to Nurse Managers.* Temperatures recommended by our dietitian and the state health department: Refrigerator: 36 degrees F to 41 degrees F. Freezers: 0 degrees F or lower. If outside range, temperature should be adjusted and if temperature continues to be outside of range report to Physical Plant Department.*Sealed Unopened Food: Discard on : Expiration date.*Until sealed foods are opened, go by expiration date.Review of the provider's undated Geriatric Program Inspection and Storage of Foods and Beverages Brought in for Residents policy revealed:Policy: It is the policy of the SDHSC-Geriatric Program to inspect and properly store all foods and beverages brought in by visitors for resident consumption.Storage of Food and Beverages: All foods and beverages will be labeled with the resident's initials and date it was received. 14. Observation on 6/2/25 at 5:20 p.m. of MHA L revealed:*After assisting a resident, she removed her gloves, carried dirty dishes to the kitchenette, and returned with clean gloves tucked between her body and bare arm. *She completed hand hygiene, then put those gloves on. *With those gloved hands, she touched the back and side of a resident's chair, lifted the top slice of bread on a sandwich, looked at the open sandwich, lowered the bread back down, and then continued assisted a resident with eating other meal items. 15. Interview on 6/2/25 at 5:40 p.m. with MHA L in the dining room revealed:*She didn't think about the gloves no longer being clean after she placed them against her clothing and her bare skin.*She agreed those gloves would not be considered clean and that she touched the sandwich and continued to assist the resident with eating with those unclean gloves. 16. Observation on 6/5/25 at 8:23 a.m. of the refrigerator in the Spruce kitchenette revealed unenclosed flats (a tray used for transporting eggs in bulk) of raw eggs on the middle shelf above ready-to-eat Jello, applesauce, and juice cups. The bottom drawer of the refrigerator had a sign stating Per CANS [Child and Adult Nutrition Services], eggs can't be stored above ready to eat foods. Store eggs in bottom drawer.17. Interview with geriatric program DON B on 6/4/25 regarding glove use while assisting residents with dining revealed she felt staff usually wore gloves only when touching food. 6. Observation on 6/3/25 at 12:52 p.m. in the [NAME] 1 kitchenette revealed: *A refrigerator contained resident food items including a carton of eggs, a container of heavy whipping cream, a block of sliced cheese in a Ziploc bag dated 5/14/25, opened 16-ounce bottles of Diet Coke and Orange Fanta, and several bottles of condiments. *A Refrigerator/Freezer Temperature Readings log was located on the front of that refrigerator.7. Review of the provider's April/May/June 2025 [NAME] 1 Kitchen Refrigerator/Freezer Temperature Readings log revealed:*IF REFRIG [refrigerator] TEMP [temperature] [is] GREATER THAN 41[degrees] F [Fahrenheit] or FREEZER TEMP [is] GREATER THAN 0 F: 1. Adjust temperature: If Refrigerator temperature does not return to 41 [degrees F] or below immediately and/or if freezer temperature does not immediately return to 0 [degrees F] or below, move ALL food items to another refrigerator/freezer. 2. Notification: Notify Program Director/Nurse Manager, after hours leave phone message or email.*There were 25 days between 4/3/25 and 6/3/25 the refrigerator temperature reading was documented as 42 degrees or higher.*There were four days no refrigerator temperatures were documented, and three days no freezer temperatures were documented between 5/18/25 and 5/30/25.*The COMMENTS column was blank each day for all three months.-Available comment codes included an up arrow to indicate Temp setting increased, a down arrow to indicate Temp setting decreased, M=Contents moved to another refrigerator, and D=Defrosted. 8. Observation on 6/5/25 at 8:55 a.m. of the [NAME] 1 refrigerator and freezer revealed:*The freezer temperature was -5 degrees F, and the refrigerator was 52 degrees F.*The refrigerator contained:-A tub of margarine dated 5/14.-A carton of eggs.-A container of heavy whipping cream dated 5/21.-A block of sliced cheese in a Ziploc bag dated 5/14/25.-A container of mayonnaise dated 4/20.-A gallon jug of milk. --An open container of I can't believe it's not butter spray, dated 5/10, which indicated refrigerate after opening.-An open container of coconut cream with almond milk dated 5/29 which indicated refrigerate after opening.9. Observations of the [NAME] 1 refrigerator on 6/5/25 revealed:*At 9:01 a.m. registered nurse (RN) G poured the milk from the refrigerator into a bowl of cereal and served it to a resident for breakfast.*At 9:13 a.m. the refrigerator temperature was 58 degrees F.10. Observation and interview on 6/5/25 at 10:22 a.m. with RN G in the [NAME] 1 kitchenette revealed:*Staff members on the night shift monitored and recorded the temperatures in that refrigerator, but all staff members were responsible for checking for outdated food.*She was the charge nurse on [NAME] 1 that day.*She confirmed the temperature of the refrigerator at that time was 50 degrees F.*She referred to the Kitchen Refrigerator/Freezer Temperature Readings log for instructions on whom to contact.*She confirmed that there were several times that the refrigerator temperature was over 42 degrees F in April, May, and June of 2025.*She was unaware that those temperatures had been over the required temperature because the staff had not reported them to her.*She expected that the staff members checking the refrigerator temperatures would have moved the food to another refrigerator and alerted their supervisor.*She stated that a documented comment code would have indicated if the food had been moved to another refrigerator during those months and confirmed that no codes had been documented.-She stated that some of the food in the refrigerator had potentially been in that refrigerator since April, since one of the opened dates indicated 4/20.11. Interview on 6/5/25 at 10:39 a.m. with geriatric program DON B regarding the April, May and June 2025 [NAME] 1 refrigerator temperatures revealed:*She confirmed that there were many dates in April, May, and June when the documented temperature was over 41 degrees F. *She expected the staff member who documented the temperature to notify their supervisor and move the food to another refrigerator when the temperature was above 41 degrees.*Refrigerator/Freezer Temperature Readings logs were forwarded to her when they were completed every three months. 12. Observation on 6/2/25 at 4:56 p.m. during the meal service in Spruce 1 revealed:*Mental health assistant L put on a pair of disposable gloves, then she:-Delivered a meal tray to a resident at their dining room table.-Removed the lids that covered the dishes on the meal tray and returned to the kitchen.-Opened the refrigerator, took out a carton of milk, and returned to the resident's table.-Opened the carton of milk, poured it into a cup, and set the cup on the resident's meal tray.-Removed her disposable gloves and put on a new pair of disposable gloves without completing hand hygiene.*She picked up a chair with those gloved hands, and moved it to the table next to a resident.-With those potentially contaminated gloves, she picked up a sandwich from the resident's plate and gave her a bite of it.*She placed the sandwich back on the plate, then touched and cut the sandwich with those same gloved hands.*She gave the resident a large bite of the sandwich from a spoon.*She caught a piece of that sandwich that fell off the spoon in her same gloved hand, placed it on the resident's plate with the rest of her food, and continued assisting the resident with eating food from that plate.13. Observation and interview on 6/2/25 at 5:20 p.m. of MHA X in the Spruce 2 dining area revealed:*MHA X had on a pair of gloves and was assisting resident 28 eating the meal.*MHA X used his gloved hand to scoop egg salad with a fork onto a slice of bread.*With that same gloved hand, MHA X picked up the bread, and assisted resident 28 to eat the egg salad sandwich.*MHA X held a dish, scooped fruit out of that dish, and then handled the egg salad sandwich with that same gloved hand.*MHA X stated he was not sure if he was to wear gloves while assisting resident 28 with eating, but he wore gloves with all of resident 28's cares, so he wore them while he assisted resident 28 at the table.*He stated he was provided education on how to assist residents with eating, but that was a long time ago.-He was not able to give a time range when that education had occurred.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to follow their policy to file an initial report to the SD DOH within two hours of an incident that involved a sampled resident (41) who had a behavioral event that required her to be placed into a manual hold by staff members according to their policy. Findings include: 1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 41 revealed: *On 3/23/25 at 6:50 p.m., resident 41 was by an exit door in the Spruce 1 unit. -She had placed her belongings in front of that door earlier that afternoon. *Resident 41 walked down the hall to the exit door where her belongings were with a mental health aide. *Resident 41 became upset and struck out at a mental health aide who was in the area. *A second mental health aide came to assist. *A low-level manual hold (physical restraint where staff physically hold a resident to prevent movement, but do not use any mechanical devices or equipment) was placed on resident 41 by the two mental health aides, and they assisted resident 41 with walking to the dining room of the day hall. Resident 41 struggled near the day hall, and the CNAs then transitioned the hold to a medium-level manual hold physical intervention used to safely manage medium to high-risk behaviors in individuals experiencing a mental health crisis when other de-escalation techniques are not effective), then back to a low-level manual hold, and continued to assist resident 41 with walking to the dining area. -The hold ended at 6:56 p.m. *Registered nurse (RN) F was the nurse on duty at the time of the incident. -She had not notified any of the required individuals of the use of the manual holds at that time. *The initial and final report was filed with the SD DOH on 3/25/25 at 10:15 a.m. Interview on 6/5/25 at 10:16 a.m. with mental health aide N revealed: *She worked for the provider for 31 years. *She had not had to use manual holds very often. *There are three types of manual holds: low, medium, and high (a manual hold is temporary and focuses on stabilization and ensuring the safety of the resident). Interview on 6/5/25 at 10:34 a.m. with RN H regarding manual holds on residents revealed: *Manual holds were used when a staff member needed to ensure their safety and/or a resident's safety, during forced cares (when a resident refuses care that their physician has ordered that they are required to receive, and the staff provides that care). *It was super rare that resident 41 required the use of a manual hold. *She received education on the approved manual holds every year and had completed the education last week. *The process for when a manual hold was used was to: -Notify the charge nurse or the nurse manager. -Notify the house supervisor if the hold was completed after normal business hours. -Complete an incident report. -Complete a note in the resident's electronic medical record. -Notify the physician. -The social worker or charge nurse was responsible for reporting the incident to the SD DOH. Interview on 6/5/25 at 11:58 a.m. with geriatric program director of nursing (DON) B regarding the manual hold for resident 41 on 3/23/25 revealed: *RN F had not documented or reported the manual hold used for resident 41 to the charge nurse or house supervisor. -RN F had not assessed resident 41 after the use of the manual hold and did not perform any nursing duties associated with the use of a manual hold. *The process for when a manual hold was used was to complete a restraint (manual hold) note, complete an assessment of the resident, and notify the house supervisor for a face-to-face assessment of the resident. -The house supervisor would document the face-to-face assessment in the resident's medical record. *DON B was not aware that the report of the incident was filed on 3/25/25 to the SD DOH. -She had thought the report was completed on 3/24/25. -She confirmed that a report should have been filed with the SD DOH within two hours of the incident that required manual hold use for resident 41 on 3/23/25. *She confirmed the provider's Abuse and Neglect Policy related to reporting to the SD DOH had not been followed by RN F.*She confirmed the provider's Prevention of Mistreatment, Exploitation, Neglect and Abuse policy had not been followed for the reporting of the use of manual holds for resident 41 on 3/23/25 to the SD DOH within two hours. Review of the provider's undated Prevention of Mistreatment, Exploitation, Neglect and Abuse policy revealed: *An initial report shall be made within 2 hours of the event to the SD Department of Health. *Nurses shall assess, provide direction for care and monitor residents with needs and behaviors which might lead to conflict or neglect, such as residents with a history of aggressive behaviors . *Reporting: Nurse in charge at the time, Abuse Prevention Coordinator, Nurse Manager, or Program Director shall, within 24 hours, report all allegations of abuse, mistreatment or neglect of residents and misappropriation of resident property .

