Every finding on record at Seven Sisters Living Center

Based on record review, interview, and policy review, the provider failed to ensure the baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was completed within 48 hours of admission for two of three newly admitted resident (4 and 26) and that it was reviewed with and a copy offered to the resident or the resident's representative within 48 hours of admission to the facility for three of three newly admitted residents (4, 26, and 54).Findings include: 1. Review of resident 54's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His baseline care plan was completed on 7/21/26. There was no documentation that resident 54's baseline care plan was reviewed with him or his representative, and that a copy of the resident's baseline care plan was offered to him or his representative within 48 hours of his admission to the facility. 2. Review of resident 4's EMR revealed he admitted to the facility on [DATE]. His baseline care plan was completed on 11/14/25. There was no documentation that resident 4's baseline care plan was reviewed with him or his representative, and that a copy of the resident's baseline care plan was offered to him or his representative within 48 hours of his admission to the facility. 3. Review of resident 26's EMR revealed he admitted to the facility on [DATE]. His baseline care plan was completed on 7/14/26. There was no documentation that resident 26's baseline care plan was reviewed with him or his representative, and that a copy of the resident's baseline care plan was offered to him or his representative within 48 hours of his admission to the facility. 4. Interview and EMR review on 8/26/26 at 2:10 p.m. with director of nursing (DON) B revealed that Minimum Data Set (MDS) nurse C was responsible for completing the resident's baseline care plan within 48 hours of their admission to the facility, reviewing the resident's baseline care plan with the resident or the resident's representative, and offering a copy of the baseline care plan to the resident or the resident's representative within 48 hours after the resident's admission to the facility. DON B acknowledged that the baseline care plans for residents 4 and 26 were not completed within 48 hours of their admission to the facility. DON B stated the baseline care plan was to be reviewed with the resident or the resident's representative by the interdisciplinary care team during the admission care conference. DON B stated there was no documentation in residents 4, 26, and 54's EMR that indicated when the resident's baseline care plan was reviewed with the resident or the resident's representative, or that a copy was offered to the resident or the resident's representative within 48 hours of their admission to the facility. 5. Interview and EMR review on 8/27/26 at 8:08 a.m. with MDS nurse C revealed that she was responsible for completing the resident's baseline care plan, reviewing the resident's baseline care plan with the resident or the resident's representative, and offering a copy of the resident's baseline care plan to the resident or the resident's representative within 48 hours of the resident's admission to the facility. She acknowledged that residents 4 and 26 did not have their baseline care plan completed within 48 hours after their admission to the facility and that there was no documentation that the residents' baseline care plan was reviewed with the resident or the resident's representative, and a copy of the resident's baseline care plan was offered to the resident or the resident's representative within 48 hours of admission to the facility for residents 4, 26, and 54. 6. Review of the provider's March 2022 Care Plan-Baseline policy revealed that A baseline plan of care to meet the resident's immediate health and safety needs is developed for each resident within forty-eight (48) hours of admission. The resident and/or representative are provided a written summary of the baseline care plan.