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, and policy review, the provider failed to follow standard of nursing practices to ensure assessments, physician notification, house supervisor notification to ensure a face-to-face assessment of the resident was completed, and documentation was entered in the resident's medical record regarding the use of manual holds for one of one sampled resident (41) was completed. Findings include: 1. Review of the provider's 3/25/25 SD DOH FRI regarding resident 41 revealed: *On 3/23/25 at 6:50 p.m., resident 41 was by an exit door in the Spruce 1 unit. -She had placed her belongings in front of that door earlier that afternoon. *Resident 41 walked down the hall to the exit door where her belongings were with a mental health aide. *Resident 41 became upset and struck out at the mental health aide. *A second mental health aide came to assist. *A low-level manual hold (physical restraint where staff physically hold a resident to prevent movement, but do not use any mechanical devices or equipment) was placed on resident 41 by the two mental health aides, and they assisted resident 41 with walking to the dining room of the day hall. -Resident 41 struggled near the day hall, and the mental health aides then transitioned the hold to a medium-level manual hold (physical intervention used to safely manage medium to high-risk behaviors in individuals experiencing a mental health crisis when other de-escalation techniques are not effective), then back to a low-level manual hold, and continued to assist resident 41 with walking to the dining area. -The hold ended at 6:56 p.m. *Registered nurse (RN) F was the nurse on duty at the time of the incident. -RN F indicated she had not assessed resident 41 after the use of the manual hold and did not perform any nursing duties associated with the manual hold. Review of resident 41's medical record revealed: *Her admission date was 3/12/25. *Her diagnoses included: major neurocognitive disorder due to another medical condition with behavioral disturbance and chronic kidney disease. *Her 3/19/25 Brief Interview of Mental Status assessment score was a 1, which indicated she had severe cognitive impairment. Interview on 6/5/25 at 10:34 a.m. with RN H regarding manual holds on residents revealed: *Manual holds were used when a staff member needed to ensure their safety and/or a resident's safety, during forced cares (when a resident refuses care that their physician has ordered that they are required to receive, and the staff provides that care). *It was super rare that resident 41 required the use of a manual hold. *She received education on the approved manual holds every year and had completed the education last week. *The process for when a manual hold was used was to: -Notify the charge nurse or the nurse manager. -Notify the house supervisor if the hold was completed after normal business hours. -Complete an incident report. -Complete a note in the resident's electronic medical record. -Notify the physician. -The social worker or charge nurse was responsible for reporting the incident to the SD DOH. Interview on 6/5/25 at 11:58 a.m. with director of nursing (DON) B regarding resident 41's manual hold on 3/23/25 revealed: *RN F was the nurse on duty on 3/23/25 when resident 41 required the use of a manual hold by staff members. *RN F had not documented or reported the manual hold used for resident 41 to the charge nurse or house supervisor. -RN F had not assessed resident 41 after the use of the manual hold and did not perform any nursing duties associated with the use of a manual hold. *The process for when a manual hold was used was to complete a restraint (manual hold) note, complete an assessment of the resident, notify the house supervisor for a face-to-face assessment of the resident, and notify the resident's physician. -The house supervisor would document the face-to-face assessment in the resident's medical record. Review of the provider's undated Physical Restraint Manual Restraint Policy revealed: *It shall be the policy of the SDHSC that manual restraint only be used to ensure the immediate physical safety of a patient, a staff member, or others and must be discontinued at the earliest possible time. *Types of physical restraints used at HSC includes a manual restraint such as forced procedure holds, and physical intervention holds. *Purpose -To provide an intervention when a patient's behavior indicates that he/she is in immediate danger of harming him/herself or others. *Manual Restraint: The use of one's hands and body to safely limit or restrict a patient's movement. *The RN shall notify the patient's physician or designee giving a detailed description of the situation necessitating the use of manual hold. *A face-to-face assessment shall be conducted by the physician or designee, or Face to Face RN within one (1) hour of initiation of physical restraint. *Assessment includes: -The patient's immediate situation; -The patient's reaction to the intervention; -The patient's medical and behavioral condition; and -The need to continue or terminate the restraint. *If a trained RN conducts the face-to-face evaluation following a Manual Hold and no further intervention or order for renewal is needed, the attending physician or designee will be notified of the hold and face to face evaluation the next working day. *This consultation shall include, at a minimum, a discussion of the findings of the evaluation, the need for other interventions or treatment, and the need to continue or discontinue the use of restraint. *Restraint/Seclusion event assessment will be documented by the assessing physician or designee or trained Face-to-Face RN. *The RN or designee shall notify the attending physician or designee of the use of manual restraint on the next working day .This review shall be documented in the patient's electronic health record with appropriate recommendations or modifications. *A RN shall document the patient's behaviors leading up to the restraint event and clinical assessment and rationale for use of a manual restraint. *A RN shall document the physician or designee, or face-to-face RN that was notified to complete the face-to-face assessment. *A RN shall document an assessment of the patient's mental and physical condition at least hourly or more frequently depending on patient need/condition or provider's orders. *The RN shall document an assessment and decision to discontinue the manual restraint along with the patient's physical condition, including vitals upon release from a manual restraint. Review of the provider's Documentation policy revealed All documentation shall be recorded as soon as possible after the occurrence.

Based on record review, observation, interview, and policy review, the provider failed to ensure infection control practices were maintained for: *The storage of suprapubic catheter (a tube surgically placed through the abdomen into the bladder to drain urine) supplies for one of one sampled resident (39).*The use of personal protective equipment (PPE) while caring for one of one sampled resident (39) who had a suprapubic catheter and required the use of enhanced barrier precautions (EBP) (a set of infection control practices to reduce the spread of infection) per their policy.*For appropriate glove use for one of one housekeeper (custodial crew leader) (S) while cleaning resident rooms.Findings include:1. Review of resident 39's electronic medical record revealed:*He was admitted on [DATE].*His 4/24/25 Brief Interview of Mental Status (BIMS) assessment score was 8, which indicated he was moderately cognitively impaired.*His diagnoses included prostate enlargement and obstructive uropathy (a blockage in the urinary tract, preventing urine from draining properly).*A 3/25/25 physician's order, to Cleanse suprapubic area with soap and water. Pat dry and change split sponge gauze PRN [as needed].*A 4/23/25 physician's order, for a New leg bag every month.*A 6/3/25 physician's order, for May place leg [drainage] bag on suprapubic catheter in am [morning] and remove at HS [bedtime], large urine collection [drainage] bag on at HS.*A 6/3/25 physician's order, to Clean catheter leg bag every night and urine collection bag every am with 1:10 ratio bleach/water-use funnel to flush diluted bleach solution through tubing, wipe outside of bag with soap and water to clean; allow bag to air dry and keep in basin with paper towel in bottom of basin; change paper towel daily.2. Observation and interview on 6/2/25 at 1:36 p.m. of resident 39's room revealed:*He was uncertain if his catheter had been removed.*Staff members did not wear a gown when they provided his care.*There was no signage on the door or near the entrance of his door indicating that resident 39 was on EBP.3. Observation on 6/2/25 at 4:44 p.m. in resident 39's room and shared bathroom revealed:*The bathroom was shared by the two residents who resided in rooms on either side of the bathroom.*There was a cabinet with four doors inside the bathroom. The cabinet was not labeled with the residents' names.*Two stacked gray basins were together inside the bathroom cabinet.-A paper towel and a catheter urine drainage bag with an attached drainage tube were inside the top basin.--There was no protective cap on the end of that drainage tube.--The date 5/22 was marked in the corner of that drainage bag, but it was not marked with the resident's name or initials to identify which resident it was used for.-The bottom basin was labeled Dirty 5/22.*A graduated measurement container was on a washcloth on the shelf inside the cabinet, and was not labeled or dated. *There were no gowns or eye protection in resident 39's room or shared bathroom.4. Interview on 6/3/25 at 9:20 a.m. with mental health aide (MHA) AA and resident 39 revealed:*She confirmed she had assisted resident 39 to get dressed that day.*Resident 39 used an overnight bag at night and wore a leg bag during the day.*She wore gloves when she cared for resident 39's catheter, but did not need to wear a gown.*Resident 39 walked hand-held with two staff members assisting him, each holding one of his hands.*She did not need to wear gloves or a gown when she assisted resident 39 with walking. 5. Observation and interview on 6/3/25 at 9:35 a.m. of the W1 soiled utility room and resident 39's room with MHA AA revealed:*The soiled utility room was used to clean resident 39's catheter equipment.*The room contained a two-part metal sink, a separate hand washing sink, and a hopper (a specialized sink flushing device used to rinse soiled items and linens of body fluids).*On the right-side counter of the metal sink, there was a graduated measurement container that contained two syringes, a bottle of hand sanitizer, and two one-gallon jugs of bleach used to clean resident 39's catheter equipment.-The graduated container and syringes were stored in the soiled utility room.--That container was not labeled with resident 39's name or dated.--The syringes were not labeled with resident 39's name. One syringe was dated 4/23.*The left-side counter of the metal sink contained vacuum cleaner parts.*She stated that the urinary drainage catheter bag was to be transported to the soiled utility room in the dirty basin, and after it was cleaned, the catheter was placed in the clean basin and was to be returned to resident 39's bathroom. She called that process the two-bin system.*She stated she used 200 cc [cubic centimeters] of bleach to clean the catheter bag. The bleach was measured in the graduated container and drawn into the syringe. She would shake it around to coat the inside of the catheter bag, then drain the bleach into the sink.-She stated no water was needed to dilute the bleach to clean or rinse resident 39's catheter bag or tubing.-She confirmed that she used the sink and did not use the hopper when she drained the bleach out of resident 39's catheter bag.*She stated she did not need to wear a gown when she cleaned of resident 39's catheter bag.*She confirmed that the basins and the catheter bag were stored stacked inside each other in the left side of resident 39's unlabeled shared bathroom cabinet.6. Observation on 6/3/25 at 9:45 a.m. of the W1 soiled utility room revealed:*The metal sink basin used to clean resident 39's catheter bag contained a black film and rust.*The right-side counter of the metal sink, where the items used to clean resident 39's catheter bag were stored, contained spots of a white film.*The hot and cold water of the hand-washing sink produced a small trickle of water that decreased to drips when turned on, which did not provide a sufficient flow of water for staff to effectively wash and clean their hands.7. Observation on 6/3/25 at 3:24 p.m. revealed:*MHAs Q and M entered resident 39's room.-They did not complete hand hygiene (hand washing or the use of hand sanitizer) and did not put on gowns or gloves.*No signage on the door or near the entrance of his door indicated that resident 39 was on EBP.*MHA Q knelt on the floor beside resident 39's bed and assisted him to put on his shoes.*MHA M had a gait belt (a waist strap gripped as a support for safe mobility and transfers) removed the gait belt from her waist and placed it around resident 39's waist.*MHAs Q and M assisted resident 39 to stand and walk while holding the gait belt and his hands, to the whirlpool room.*MHA M assisted resident 39 to remove his shirt while seated on the whirlpool tub seat and into the whirlpool tub.*MHA Q exited the whirlpool room, entered resident 39's room, then returned to the whirlpool room carrying an uncovered gray basin with a graduated measurement container, an alcohol wipe, and a box of gloves. He did not wear a gown or gloves. *Resident 39 was observed partially undressed, seated on the whirlpool tub seat.*MHA M wore gloves but did not wear a gown.Continued observation and interview on 6/3/25 at 3:36 p.m. with MHA Q revealed:*He carried resident 39's gray basin labeled dirty with the empty graduated urine collection container, and a box of gloves uncovered under his left arm and against his clothes from the whirlpool room to the W1 soiled utility room and set them on the right-side counter of the metal double sink.-The dirty basin was stacked inside another basin that was labeled clean.-There was no barrier between the clean basin and the sink counter.*He stated he only needed to wear gloves when cleaning resident 39's catheter equipment and did not know of any other PPE that would be required to use when cleaning those items.*He confirmed resident 39 wore a leg bag during the day, as a fall prevention intervention.*Once in the soiled utility room, MHA Q used hand sanitizer and put on a pair of gloves. He did not put on a gown or eye protection.*With those gloved hands, he:-Poured bleach into the container that he had used to empty urine from resident 39's catheter bag.-Added water to that container and rinsed it. -Removed those gloves, cleansed his hands with hand sanitizer, and put on a new pair of gloves.-Then placed a paper towel and the cleaned container into the basin marked clean. -Placed a second paper towel and the clean basin into the dirty basin.*He stated he used a Ten to one ratio (ten parts water to one part bleach) to clean all of resident 39's catheter equipment.*The graduated measurement container that was stored in the soiled utility room was marked with the date 6/3/25, resident 39's name, and had two marked lines on it, one labeled bleach and the other H20.*MHA Q removed his gloves, did not perform hand hygiene, placed the box of gloves on top of the graduated measurement container that was inside the two stacked basins, held them under his arm, against his shirt, and opened the door with his opposite hand.*When asked about the hand-washing sink, he stated he was unaware that the hand-washing sink did not work and confirmed that it did not produce a stream of water when turned on and off.*MHA Q then carried those above items uncovered to resident 39's room and placed them into the unlabeled cabinet in the shared resident's bathroom.8. Observation on 6/4/25 at 8:39 a.m. of MHA CC and MHA J revealed:*MHA J had a gait belt, removed that gait belt from her waist, and placed it around resident 39's waist.*MHA J and MHA CC assisted resident 39 to stand and walk while holding the gait belt and his hands, to his room and into his shared bathroom.*Without performing hand hygiene, MHA J put on gloves and assisted resident 39 to sit on the toilet.*Without performing hand hygiene or putting on gloves, MHA CC assisted resident 39 to lower his pants and to sit on the toilet. Once resident 39 was seated, MHA CC put on a pair of gloves.*After resident 39 was finished, he assisted the staff in readjusting his undergarments.*With those same gloved hands, MHAs J and CC assisted resident 39 from the bathroom to his bed.*Resident 39 was not offered an opportunity to wash his hands after having used the toilet.Observation on 6/4/25 at 8:45 a.m. in resident 39's room revealed:*MHA CC without completing hand hygiene, put on a pair of gloves.*MHA J completed hand hygiene and put on gloves. With those gloved hands, she:-Placed two open plastic bags on the recliner.-Placed four wash cloths in the bottom of resident 39's hand washing sink in his room.-Ran water on those four wash cloths.-Placed soap on two of those washcloths.-Placed those washcloths into the plastic bags on the recliner, and then removed her gloves. *Without performing hand hygiene, mental health aide J put on a pair of gloves, and with those gloved hands, she lowered the front waistband of resident 39's pants to expose his suprapubic catheter.*MHA CC used a soapy washcloth to wash the skin around the suprapubic catheter insertion site, then washed down the catheter tubing, back up the tubing, and then washed around the suprapubic catheter insertion site a second time. She repeated those steps with another wet washcloth that did not contain soap, then pulled resident 39's pants back up to cover the suprapubic catheter site.-There was no split sponge gauze observed at the suprapubic insertion site.*MHA CC and J then removed their gloves. MHA CC completed hand hygiene. *MHA J did not complete hand hygiene and placed the gait belt that was worn by resident 39 around her waist and exited resident 39's room carrying the bags of soiled linen.*MHA J and CC did not wear gowns when they completed resident 39's catheter care.9. Observation and interview on 6/4/25 at 1:17 p.m. with registered nurse (RN)/nurse manager E in resident 39's room revealed:*She confirmed:*There were no signs that indicated resident 39 was EBP.*The bathroom was shared by the two residents who resided in rooms on either side of the bathroom.*The cabinet in that bathroom was not labeled with the residents' names.*Two stacked gray basins were together inside the bathroom cabinet.A paper towel and a catheter urine drainage bag with an attached drainage tube were inside the top basin.--There was no protective cap on the end of that drainage tube.-The date 5/22 was in the corner of the urinary drainage catheter bag. That bag did not contain the resident's name or initials.-The bottom basin was labeled Dirty 5/22.-The graduated measurements container was on a washcloth on a shelf inside the cabinet and was not labeled or dated.*There were no gowns or eye protection in resident 39's room or shared bathroom.*RN E expected that the catheter bag to have been labeled with the resident's initials, and a cap to have been on the end of that tube.*She was unaware that resident 39 required the use of EBP.10. Interview on 6/04/25 at 1:25 p.m. and again at 3:04 p.m. with infection preventionist (IP) C revealed:*She confirmed that resident 39 had a suprapubic catheter and required the use of EBP with all close contact care, including assisting with toileting, bathing, and care of his catheter bag.*She expected there would have been a sign outside of resident 39's room to notify staff that resident 39 was on EBP and what PPE was required to use while completing his care needs.*She confirmed that items, including bleach, a graduated measurement urine collection container, and syringes, would be left in the soiled utility room and used to clean resident 39's catheter. -She expected those items to be changed monthly, dated, and labeled with resident 39's initials.*She expected that staff members would use a two-basin system for transporting resident 39's catheter items in the hall. She expected those bins to be covered during transport and stored in resident 39's room, and not in the bathroom shared with another resident.*Staff members received education when they were hired and annually on hand washing and the use of PPE.*She expected staff members to wash their hands when they were visibly soiled or to use hand sanitizer when changing their gloves.11. Interview on 6/5/25 at 11:38 a.m. with geriatric program director of nursing (DON) B revealed:*Resident 39 had a suprapubic catheter that was last changed on 5/22/25 as ordered.-That catheter was ordered to be changed monthly and was not required to be changed to obtain a urine specimen or after a resident had a UTI.*She expected resident 39 to have been on EBP and that staff members would have worn a gown and gloves when providing close contact care to resident 39.*She expected staff to wash their hands or use hand sanitizer when they changed their gloves.12. Review of the provider's ENHANCED BARRIER PRECAUTIONS door sign revealed:*TO PREVENT THE SPREAD OF INFECTION, Staff performing the following resident care activities:-Dressing, Bathing/Showering, Changing Linens, Providing Hygiene, Assisting with toileting, Transferring (with high degree of contact - PT [physical therapy] bathing, etc.), Device care/use (urinary catheter, feeding tube, etc.), Chronic wound care Must wear the following PPE: PRACTICE HAND HYGIENE *Including before entering and when leaving the room WEAR GLOVES WEAR GOWNS .13. Observation on 6/3/25 at 9:49 a.m. with custodial crew leader (CCL) S while cleaning resident rooms revealed:*Without completing hand hygiene, CCL S put on a pair of gloves and entered room [ROOM NUMBER].*With those gloved hands, CCL S completed the cleaning of that room, exited that room, removed those gloves, disposed of them in her housekeeping cart, and pushed that cart down the hall. *Without completing hand hygiene, CCL S reached into the next room, turned on the light switch, put on a pair of gloves, and began to clean that room.Observation and interview on 6/4/25 at 11:26 a.m. with CCL S while cleaning resident rooms revealed:*Without completing hand hygiene, CCL S put on a pair of gloves and entered a resident's room. With those gloved hands, she completed the cleaning of that room, exited the room, removed her gloves, disposed of them in her housekeeping cart, and without completing hand hygiene, she put on a new pair of gloves. *CCL S stated she was taught to change her gloves between every room she cleaned when she received her training when she was hired about six months ago, and that this was her routine practice between each room she cleaned.-She had not been told that she needed to wash her hands or use hand sanitizer when she changed her gloves*She confirmed that she removed her gloves and, without washing her hands or using hand sanitizer, she had put on a new pair of gloves. *CCL S cleaned all the resident rooms on the W1 hall each day.Interview on 6/4/25 at 3:04 p.m. with infection preventionist (IP) C revealed:*All staff receive education on hand washing and the use of hand sanitizer when they are hired and annually. *She expected all staff members, including housekeepers, to complete hand hygiene whenever they changed their gloves. *She expected all staff member to wash their hands with soap and water when they were visibly dirty.Review of the provider's undated Handwashing Techniques and Use of Hand Sanitizers policy revealed:*Protect yourself and your patient by frequently hand washing or the use of hand sanitizers if your hands are not obviously soiled.*Cleanse hands before: . Caring for a patient, Donning gloves.*Cleanse Hands after: Using [the] toilet or assisting [the] patient [resident] in using [the] toilet, Handling body secretions, Giving care to patient or handling his equipment, . Following the removal of gloves.Review of the provider's undated Suprapubic Catheter Replacement and Care policy revealed:*The policy did not include the need for EBP, gowns, or eye protection in the care of a resident with a suprapubic catheter. *For Care of Indwelling Catheter: there was a referral to (See policy entitled Catheterization-Insertion, Care and Removal of Indwelling Urethral Catheter located in this document).Review of the provider's undated Catheterization-Insertion, Care and Removal of Indwelling Urethral Catheter revealed:*The policy did not include the need for EBP, gowns, or eye protection in the care of a resident with a catheter. *Care of Leg Bag and Drainage Bag: Patient's name or initials and date bag initiated or changed should be on the leg bag and drainage bag.*When alternating between the leg bag and drainage bag, they are washed daily, after use with diluted bleached solution (1 part bleach to 10 parts water). Perform hand hygiene before and after cleaning the bag. Apply gloves per precaution standards. Wipe the outside of the leg bag or drainage bag with soap and then rinse with water. Use [a] funnel to flush diluted bleach solution (1 part bleach to 10 parts water) through tubing. Completely fill and soak the inside of the leg bag or drainage bag with diluted bleach solution. The bag and tubing with water.*Daily cleanse around [the] area where [the] catheter enters the urethral meatus with soap and water. Inspect the tissue around the suprapubic insertion site for signs of irritation.-Cleansing of the suprapubic insertion site was not addressed.Review of the provider's undated Enhanced Barrier Precautions policy revealed:*Enhanced Barrier Precautions are recommended for residents during high contact resident care activities with any of the following conditions which places them at high risk . indwelling medical device . urinary catheters. *Perform hand hygiene before and after leaving the room and between patient cares in addition to the use of gowning gloves for high contact resident care activities .These cares include the following activities: Dressing .

Based on observation, interview, record review, and policy review, for one (18) of two residents with facility-acquired pressure ulcers the provider failed to:*Ensure the stage two pressure ulcer had not worsened. *Reassess the pressure ulcer treatment to prevent worsening of the ulcer. *Develop/modify a pressure ulcer care plan with interventions to prevent worsening of the ulcer. Findings include: 1. Interview on 7/13/21 at 10:00 a.m. during an initial tour with registered nurse (RN) charge nurse J regarding resident 18 revealed she: *Had a facility-acquired pressure ulcer on her right buttock that had recently worsened. *Had stated: -The ulcer began as a Stage 2 (partial thickness skin loss). -The skin surrounding the open area had now become discolored. --They began measuring the wound itself and the large discolored area because it was worsening. -Her doctor had discussed her pressure ulcer with RN charge nurse that morning and had decided to consult a surgeon to review treatment options. Observation and interview on 7/13/21 at 10:15 a.m. with resident 18 revealed:*She was lying on her bed. *A pillow was lying next to the right side of her back. -The pillow was not providing pressure relief. *She: -Stated she had a pressure ulcer and wanted to know how to make it heal. -Had a walker in her room. -Moved very slowly and repositioned herself in very small increments on the bed. Observation and interview on 7/14/21 at 1:55 p.m. with RN I during a wound measurement and dressing change for resident 18 revealed: *RN I measured the wound at 2.5 centimeters (cm) by (X) 1.1 cm x 0.3 cm deep. *The yellow/white eschar (dead skin tissue) covering the ulcer had begun to detach leaving an opening large enough to allow the nurse to measure the depth with the cotton end of a cotton-tipped applicator. *RN I stated: -The pressure ulcer had worsened to a stage 3 (full thickness tissue loss). -There was a new closed dark purple area that was also on the right buttock below the stage 3 ulcer. --That area was identified on 7/6/21. -The staff were to have encouraged her to reposition herself every two hours because she was able to get out of bed by herself and walk. -The dietitian followed her and she received Juven (a dietary supplement) twice daily for protein. -The total wound circumference had been measured as 6 cm X 4 cm including the red surround on 7/13/21. -The wound had a foul odor. *RN I applied an [MEDICATION(S)] Extra/[MEDICATION(S)] dressing. Review of resident 18's Skin Status Record for Wounds weekly flowsheet revealed:*The initial pressure ulcer had been identified as Stage 2 on 2/3/21 and measured 2.0 cm X 0.5 cm. -An [MEDICATION(S)] dressing was applied. -Interventions included a ROHO cushion (decreases amount of pressure, allows air flow aids in weight distribution) and pressure reduction mattress. *On 2/11/21 the wound measured 2 cm X 3 cm total, with a 2 cm X 0.9 cm eschar center. -The wound dressing had changed to [MEDICATION(S)] Extra and [MEDICATION(S)]. *Weekly wound documentation from 2/11/21 through 4/27/21 indicated: -Scant drainage. -Slight odor at times. -A consistent white center with red or pink surround. -Wound measurements were not consistent, ranging between 3 cm X 2 cm to as small as 0.4 cm X 0.1 cm. *Juven was added on 2/23/21 for protein. *On 5/11/21 the total wound area was documented as 2 cm X 1 cm with the white center at 0.2 cm X 0.1 cm. -The wound color had changed to beefy red with a white center. *From 5/25/21 through 6/15/21 the pressure ulcer was documented as closed. *On 6/22/21 wound documentation indicated the total area had increased to 2 cm X 2 cm, with the white center measuring 2 cm X 1 cm. -The wound was draining. *On 6/29/21 the total area measured 3 cm X 4.5 cm. -The color was red with a yellow center. -The yellow center measured 2.7 cm X 1 cm. -The wound was identified as a Stage 3 pressure ulcer. -There was a foul odor. *On 7/6/21 the above documentation and measurements remained the same. -There was a foul odor. *On 7/13/21 the total wound measurement was 6 cm X 4 cm. -The yellow/white center measured at 3 cm X 1.8 cm X 1 cm deep. -There was a foul odor. The above pressure ulcer interventions had not been updated for: *Use of a pressure-reducing mattress and ROHO chair cushion since the wound was identified. *The wound dressing since 2/11/21. *Dietary changes since 2/23/21. Review of a new 7/6/21 Skin Status Record for Wounds flowsheet belonging to resident 18 indicated: *On 7/6/21 a Stage 1 (a discolored, non-blanchable area of skin) pressure ulcer was identified below the first wound on her right buttock. The area: -Measured 3 cm X 2 cm. -Was closed and purple purple. *A 7/13/21 documentation of the wound indicated there was no change in measurements or color. *The interventions identified for the above wound on 7/6/21 and 7/13/21 had been: -[MEDICATION(S)]/[MEDICATION(S)] dressing. -Juven. -Pressure reduction mattress. -ROHO cushion. Review of resident 18's requested physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] *A 2/11/21 Physical Therapy (PT) progress note revealed: -She was referred for wound care recommendations. -The wound measured 3 cm X 2 cm with center eschar of 2 cm X 0.9 cm. -There were two layers of eschar. --The center was more firm to the touch. -Recommendations included:--[MEDICATION(S)] Extra covered with [MEDICATION(S)] or Allevyn dressing. --Staff and patient education regarding the importance of repositioning including wedges when in bed for sidelying to offload to the left side. --Dressing changes weekly and as needed. --PT to follow up with the patient and nursing and make any further recommendations. -Goals to have been met in one month: --the resident would be compliant with repositioning when in bed. --The wound would decrease in size and show increased granulation tissue. --The resident would have no further areas of skin breakdown. *A 4/20/21 recertification summary by certified physician assistant (PA-C) K revealed:-Her Braden Pressure Ulcer Risk Assessment score was 19 (indicating there was no risk for a pressure ulcer). -She has dark pink area below her breasts. --A treatment was ordered for that. -Resident 18 was reviewed for medical and psychiatric needs during rounds with PA-C K, her psychiatrist, and RN/charge nurse J. -There was no mention of her pressure ulcer. *A 6/15/21 recertification summary by PA-C K revealed:-She does have an area to her right buttock that was open, but in assessing it today, it is closed. But that area is quite small, but still now, although the skin area is closed, there is a darker pigmentation of almost bluish purplish at the area and at this time, we are going to continue with observing that and watching that closely for the next week. -She walked slowly with a walker. --She had previous orders for physical therapy but she was refusing to go so therapy was discontinued. -Staff assisted her in toileting during the day because she was incontinent of bowel and bladder at times. -There was discussion with PA-C K, physician M, and RN/charge nurse J regarding medical and psychiatric concerns during rounds. -There were no order changes. *A 6/21/21 recertification summary by resident 18's physician M revealed:-She was seen today, June 15, in doctor's rounds. -The physician also seen on the unit after rounds. -She was incontinent of bowel and bladder and required the assistance of one staff. -There was an open area on her right buttock that opened at times, but was closed on June 15. -There were no order changes. No further PT or physician notes had been provided when they were requested. Review of Resident 18's Treatment Plan regarding her pressure ulcers revealed: *A problem indicating the resident was at risk for skin impairments. -The skin impairment problem area had not been updated to add the pressure ulcer. *The goals were to have no skin breakdown due to pressure or incontinence. *5/4/21 Interventions included:-Weekly skin assessments. -Head to toe assessments checking pressure areas with hygiene care. -Protecting the skin from contamination. -Avoiding friction and shearing. -Staff were to have checked her skin with toileting. -The nurse was to have checked her legs and feet daily. -Continue to keep pressure off areas and monitor for breakdown. *ROHO cushion. *[MEDICATION(S)] and [MEDICATION(S)] dressing. Change weekly with a bath and as needed. *On 7/6/21 To right lower buttock had been added. *The problem had not indicated the resident had pressure ulcers. *The skin impairment treatment plan had not included a repositioning intervention. *A self-care deficit revealed [Resident 18] is independent with repositioning, transfers, and mobility. Review of the nursing pressure ulcer progress notes regarding communication with the PA-C or physician revealed the communication had been documented on 3/16/21, 3/23/21, 3/30/21, and 5/4/21. Record review and interview on 7/14/21 at 3:50 p.m. with RN/charge nurse J, RN I, and RN L regarding resident 18's pressure ulcer treatment revealed: *RN/Charge nurse J and RN I confirmed the pressure ulcer had worsened. *The pressure ulcer treatment had not been revised for: -More appropriate dressing options. -Updating skin interventions. *The treatment plan: [MEDICAL RECORD OR PHYSICIAN ORDER] -Had not identified the problem as a pressure ulcer. -Had not addressed repositioning the resident. *RN/charge nurse J confirmed the pressure ulcer dressing had not been updated. -She was not sure why changes had not been made in the treatment. *RN I stated the resident's pressure ulcer had changed slowly and then rapidly declined from a Stage 2 to a Stage 3. -She confirmed the pressure ulcer had been present for five months. *RN L stated the most recent pressure ulcer education for the nursing staff had occurred in March 2019. *RN/charge nurse J confirmed: -The provider did not have a specified wound nurse. -The nurse who was assigned to the floor did the wound assessments for the day. -The wound assessments were not consistent. *RN/charge nurse J stated in regard to physician communication for wounds : -The PA-C came to the floor frequently and visited with the staff. -The communication had not been documented, but it should have been documented. Interview on 7/20/21 at 9:30 a.m. with director of nursing (DON) C confirmed: *The provider had not had a wound nurse since the COVID-19 outbreak. *The nursing staff had not received pressure ulcer education since March 2019. *Resident 18's facility acquired pressure ulcer had worsened with the current treatment. -The wound treatment had not been updated. Review of the provider's revised February 2021 Skin/Wound Care policies revealed: *Positioning/Turning: -The nurse was to have assessed the patient's condition, ability to change positions independently and skin tolerance to pressure. -A repositioning schedule would be considered for those residents that were immobile, declining health status, needed assistance with position changes, needed reminders to shift weight when sitting or in bed and those residents with the head of the bed or back of the chair raised thirty degrees. -The nurse was to have evaluated residents that could change positions independently and determined if those residents required supportive devices and frequent reminders to facilitate position changes every fifteen minutes. -The nurse was to have initiated a repositioning schedule on residents at risk for skin breakdown and demonstrating the above conditions. -The nurse would direct the staff on the frequency of turning the patient based on their condition and their skin's tolerance to pressure. *Decubitus Ulcer - Prevention and Care: -Prevention and care of pressure ulcers would be provided to treat pressure ulcers. -Prevention had included: --Heel or elbow protectors. --Pillows for positioning. --Egg crate or alternating pressure mattress, air, gel or water cushions. -The nurse was responsible for informing the Treatment Team of pressure relieving devices being used to promote skin integrity and for adding the devices to the resident's Treatment Plan. *Follow-up Activities for Decubitus Ulcer:-The resident may require an alternating air mattress. -Nursing directive to institute repositioning schedule for turning may be required. -The dietitian was to have been notified of pressure ulcer concerns. -Inspect the bed linen and bed clothes to ensure they were clean, dry, and wrinkle-free. *Documentation and reporting:-The pressure ulcer was to have been assessed and documented for the size, appearance, any [CONDITION(S)], inflammation or tenderness surrounding the ulcer, any type of drainage, any topical agent used daily or at the nurse's discretion. -Any worsening of the ulcer's condition was to have been reported to the charge nurse or physician/PA-C. Review of the provider's revised 9/4/18 Treatment Plan policy revealed:*A comprehensive Individualized Treatment Plan was to have been based on patient's strength, needs, input, and prepared with the participation of the resident, family or legal appointed decision maker, when possible. *The Geriatric Treatment Plan was to have shown all active treatment methods and interventions used to treat and care for the resident. *The physician provided the final approval for the treatment plan. *Problems/needs were to have been identified fro the psychiatric and psychological evaluations, nursing assessments, or psychosocial assessment for the Treatment Plan. *All problems were to have been written in observable, behavioral, descriptive terms to facilitate measurable goals. *Ask for the resident's input to incorporate into the Treatment Plan. *Goals were written based on identified problems. *The plan was to have included methods and interventions, specific treatment approaches utilized, responsibilities of each member of the treatment team. *Progress notes were to have reflected progress/performance/status/and condition of the resident. -They should describe changes in the resident's status related to physical, medical, emotional or behavioral issues/concerns. -The frequency of the progress note depended on the condition of the resident.

Based on observation, interview, and policy review, the provider failed to ensure: *Three of three medication rooms were kept secured from access of unauthorized and unlicensed staff. *Medication room keys were kept secure. Findings include: 1. Observation on 7/13/21 at 10:00 a.m. on the Spruce 2 resident unit of maintenance supervisor A revealed he opened the medication room with a key. He was showing the life safety surveyor around the building. Surveyor: 2. Interview on 7/14/21 at 2:30 p.m. with RN charge nurse J regarding the medication room keys revealed: *All nurses and med aides have their own medication room keys. *They took the medication room keys home with them at the end of their shift. *The medication rooms had secured automated medication machines, but there were also medications in the medication room that were not locked in a drawer. *She confirmed maintenance supervisor A should not have had the authority to enter the medication room alone. Surveyor: 3. Interview on 7/14/21 at 6:45 p.m. with administrator B and director of nursing C confirmed: *All nurses and medication aides have a key to the medication rooms. *The maintenance department also had access to the medication rooms. *Those keys were kept by each nurse, medication aide, and maintenance person unless they terminated their employment. *The nurses and medication aides took the medication keys home with them after their shifts. Surveyor: 4. Review of the provider's revised January 2017 Issuing of Employee Keys policy revealed: *It was the policy that the control of keys would be maintained for safety and security of patients, staff, and property. *Keys were issued by the Physical Plant Manager or designee. *Employees were to have been issued only those keys necessary to complete job responsibilities.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Two of five observed certified nursing assistant (CNA) (D and E) had performed hand hygiene and glove changes during one of five observed sampled residents (47) personal care. *Sanitizing of the total body lift between resident use by one of one observed CNA (D). *Sanitizing of the glucometer between each resident use by one of one observed registered nurse (RN) (H) to monitor blood sugar levels. Findings include: 1. Observation on 7/13/21 at 2:48 p.m. of CNA D and E while they provided personal care to resident 47 revealed: *CNAs D and E entered the room with the full body lift. *With no hand hygiene they put on gloves. *They used the full body lift to transfer him from his wheelchair to his bed. *Without changing their gloves CNA D and E: -Removed his pants and unfastened his incontinence brief. -CNA D then provided perineal care. -Resident 47 had been incontinent of a large amount of stool. -They then repositioned him onto his right side. -While CNA E held onto the resident CNA D continued to clean him and then removed his incontinence brief. -CNA E then went to the residents closet and took a disposable underpad. -CNA D placed this on the end of the bed and placed the soiled incontinence brief and soiled cleansing wipes on top of it. -CNA D continued to provide perineal care. -CNA D removed her gloves, took the disposable underpad she had set the soiled incontinence brief and wipes on, and placed it in the garbage can. There was no garbage bag in the garbage can. -Without any hand hygiene or putting on a new pair of gloves CNA D assisted to put on a new incontinence brief and pull his pants up. -CNA E removed his gloves and did not do any hand hygiene. -CNA E moved the residents wheelchair into the bathroom. -CNA D took the full body lift to the shower room. She did not sanitize the lift. -Upon returning to the resident's room CNA E had placed the garbage into a garbage bag. He then washed his hands and picked up the garbage bag and carried it to the shower room. He did not sanitize his hands after. -CNA D then washed her hands. Interview on 7/14/21 at 10:04 a.m. with registered nurse (RN)/clinical support manager F and RN/infection control preventionist G revealed: *Both CNAs D and E had missed opportunities for hand hygiene and glove changes. *Were not sure if they had a policy and procedure for sanitizing the lifts between residents. Review of the provider's 3/23/21 Handwashing Technique and Use of Hand Sanitizers policy revealed hands were to have been cleansed: *Before caring for a resident. *After: -Giving care to a resident or handling the residents equipment. -Following the removal of gloves. -Handling body secretions. Review of the provider's 1/26/21 Mechanical Lifts policy revealed all surfaces should have been wiped with human services center (HSC) approved germicidal solution per HSC policy. 2. Observation on 7/13/21 at 4:50 p.m. of RN H obtaining blood sugar tests revealed she: *Entered resident 44's room and obtained the test results. *Picked up the glucometer and exited the room. *Entered resident 50's room with the same glucometer without disinfecting the glucometer obtained his test results. *Picked up the glucometer and exited the room. *Entered the medication room and disinfected the glucometer with a Sanicloth disinfectant wipe. Interview at the above time with RN H regarding the glucometer disinfection revealed: *The above glucometer was used for all residents who required blood sugar testing. *RN H normally disinfected the glucometer one time, after all the residents' blood sugar testing had been completed. *She confirmed she should have disinfected the glucometer after each resident had been tested . Interview on 7/20/21 at 9:30 a.m. with the director of nursing confirmed the glucometer was to have been disinfected between each resident use. Review of the provider's revised May 2021 Blood Sugar Testing/Accu-chek policy regarding cleaning the Accu-chek glucometer revealed the nurse was to have: *Put on gloves. *Used an approved germicidal disinfecting wipe to thoroughly clean the glucometer after each resident use. *Disposed of the wipe after one use. *Allowed the glucometer to air dry after the approved disinfectant contact time. *Remove gloves and wash hands.

Based on observation, interview, and policy review, the provider failed to ensure three of three medication room refrigerators (Willow 1, Spruce 1, and Spruce 2) controlled medication storage was permanently affixed. Findings include: 1. Observation and interview on 2/27/19 at 3:45 p.m. of the Spruce 1 medication room with registered nurse (RN) J revealed: *A small medication refrigerator with four vials of [MEDICATION NAME] injectable 2 milligram (mg)/milliliter (ml), four vials in a clear rigid plastic container with a small padlock on it. *The container was not affixed to any part of the refrigerator and was able to be easily removed from the refrigerator. *RN J confirmed the above findings. 2. Observation on 2/27/19 at 4:00 p.m. of the Spruce 2 medication room revealed: *A small medication refrigerator with four vials of [MEDICATION NAME] injectable 2mg/ml in a clear rigid plastic container with a small padlock on it. *There was also another container with forty capsules of dronabinol 2.5 mg in it. *Those containers were not affixed to any part of the refrigerator and were able to be easily removed from the refrigerator. 3. Observation on 2/27/19 at 3:05 p.m. of the Willow 1 medication room revealed: *This room contains the Omnicell unit that dispensed most of the medication for the unit. *They had a small medication refrigerator in the corner. *This refrigerator contained: -Forty-nine tablets of dronabinol 2.5 mg in a small locked metal box. -Four vials of liquid [MEDICATION NAME] 2 mg/ml in a see through small plastic locked box. --Those medication boxes were not affixed to the refrigerator. Interview on 2/27/19 at 2:10 p.m. with pharmacists D and E revealed: *They agreed that [MEDICATION NAME] and dronabinol were narcotics. *They had not heard that narcotics would have to be affixed to the fridge. *They considered it double-locked if the door was locked and the box was locked. *They agreed the locked box could have easily been taken out of the medication room. 4. Interview on 2/27/19 at 3:30 p.m. with registered nurse C revealed: *She agreed the narcotics could have easily been taken out of the room while still in the box. *It has always been done like that. *She did not know if the boxes needed to be affixed to the refrigerator. *It would have been difficult to investigate if the medications would have been missing. Review of the provider's revised 8/24/18 Medication Administration policy revealed no procedure for the security of controlled medications in the medication refrigerators.

Based on observation, interview, record review, and policy review, the provider failed to ensure 1 of 18 sampled residents (32) had a comprehensive recreation program. Findings include: 1. Review of resident 32's 7/26/18 admission Minimum Data Set (MDS) assessment revealed: *The activities that were very important to her were: -Reading materials, music, being around animals/pets, keeping up with the news, and being outside getting fresh air. *Doing things with groups of people was somewhat important. *Religious activities were not very important. Review of resident 32's 1/29/19 treatment plan revealed: *Problem: At risk for impaired communication related to cognitive impairments which may limit her participation in groups and activities. (Name) will need assistance in finding activities to occupy her leisure time. *Activity interventions included: -She enjoyed listening to music, having books/magazines to read and going outside when the weather was nice. She also enjoyed pets and indicated she had a dog named Hershey. -She would be invited to on and off unit groups to occupy her time. *They would provide small groups, one-to-ones (1:1) and on-and-off unit groups when behavior permitted. *It did not address: -What kind of music or books she enjoyed. -What types of small groups would have been appropriate. -What behavior was occurring to prevent off unit groups. Review of the provider's Willow 1, (MONTH) 2019 Activities calendar revealed: *News and Views was offered four of seven days each week at 10:30 a.m. -That was the first scheduled activity of the day. *Other activities included: -Daily devotions three times per week. -A movie one time a week. -A church service one to two times per week. -Off unit activities one to three times a week. Surveyor: Random observations on 2/26/19 from 8:30 a.m. through 4:30 p.m. of resident 32 revealed she had either been wandering on the unit or laying in her bed. There was minimal staff engagement throughout that timeframe. Surveyor: Interview on 2/27/19 at 2:26 p.m. with recreation therapist (RT) A regarding resident 32 revealed: *The resident had a hard time focusing on anything. -She would get up and walk, and then sat down, only to get up again as soon as she sat down. *She frequently just said no to anything that was said to her. -They were not sure if she really meant no when she said it. *Her boyfriend visited everyday for maybe an hour. -She would get up several times during his visits and walk away. *She might listen to the news activity. *She did not do any activity such as coloring or puzzles. *She had stuffed animals in her room, but she had no interest in the stuffed animals and babies in the dayroom. *Sometimes she would come out for devotions. -If she did not come out, she would bring her a copy of the printed devotion that had been read in the group. -She did not know if she had an intellectual disability or if she could read. --She confirmed she did not know if the resident could actually read the devotion when she had been given it. *When the RT came in each day she tried to spend a few moments with each resident greeting them for the day. *She took resident 32 for a walk around the indoor campus which the resident really enjoyed. -It was a one-third mile walk. -She thought she liked the one-to-one time. -She took her to the cafeteria, and she would get a treat. --She loved ice cream, but she would even get up and leave the ice cream. ---In the summer she loved to go outside. ---When asked if she could have taken her for more than one walk she said she had one resident she took for two walks a week. *They had recently added the Music and Memory program, and she had several residents who had been set-up for that. -She had not set-up this resident yet, because they had concerns about the safety of the cord and wrapping it around her neck. --They had ordered cordless headsets and planned to get one for her, but that was pending. ---She would have to talk to her boyfriend about what kind of music she liked. *They did not have pet therapy, and she was unsure what had happened to her dog. Review of the provider's undated Treatment Unit Activities policy revealed: *Therapeutic Recreation Specialists are responsible for developing a comprehensive therapeutic recreation program to meet the leisure/recreational needs of the patients (residents) on their specific treatment unit. *This may include developing goals and implementing a specific leisure/recreational plan for each individual on the unit. *The plans are to be based on individual's strengths and interests. *It shall include all three modalities of Therapeutic Recreation: -1. Therapy to improve functional abilities, -2. Leisure education to teach or enhance recreational skills, and -3. Recreation participation to promote health and growth. *To achieve the patients' goals the Therapeutic Recreation Specialists shall offer a variety of programs from individual sessions and small groups to large, all hospital events. *The activities within each of these programs may include: physical, intellectual, emotional, expressive, social and or spiritual activities to meet each individual's needs.

Based on observation, interview, record review, and policy review, the provider failed to ensure accurate assessment, documentation, and timely notification to the physician had occurred for one of one sampled resident (2) who had developed a facility-acquired pressure ulcer. Findings include: 1. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Alzheimers. -Major neurocognitive with behaviors. -Unspecified [MEDICAL CONDITION]. *She had developed a stage two pressure ulcer on 1/28/19 to her sacrum measuring 1.0 centimeter (cm) x (by) 2.0 cm. -Wound color described as red/scattered scabs. -No drainage or odor present. *She had developed a stage two pressure ulcer on 1/28/19 to her coccyx measuring 1.0 cm x 1.0 cm. -Wound color described as red/scattered scabs. -No drainage or odor present. *She had developed a stage two pressure ulcer on 2/5/19 to her coccyx. Review of resident 2's 11/29/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was three indicating her cognition was severally impaired. *She was independent with bed mobility, walking, and eating. *She required limited assistance of one staff member for transferring. *She required extensive assistance of two staff members for dressing, toilet use, personal hygiene, and bathing. *She was frequently incontinent of bladder and occasionally incontinent of bowel. *She was at risk for pressure ulcers. *She did not have a current pressure ulcer. *She had a pressure reducing device on her bed and in her recliner. Random observations on 2/26/19 from 8:30 a.m. through 4:13 p.m. of resident 2 revealed: *From 8:30 a.m. through 12:30 p.m. she had been sitting in a recliner in the common area. -They had taken her to the bathroom one time during that time period for a dressing change to her coccyx. -She had not been repositioned during that time period. *At 1:55 p.m. she was taken to her room and laid down. *At 2:28 p.m. she was up ambulating with her walker and one staff person. *From 2:28 p.m. through 4:13 p.m. she was sitting at a table in the common room reading the newspaper and listening to music. Interview on 2/26/19 at 10:21 a.m. with charge/registered nurse (RN) C regarding resident 2 revealed she had no opened pressure ulcer. They were putting an [MEDICATION NAME] dressing to her coccyx area. Observation and interview on 2/26/19 at 11:22 a.m. with RN B completing a dressing change for resident 2 revealed: *The dressing was removed, and the area was opened with pink blood tinged drainage on the dressing. *RN B confirmed the area was opened. -That area measured 1.0 cm x 0.5 cm. *RN B cleansed the area with soap and water and covered it with an [MEDICATION NAME] dressing. *There was no date or time on the old or new dressing. Review of resident 2's 2/6/19 physician's assistant order revealed an order for [REDACTED]. Review of resident 2's short term care plan initiated on 2/5/19 revealed: *They had measurements for two areas: -Stage one 4.6 cm x 2.0 cm to coccyx. -Stage two 0.3 cm x 0.5 cm to coccyx. *There was no description of either wound regarding color, drainage, or odor. Interview and record review on 2/26/19 at 11:26 a.m. with RN B regarding resident 2's pressure ulcer flow sheet revealed: *On 2/5/19, pressure ulcer to coccyx score two, measured 0.3 cm x 0.5 cm x 0.1 cm with clear drainage, no odor, and pink wound color. *On 2/8/19, pressure ulcer to coccyx score two, measured 0.3 cm x 0.5 cm x 0.1 cm with no drainage, no odor, and pink wound color. *On 2/14/19, pressure ulcer to coccyx score one, measured 1.0 cm x 0.4 cm with no drainage, no odor, and red wound color. *On 2/15/19, pressure ulcer to coccyx score one, measured 1.0 cm x 0.4 cm with no drainage, no odor, and red wound color. *On 2/22/19, pressure ulcer to coccyx score one, measured 0.5 cm x 0.1 cm with no drainage, no odor, and pink would color. *On 2/26/19, pressure ulcer to coccyx score two, measured 1.0 cm x 0.5 cm pink blood tinged drainage, no odor, and red wound color. *There had been no documentation on 2/11/19, 2/18/19, or 2/25/19 of the scoring, measurements, or description. *RN B stated the score one meant the wound was closed. *Their Skin Status Record for Wound flow sheet defined score as: -Score 1: An area of persistent, non-blanchable, redness that may appear with persistent red, blue, or purple hues, and/or changes in; skin temperature (warmth or coolness); tissue consistency (firm or boggy); sensation (pain, itching) when compared to an adjacent or opposite area on the body. -Score 2: Partial thickness loss of dermis. Present as shallow open ulcer/crater with a red-pink wound bed without slough. (MONTH) also present as an intact or open/ruptured blister. Observation on 2/27/19 from 9:14 a.m. through 11:30 a.m. of resident 2 revealed she had been laying in her bed on her right side. Interview and record review on 2/27/19 at 4:31 p.m. with charge RN C regarding resident 2 revealed: *The short term care plan had measurements for two areas, but she only had one pressure ulcer. -She was unable to explain the two separate measurements. *The flowsheet score of two was the same as a stage two pressure ulcer. *She stated the two areas documented on 1/28/19 were not considered pressure ulcers. -The staff had assessed and documented those areas inaccurately. *Regarding the 2/5/19 pressure ulcer she agreed the staff should not have changed the staging. *There was no physician's notification on 2/14/19 when the area had gotten bigger. *They were not able to locate any documentation for the above missing dates. *They did not have any Braden score assessments documented from 11/2/18 through 2/22/19. Review of the provider's 4/1/18 Geriatric Skin Assessment policy revealed: *It shall be the policy of the South Dakota Human Services Center that a skin assessment shall be completed on all patients (resident) within 8 hours of admission, re-admission, and prior to discharge and/or when there is a significant change. RN shall complete the Braden Skin Assessment on all patients within the first 24 hours from admission, then quarterly, and with any significant change. Nurse shall complete skin assessment weekly X4 from admission, re-admission or significant change. After monitoring weekly x4, skin assessments shall be completed: weekly if patient has a Braden Skin Assessment score of 14 or below or the patient is a diabetic or has [MEDICAL CONDITION], or [MEDICAL CONDITION] or every two weeks if patient's Braden Skin Assessment score is 15 or above and has no chronic skin or circulatory problems. *Nurse shall notify Physician/PA-C/CNP of: results of Skin Assessment/Braden Scale and obtain orders to treat any skin problems, [MEDICAL CONDITION]/sores i.e. medical treatments, dietary/nutritional consultations and interventions, ect. as needed, on the condition and effectiveness of treatment on [MEDICAL CONDITION]/sores/ulcers every two weeks or more often if needed, any decline in condition of [MEDICAL CONDITION]/sores/ulcers as soon as noted. *The policy had not addressed dating or timing the dressing change.

Based on record review and interview, the provider failed to ensure interventions identified in the care plan had been implemented for two of three sampled residents (2 and 24) who exhibited behaviors. Findings include: 1. Review of resident 2's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Major neurocognitive with behaviors. -Unspecified [MEDICAL CONDITION]. Review of resident 2's 11/29/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was three indicating her cognition was impaired. *She had physical behaviors four to six times during the assessment period. *She had verbal behaviors one to three days during the assessment period. *She rejected care four to six days during the assessment period. *Behaviors were noted to be improved. *She was on antipsychotic, antidepressant, antianxiety, and opiod medications. Review of resident 2's 12/11/18 care plan revealed: *Focus area: Altered thought process related to Major Neurocognitive Disorder-Alzheimer's type with Behavioral Disturbances and [MEDICAL CONDITION] as evidenced episodes of physical aggression, verbal aggression, and repetitive/anxious concerns. She does have mood swings that fluctuate quickly. -Interventions included: --Balance the amount of stimuli with the patient's (resident) ability to tolerate it; minimize distractions that can frighten or confuse. --Will monitor behaviors and mood on personal care record every shift. *Focus area: At risk for Impaired Communication related to cognitive impairments, speech dysfunction and hearing impairment which may limit her participation in groups and activities. (Resident name) does need information repeated at times and does need time to process information at times. (Resident name) will need assistance in finding activities to occupy her leisure time. -Interventions included: --Staff will help (resident name) make safe choices. --Staff will take time to listen to (resident name)'s concerns/verbalizations and will also allow her time to respond to questions. --(Resident name) has indicated that she enjoys looking at magazines, drawing, watching TV(FOX news) and movies, music (especially hymns), and visiting with peers and staff. She also enjoys bingo and crossword puzzles. --Allow adequate rest between stimulating events. Review of resident 2's behavior documentation from (MONTH) (YEAR) through (MONTH) 2019 revealed: *October (YEAR) they had documented sixty behaviors. -Fifty-seven out of those sixty opportunities they used redirection and encouragement. --Five of the fifty-seven attempts had been effective. -Three of those sixty opportunities had no intervention. *November (YEAR) they had documented thirty-eight behaviors. -Thirty-eight out of thirty-eight opportunities they had used redirection and encouragement. --Three times that intervention had been effective. *December (YEAR) they had documented fifty-four behaviors. -Fifty-one out of fifty-four opportunities they had used redirection and encouragement. --Two of those attempts had been effective. -Three of those fifty-four opportunities they had no intervention listed. *January (YEAR) they had documented forty-two behaviors. -Forty-one of those forty-two opportunities they used redirection and encouragement. --Three of those forty-one attempts were documented as effective. -One of the forty-two times they provided a one-to-one and took her to the bathroom. --That had not been effective. *There was no documentation of the above care plan interventions being implemented. *When the interventions had not been effective there was no documentation they had attempted anything else. 2. Review of resident 24's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Neurocognitive disorder unspecified. -Unspecified [MEDICAL CONDITION]. Review of resident 24's 1/10/19 MDS assessment revealed: *Her BIMS score was ninety-nine indicating she could not be interviewed. *She had long and short term memory problems. *Her cognitive skills were moderately impaired. *Physical behaviors occurred one to three days during the assessment period. *She rejected care one to three days during the assessment. *Her behaviors had worsened from the prior MDS assessment. *She was on antipsychotic, antidepressant, and opiod medications. Review of resident 24's 1/22/19 care plan revealed: *Focus Area: Altered Thought Process related to neurocognitive disorder as evidenced by physical aggression and verbal outburst. She has pushed peers who come into her room or space. She does get agitated if staff offer her numerous reminders, such as coming out for meals. -Interventions included: --Will monitor behaviors and mood on personal care record every shift. --Staff will be aware that (resident name) enjoys hugs from staff that she knows well. *Focus Area: (Resident name) is also at risk for impaired communication related to cognitive deficits. (Residents name) first language was not English, but she understands and speaks English well. (Resident name) needs to be informed of the variety of groups that are offered to occupy her leisure time. -Interventions included: --Staff will take the time to listed to (residents name) concerns/verbalizations and will also allow her time to respond to questions. --Reminisce about (residents name) strengths. (Resident name) like music, such as Native American and Country-Western. She also enjoys looking at magazines. She used to enjoy watching western movies. She likes horses. (Resident name) will also propel on the unit daily for exercise in a wheelchair. --Allow adequate rest between stimulating events. Review of resident 24's behavior documentation from (MONTH) (YEAR) through (MONTH) 2019 revealed: *October (YEAR) they had documented sixteen behaviors. -All sixteen of those opportunities they used redirection and encouragement. --One of the sixteen attempts had been effective. *November (YEAR) they had documented twenty-four behaviors. -Twenty-three out of twenty-four opportunities they had used redirection and encouragement. --None of the interventions had been effective. -One out of twenty-four opportunities they documented talking to the resident. *December (YEAR) they had documented fifty-three behaviors. -Fifty-one out of fifty-three opportunities they had used redirection and encouragement. --None of those attempts had been effective. -Two of those fifty-three opportunities they had no intervention listed. *January (YEAR) they had documented thirty-nine behaviors. -Thirty-eight of those thirty-nine opportunities they used redirection and encouragement. --None of those thirty-eight attempts were documented as effective. -One of the thirty-nine opportunities they provided a one-to-one. --That was documented as effective. *There was no documentation of the above care plan interventions being implemented. *When the interventions had not been effective there was no documentation they had attempted anything else. Interview on 2/27/19 at 2:30 p.m. with certified nursing assistant/mental health aide M regarding resident 24 revealed: *One person assisted her to the bathroom, but two people assisted her with the bath because of her behaviors. *She cried during her bath. *They attempted to redirect her when she cried with minimal success. 3. Interview on 2/27/19 at 4:31 p.m. with charge/registered nurse C and the director of nursing regarding dementia care and the above residents revealed: *She agreed the interventions on the care plans were appropriate but had not been used according to the behavior documentation. *A dementia care policy had been requested at that time but they did not have one.

Based on observation, interview, record review, and policy/job description review, the provider failed to ensure social service interventions were implemented and documented for one of three sampled residents (45) who had depression. Findings include: 1. Review of resident 45's medical record revealed: *Her admitted was 11/7/18. *Her [DIAGNOSES REDACTED].>-Unspecified [MEDICAL CONDITION]. -[MEDICATION NAME] use disorder. -History of alcohol use disorder. -Brain [DIAGNOSES REDACTED]. -Hepatic [MEDICAL CONDITION]. *She had a history of [REDACTED]. Review of resident 45's 11/14/18 Minimum Data Set (MDS) assessment revealed: *Her Brief Interview for Mental Status (BIMS) score was thirteen indicating her cognition was intact. *She had other behavioral symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily waste, verbal/vocal symptoms like screaming, or making disruptive sounds for one to three days during that assessment period. *She wandered one to three days during the assessment period. *She was minimally depressed. *She was independent with bed mobility, transferring, walking, and eating. *She required limited assistance from one staff member for dressing, toileting, personal hygiene, and bathing. *She was frequently incontinent of bowel and bladder. *She had no scheduled pain medication but had as needed (PRN) medications. *There were no non-pharmacological interventions. *She had falls prior to admission. -She had one fall with injury and two or more falls with no injury prior to admission. *She had been receiving an antidepressant during the review period. Review of resident 45's 1/31/19 MDS assessment revealed: *Her BIMS score was eleven indicating her cognition was moderately impaired. *Her behaviors had improved. *She was minimally depressed. *She was independent with bed mobility, transferring, walking, dressing, and eating. *She required supervision from one staff member for toileting and personal hygiene, *She required limited assistance of one staff person for bathing. *She was occasionally incontinent of bladder. *She was frequently incontinent of bowel. *She was on scheduled pain medications and PRN medications. *There were no non-pharmacological interventions. *She had frequent moderate pain. *She had two or more falls with no injury. *She was on an antidepressant, Opiod, and antianxiety medications. *She was not on any restorative or physical therapy. Observation and interview on 2/26/19 from 5:05 p.m. through 5:25 p.m. with resident 45 revealed: *She stated she wanted to go home to live with her daughter. *She could not recall if anyone had visited with her about discharge planning. -She would like more information regarding discharge planning. *She expressed concerns with a certified nursing aide being snotty with her, but stated she had not discussed it with anyone. *She became tearful during the conversation and stated she missed her grandchildren. *She stated her daughter and brother wanted her to see a counselor, but that had not been offered to her. -She would talk to someone if it was offered. Review of resident 45's 2/12/19 care plan revealed: *Focus Area: (Resident name) was previously at Avera Behavioral Health from 08/30/2018-09/07/2018 for suicidal ideation; she was discharged to her daughter's home. (Resident name)'s daughter reported (resident name) stole money from her and stole medications from her granddaughter. (Resident name) presented to Avera Sacred Heart Hospital with suicidal ideation and was admitted to SDHSC on 09/11/2018. (Resident name) is unable to return to living with her daughter, is unable to care for self and will require a supportive, structured environment. -Intervention included: Social worker will assist (Resident name) and her supports to find placement when behaviors allow. Review of resident 45's (MONTH) 2019 personal care record for behaviors revealed she had four incidents where she had become teary eyed and stated she wanted to go home. The interventions implemented had been redirection and encouragement with one documentation of being effective. Review of resident 45's interdisciplinary progress notes revealed: *On 1/2/19, the resident had requested to speak with the social worker. -There was no follow-up documentation stating that had occurred. *There had been no documentation regarding follow-up to the above behaviors, discussion of discharge planning with the resident, or potential referrals for counseling. Interview on 2/27/19 at 4:07 p.m. with licensed clinical social worker K and charge/registered nurse C regarding resident 45 revealed: *Due to past noncompliance the daughter did not want her to come live with her. *They had stated the current plan was to refer her to another nursing home. *They had contacted the nursing facility she had come from, and they would not take her back. *They had not referred her for counseling. *They agreed they had not documented communication with the resident or interventions they had attempted with her. *At 6:04 p.m. they had brought documentation of a referral for a psychological assessment they had made after our above conversation. Review of the provider's 12/18/18 Social Services Assignment of Staff policy revealed: *Geriatric Services: Human Services Social Worker will manage a caseload of up to 46 residents for which social worker will focus on discharge planning through completion of annual psychosocial assessments and collaboration with personal supports and community providers. Social worker will assist with legal, personal, and financial matters. The Human Services Social Worker is the treatment team member who will seek feedback from community providers and personal supports and bring these to the treatment team for consideration and inclusion in planning discharge and treatment interventions.

Based on observation, interview and policy review, the provider failed to clean one of one section of pipe covering for an incoming steam system, failed to properly store cleaning items in one of one area under the grill, and failed to adhere to sanitary food preparation practices using a digital temperature probe during one of one meal service observation in the kitchen. Findings include: 1. Observation on 2/26/19 at 8:15 a.m. in the kitchen revealed: *An approximate 10 foot section of pipe covering for an incoming steam system behind the fryer/grill unit had built up surface grime and grease that was yellow, brown, orange and black. -An approximate 2 foot section of that pipe cover behind the grill was burned. -Pipe cover was torn and exposed insulation where the pipe turned up toward the ceiling near the end of the fryer. Interview on 2/27/19 at 9:45 a.m. with assistant director H revealed: *Staff were wiping what they could off the covered surface of the pipe cover. *The pipe cover was not able to be thoroughly cleaned. Interview on 2/27/19 at 3:00 p.m. with the physical plant manager revealed he: *Was in agreement the pipe cover surface was not cleanable. *Thought there was a way to cover the pipe to make it a cleanable surface. 2. Observation of the grill at that same time revealed: *A metal sheet pan on an open shelf that held a scrub brush with greasy, black bristles; a food surface scraper; and pieces of black grease debris. *A blue milk crate filled with cloths that were stained black with pliable and hardened grease. Interview on 2/27/19 at 3:10 p.m. with the assistant director H revealed: *That storage location was near food preparation areas. *The manner of storing the cleaning supplies was potentially hazardous. 3. Observation on 2/27/19 between 9:00 a.m. and 9:30 a.m. of cook L revealed she: *Was testing food temperatures using a digital temperature probe prior to serving food. *Was unable to verify the temperature probe was calibrated prior to use to ensure accurate readings. *Was unable to verbalize or demonstrate how to calibrate the temperature probe. *Was inserting the temperature probe through the plastic wrap covered containers she was temping. *Was not consistently wiping the probe with the alcohol pad in between temping different food items. Interview on 2/27/19 at 9:30 a.m. with cook L revealed she: *Was not sure how to calibrate the temperature probe. *Was unaware she was not supposed to insert the probe through plastic to temp foods. *Was unaware she was not consistently wiping the probe between the foods she was temping. Review of the undated 1.6 Thermometer Guidelines policy revealed: *Thermometer Calibration: Calibrate thermometers daily (and more frequently when the thermometer is dropped or stored with other utensils), per the manufacturer's instructions. *Checking Food Temperatures: After sanitizing the thermometer, allow the thermometer to dry, then insert thermometer stem into the thickest part of the food.

Based on observation, record review, interview, and policy review, the provider failed to ensure discharge planning had been actively pursued for one of two sampled residents (40). Findings include: 1. Observation of resident 40 on 1/2/18 at 5:30 p.m. during supper and 1/3/18 at 8:30 a.m. during breakfast revealed she: *Was seated at the dining table during those two meals. *Required set-up assistance and cueing during the meals. *No behaviors of hitting, scratching, or resistance to staff assistance was noted. Review of resident 40's social services notes from 8/15/16 through 11/14/17 revealed: *She had been admitted on [DATE] to the geriatric program. *On 8/15/16: -Her son had voiced his request for discharge and which nursing facility he would like her to be discharged too. - (Son) stated he does not want (resident name) at SDHSC (South Dakota Human Services Center) and would like to be involved in her care and discharge planning. *On 8/17/16: -10:51 a.m. Patient (resident name) had in home services for a couple of months prior to be hospitalized at Rapid City Regional West. Patient had been denied by over 30 nursing homes. -4:28 p.m. Son also stated resident transferred back to Rapid City Regional West so that resident could be closer to his dad to visit resident regularly; he was informed this would be brought to the treatment team. This recorder spoke about this with the treatment team and it was said this would not be possible. This recorder attempted to contact son to inform him of this, but the call was not successful; a voice message was left. *On 8/19/16: 2:03 p.m. Resident 40's son had expressed his disagreement regarding his mother not being able to be transferred back to Rapid City Regional West. This recorder educated son that when resident is ready for discharge, she will be discharged to a nursing home. Son expressed several times his want for resident to be out of SDHSC due to the distance between resident and her family while she is here. *On 8/22/16: 10:52 a.m. Son contacted this recorder regarding discharge planning for resident. He asked if she could be transferred to Rapid City Regional West, he was educated we do not do this. Son was wanting to know who could make this happen; this recorder will check further into the request and get back to him. Son also asked if resident would be ready for discharge tomorrow and if referrals would be sent out. Son was educated that placement will not be sought until resident's aggressive behaviors are reduced and medications are stable. Son voiced an understanding of this. *On 9/7/16: 12:30 p.m. Son expressed his want for resident to be transferred to Rapid City Regional West. Son stated resident's depressive symptoms are stemming from her being so far away from home and family being unable to visit on a regular basis. *On 9/16/16: 4:02 p.m. Son asked about discharge planning for resident. Son was educated that no referrals have been made due to residents display of agitation and aggression as well as continuing to have her medications adjusted. *On 10/12/16: 1:10 p.m. This recorder and the charge registered nurse (RN) contacted son and updated him on the residents behaviors and that there is currently no discharge planning. *On 11/7/16: 4:12 p.m. Resident's son contacted provider regarding mother's discharge planning process. He was informed the treatment team believed resident was not ready for discharge. *On 2/14/17: 11:09 a.m. Resident's son contacted provider regarding mother's treatment team meeting. He was informed the treatment team would reassess residents readiness for discharge after her URI (upper respiratory infection) resolved. He was told there was no current discharge planning. *On 3/15/17: 3:30 p.m. Son contacted this recorder, upset that resident remained at SDHSC. Son expressed his belief that resident could be cared for in a community nursing home; this recorder educated son that the treatment team does not believe resident is ready for discharge at this time, although there has been some improvement in her behaviors. Son requested the information for resident's court-appointed attorney, son was given the name and contact number for resident's attorney. *On 3/17/17: 2:51 p.m. Son requested that records be sent to GSS-New(NAME)stating that he talked to them and they have an opening. This recorder educated son that this would be discussed with the treatment team as a doctor's order for an override of release of information would be required. *On 3/22/17 2:28 p.m. Records were sent to GSS-New(NAME)per son's request and with a doctor's order to release information. Son informed social worker that resident had been denied. *On 8/8/17 12:48 p.m. Son asked where resident was at for discharge planning. Son was informed that there were no current plans for discharge as resident continued to be resistive with bedtime cares. Son stated he believed she would always be resistive for bedtime cares as she acted the same way toward him while he provided care for her in the home. Son requested we begin discharge planning to get her back to her home area. Review of resident 40's 9/1/16 treatment plan last reviewed on 12/5/17 revealed on 9/1/16: *Problem #1: Altered Thought Process related to [DIAGNOSES REDACTED]. (Resident) was admitted due to physical and verbal aggression towards prior caregivers. -Goals: Will accept all medications as ordered. Will have no shifts of physical aggression. Will have no shifts of verbal aggression. Will have no shifts of socially inappropriate behaviors. Will have no shifts of verbal outburst. *Problem # 3: SELF CARE DEFICIT related to cognitive impairments and physical limitations as evidenced by requires extensive assistance with most cares. (Resident) is frequently incontinent of bladder. She can be resistive with cares. -Goal: Shifts of being resistive with cares will decrease. *Problem #9: (Resident) was previously living in her home with her husband with Adult Services and Aging involvement. (Resident) was approved for in-home services and they began in May. Two in-home service agencies terminated services due to (Resident's) agitation and aggression toward them and three others denied her for services. (Resident) is unable to care for herself and will require continued nursing home care. -Goal: (Resident) will display a decrease in agitation and aggression so that community nursing home placement can be sought. -Interventions: Social worker will assist (Resident) and her family to find placement when her behaviors allow. Review of resident 40's treatment team meetings conducted on 11/15/16, 2/14/17, 5/15/17, 8/15/17, and 11/14/17 revealed the goal for problem #9 had not been met. Documentation included Goal not met and will be continued. Resident continues to display agitation and aggression regularly, primarily during cares on the PM shift. When ready for discharge, community placement will be sought. Interview on 1/04/18 at 10:33 a.m. with the RN and the social worker (SW) regarding discharge plans for resident 40 revealed: *Her son had inquired many times about her discharge and/or transfer to another provider closer to their home. *No discharge planning had been started, as her behaviors had not decreased to meet her goals in her treatment plan. *One provider had been provided information per the son's request, but the resident had been denied. The SW had not called that facility but had just sent information. *They agreed her treatment plan did not have realistic goals of no behaviors or resistance to care. *There was no measurable goals set for discharge planning. *They had problems with other nursing homes accepting residents from the SDHSC due to their behaviors, even if those behaviors had decreased greatly. *The SW had not attempted to contact any other providers for resident 40. Review of the provider's 9/13/17 Social Services Discharge Planning policy revealed:*The SW should have continually evaluated their assigned residents and assisted in determining when the resident might have been discharged to the least restrictive treatment alternative. *When a resident no longer met the commitment criteria or had reached their maximum benefit from treatment, a discharge plan should have been verified, and the resident should have been discharged or transferred to the least restrictive treatment alternative.

A. Based on observation, interview, manufacturer's instructions review, and procedure review, the provider failed to disinfect residents' toilets on two of two observed units (Spruce One and Spruce Two). Findings include: 1a. Observation and interview on 11/2/16 at 8:05 a.m. of crew leader D cleaning residents' rooms in Spruce Two revealed: *She worked with a cleaning assistant. *She sprayed the sink and other surface areas with Virex disinfectant and waited ten minutes to wipe it off. *The assistant sprayed the toilet surfaces including the seat with Lysol foam cleaner, waited one minute, then wiped it off with a dry cloth. *That was how they had always cleaned the toilets. *She thought Lysol only needed to be on toilet surfaces for a minute to disinfect them. *The instructions on the Lysol label were to leave on ten minutes to disinfect before wiping off. b. Observation and interview on 11/2/16 at 8:20 a.m. of crew leader E cleaning residents' rooms in Spruce One revealed: *She worked with a cleaning assistant. *She sprayed the sink and other surface areas with Virex disinfectant and waited ten minutes to wipe it off. *The assistant sprayed the toilet surfaces including the seat with Lysol foam cleaner, waited two minutes, then wiped it off with a dry cloth. *She stated she would wait five minutes before wiping off the Lysol foam cleaner. *That was how they had always cleaned the toilets. *She was trained to use the Virex first on the toilets, but she thought the Lysol cleaned better. *She agreed the label said to leave it on for ten minutes to disinfect. c. Interview on 11/2/16 at 2:30 p.m. with the infection control coordinator regarding cleaning of residents' toilets revealed: *The housekeeping manager for geriatrics was not available today. *She agreed residents' toilets had not been adequately disinfected in the above observations. Review of the provider's 9/21/15 Clean and Disinfect A Toilet Bowl Seat procedure revealed: *After cleaning toilet bowl, wash seat and flush handle and an area around toilet paper holder with a wet cloth and (facility name) approved germicidal disinfectant solution. *Allow to air dry. B. Based on observation, interview, and policy review, the provider failed to ensure proper infection control techniques were used for one of one sampled resident's (6) dressing change completed by one of two physical therapists (PT) (F). Findings include: 1. Observation on 11/2/16 at 9:15 a.m. of resident 6's dressing change revealed PT (F) and PT (G) put on gloves and positioned her on her right side. PT (F) then: *Placed the dressing supplies on a clean surface. *Uncovered her lower back exposing the wound area. *Removed the existing [MEDICATION NAME] foam dressing and pad. -The pad had visible drainage on it. *Cleansed and measured the wound area. *Placed a clean [MEDICATION NAME] pad and foam dressing over the wound area. *Gathered up the used dressing, the used pad, the empty dressing and pad packages, and placed all items in a biohazard bag. *Removed her gloves. *Placed a pillow behind the resident's back. *Repositioned her and arranged her clothing and bedding. *Lowered her bed. *Then washed her hands. Interview on 11/2/16 at 9:30 a.m. with PT (F) confirmed: *She had not changed her gloves after removing the existing [MEDICATION NAME] foam dressing and pad. *She would not have changed her gloves as the drainage had been confined to the [MEDICATION NAME] pad. Interview on 11/2/16 at 11:15 a.m. with the director of nursing revealed: *PT had been doing dressing changes for residents with wounds. *She would have expected gloves to have been changed after handling used dressings. *Hands should have been washed before putting on clean gloves. Review of the provider's 6/1/16 Sterile Dressing Application policy revealed: *Sterile dressings would be used on open wounds. *Clean disposable gloves would be used to remove old dressings. *Dressings and gloves would be placed in a biohazard bag. *Hands would be washed with soap and water. *Sterile gloves would be worn to cleanse wounds and to apply dressings. *Gloves would be removed and disposed of in a biohazard bag. *Resident would be assisted to a comfortable position. *Hands would be washed.

Based on observation, record review, interview, and policy review, the provider failed to assess two of three residents (1 and 10) for the use of a potential physical restraint. Findings include: 1. Random observations on 11/1/16 from 10:35 a.m. through 2:00 p.m. of resident 1 revealed he had a foam cushion safety-belt harness around his waist and between his legs. Review of resident 1's medical record revealed: *[DIAGNOSES REDACTED]. *A 6/6/16 physician's orders [REDACTED]. *His 9/7/16 treatment plan had an intervention of Use of pelvic straps to improve positioning when in care foam full reduction 2 piece chair, due to increased and uncontrolled movements. *There were no initial or quarterly assessments for the use of the safety-belt. Interview on 11/2/16 at 7:30 a.m. with registered nurse A regarding resident 1 revealed they had discussed the use of the safety-belt in meetings. But they had not done initial or quarterly assessments for its use. 2. Random observations on 11/2/16 from 1:00 p.m. through 2:55 p.m. of resident 10 revealed he had a pommel cushion in his wheelchair. Review of resident 10's medical record revealed: *[DIAGNOSES REDACTED]. *A 5/27/16 physician's orders [REDACTED]. *His 10/18/16 treatment plan had an intervention of May use pommel cushion in wheelchair. *There were no initial or quarterly assessments for the use of the pommel cushion. 3. Interview on 11/2/16 at 1:50 p.m. with the director of nursing and the Minimum Data Set assessment coordinator revealed they had not completed initial or quarterly assessments for the above residents for the use of the pommel cushion or the use of the safety-belt. Review of the provider's 7/9/15 Protective Medical Restraint policy revealed Protective medical restraints may be used in non-emergent situations if comprehensive individualized assessment determines it is necessary in order to treat a patient's medical symptoms so the patient can attain and/or maintain his/her highest practicable level of functioning. There will be on-going systematic assessment and treatment planning aimed at reducing/eliminating the use of the protective medical restraint by minimizing or eliminating the medical symptom as well as identifying and addressing underlying problems causing the medical symptom.

Based on record review, interview, and policy review, the provider failed to thoroughly investigate unexplained injury incidents for one of three residents (16). Findings include: 1. Review of resident 16's 4/11/16 incident report revealed: *Staff had noticed an injury to the top of his hand. *He had 2 small skin tears side by side, both measuring at 0.8 cm, both are open with dried blood. *He was unable to report how his hand had become injured. *There had been no documentation of an investigation into how he had gotten the skin tears. *There had been no documentation staff had been interviewed regarding what might have happened. 2. Interview on 11/2/16 at 9:00 a.m. with the administrator revealed they had no other documentation regarding staff interviews or that thorough investigations had been completed for the above mentioned residents' incident report. Review of the provider's 4/28/15 Abuse, Corporal Punishment, Involuntary Seclusion, Mistreatment, Neglect, and Misappropriation of Patient Property Prevention policy revealed a thorough objective investigation should have been conducted.

Based on observation, interview, and record review, the provider failed to have documentation physical therapy or occupational therapy had participated in the evaluation of a special chair for one of one sampled resident (1). Findings include: 1. Random observations of resident 1 from 11/1/16 through 11/2/16 revealed he had been sitting in a specialized chair. The chair resembled a living room armchair. It was on wheels, and there was an ottoman that could have been attached to the lower portion of the chair. He had been slouching in the chair. There was a backrest that could allow him to sit up straight. He had only been sitting up straight for small amounts of time before he slouched into the chair. Observation on 11/1/16 at 11:45 a.m. of resident 1 revealed staff had brought him out of his room in the above mentioned chair. His feet were dragging on the floor. The staff member then turned him around and pulled him backwards into the dining room. Interview on 11/1/16 at 12:00 noon with registered nurse A revealed he had been in a different type of chair, but it had been falling apart. They had spoken to the restorative nurse and physical therapy about getting a new chair. She could not locate the documentation physical therapy had completed an evaluation. Review of resident 1's medical record revealed: *[DIAGNOSES REDACTED]. *There had been no referral to physical therapy for evaluation of a new chair. *There had been no documentation physical therapy or occupational therapy had conducted an evaluation to determine if the new chair was appropriate for his specific needs. Interview on 11/2/16 at 11:25 a.m. with the restorative nurse revealed she had gotten the information on the chair from the vendor. It was a two-piece plus carefoam chair. It had been suggested for patients with [MEDICAL CONDITION]'s disease. There had been no documentation physical therapy had evaluated the resident to see if that type of chair was appropriate for his needs.

Based on interview, observation, and policy review, the provider failed to maintain limited access to used Fentanyl (narcotic pain medicine) patch destruction and wasted narcotic pain medication in three of three geriatric (elderly) resident units (Spruce One, Spruce Two, and Willow One). Findings include: 1. Observation and Interview on 12/1/15 at 10:51 a.m. with registered nurse (RN) A in the Spruce One geriatric unit medication room regarding used Fentanyl patch destruction revealed: *The on-campus pharmacy gave the option to either place the patches in a locked box to be returned to pharmacy for destruction, or they could place them in the sharp's box (used to put needles and syringes in). *Those sharp's containers were taken to the admissions department by the unit secretary or the nurse. *Any other narcotic medications that would need to be wasted, for example, if it had been dropped on the floor it would also be placed into the sharps box. Observation and interview on 12/1/15 at 11:10 a.m. with patient services representative M revealed: *Sharps boxes were brought from the units to the admissions office. *There, they were stored under the counter in an unlocked cupboard labeled sharps until they were picked up weekly and taken to the chicken coop (an old chicken coop converted into storage on the property). *To the best of her knowledge that building was not locked or secured. Observation and interview on 12/1/15 at 11:15 a.m. with RN N in the Willow One geriatric unit revealed: *They used the black pharmacy tackle box to return medications back to the pharmacy. *When a used Fentanyl patch was discarded they would place it in that box. *That box was supposed to be returned to the pharmacy that same day if a narcotic medication was known to be in it. *One used Fentanyl patch with a placed-on date of 11/25 was found inside. *That medication was to have been removed after seventy-two hours, so it would have been placed there on 11/28/15. It had not been taken to pharmacy according to their policy. Interview on 12/1/15 at 1:30 p.m. with the on-campus pharmacist O revealed she: *Had been aware the pharmacy gave nursing staff both of the above options to dispose of used or wasted medication. *Was unsure where the full sharps containers were stored off the unit. *Was unsure what the nursing protocol was for the storage of used sharps containers. Interview on 12/1/15 at 2:23 p.m. with RN P regarding narcotic drug disposal on Spruce Two geriatric unit revealed: *The nurses on that unit placed the used Fentanyl patches in the black pharmacy box, and wasted medications in the sharps box. *She agreed the medications would not be secured if they were not taken to pharmacy right away in the pharmacy box or taken to the admission office in the sharps container. Interview on 12/1/15 at 5:15 p.m. with the director of nursing regarding the above narcotic medication disposal revealed she agreed the Fentanyl patches and other wasted narcotic medication were not secured from unauthorized individuals. Review of the provider's 6/1/15 Returning Medication policy revealed: *Controlled (narcotic) medication might have been disposed of in the sharps box but must have been witnessed by another nurse. *Fentanyl patches were to be placed in the pharmacy box and locked, and returned to pharmacy.