Based on observation, interview, and record review, the provider failed to ensure side rail (bar/bars attached to the bed) assessments, informed consents, alternatives to the side rails were attempted before the side rails were installed for two of two newly admitted residents (4 and 26) who had side rails on their bed. Findings include:1. Observation and interview on 8/25/26 at 9:29 a.m. with resident 4's at the entrance to his room revealed there were bilateral side rails near the head of his bed. Resident 4 was self-propelling his wheelchair in the hallway near his room. When an interview was attempted with resident 4 his replies were not appropriate to the questions that were asked. 2. Review of resident 4's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 7/22/26 Brief Interview for Mental Status (BIMS) assessment score was 1, which indicated he had severely impaired cognition. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability) and other behavioral disturbances.He had one side rail assessment completed on 2/6/26. That side rail assessment did not include what alternatives were attempted before the installation of his side rail. The risk versus benefits of the side rail were reviewed with resident 4's representative and a consent was obtained on 2/6/26. 3. Observation and interview on 8/25/26 at 11:35 a.m. with resident 26 in his room revealed he had bilateral side rails near the head of his bed. Resident 26 stated he did not use the side rails to reposition in bed or with transferring in and out of bed. He stated the side rails had been on his bed since he admitted to the facility on [DATE]. 4. Review of resident 26's EMR revealed he admitted to the facility on [DATE]. His 7/10/26 BIMS assessment score was 15, which indicated his cognition was intact. His diagnoses included dementia, and bipolar disorder (mental condition causing extreme shifts in mood, energy, and activity levels) with psychotic (a state of losing touch with reality) features.There was no documentation that resident 26 was assessed for the safe use of the side rails, an alternative was attempted, the risk versus benefits were reviewed with the resident or resident's representative, and consent for the side rails were obtained before the side rails were installed on resident 26's bed. 5. Interview on 8/26/26 at 4:09 p.m. with certified nursing assistant (CNA) I revealed that the side rails were left on the residents' beds all the time. She thought there may be some residents without side rails, but most residents had side rails. 6. Review of the TELS (a computerized maintenance system) maintenance logs revealed there was no documentation when resident 4 and 26's side rails were installed onto their beds. 7. Interview on 8/27/26 at 8:01 a.m. with registered nurse (RN) F revealed that the nurses completed the side rail safety assessments, reviewed the risk versus benefits with the resident or the resident's representative, and obtained consent for the side rails. Once that was completed the nurse notified maintenance, either through direct conversation or through the TELS system that one or both side rails needed to be installed on that resident's bed.Sometimes alternatives to the side rails were attempted before the side rails were installed, such as raising the head of the resident's bed to help with a transfer or a referral to physical therapy, but alternatives were not always attempted before a side rail was installed on the resident's bed. If an alternative was attempted, it would be documented in a progress note or a physical therapy note. 8. Interview on 8/27/26 at 8:56 a.m. with director of environmental and dining services E revealed he oversaw the maintenance department. When a resident was admitted he expected that the admitting nurse complete the side rail assessment for safety, and then that nurse would notify the maintenance department through the TELS system to install the side rails or if there were side rails on the bed that were not appropriate for that resident would notify the maintenance staff to remove those side rails.The maintenance staff did not remove side rails from the resident's bed when that resident was discharged . If the side rail needed to be removed when a new resident was admitted into that bed the nurse was responsible for notifying maintenance to remove the side rail. The maintenance staff did not document the date when a side rail was installed or removed from a resident's bed.He stated that resident 26's side rail was not removed when he admitted to the facility because a TELS maintenance request was not entered to notify maintenance that it needed to be removed for his bed. 9. Interview and review of resident 4 and 26's EMRs on 8/27/26 at 9:55 a.m. with director of nursing (DON) B revealed that when a resident admitted to the facility, they would be assessed by a nurse or physical therapy to determine if a side rail was needed to aide that resident with their mobility and independence. If it was determined that the side rail was appropriate for the resident the nurse would review with the resident's representative the risk versus benefits of the side rail and obtain consent for the side rails. The risk versus benefits and the consent for the use of the side rails should be documented on the resident's side rail assistive device assessment form. Once the assessment had been completed and the consent was obtained from the resident's representative, maintenance staff were notified through the TELS system that one or both side rails were to be installed on the resident's bed.DON B expected that before the side rails were installed on the resident's bed alternatives to the side rails were to be attempted and documented in the resident's EMR. She acknowledged resident 4 and 26 did not have alternatives attempted in their EMRs before the side rails were installed on their beds.The side rail assessments were to be completed for each resident with a side rail on admission, quarterly, and with any significant change in the resident's condition. She acknowledged there was not a side rail assessment completed for resident 4 on admission to the facility or quarterly after 2/6/26, and that resident 26 did not have a side rail assessment completed. She acknowledged that not having the side rail assessments for safety completed before the side rails were installed on residents' beds placed the residents at potential risk for entrapment.She expected the side rails were removed from the bed when a resident discharged from the facility to prevent the side rails from being left on the bed, and the resident was not assessed for the safe use of the side rails, alternatives attempted, risk versus benefits were reviewed with the resident or resident's representative and a consent was obtained for the side rails.The provider did not have a side rail policy.

Based on record review, and interview, the provider failed to ensure residents were free from unnecessary drugs for one of two sampled residents (43) who received an antipsychotic medication (a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) had their antipsychotic order written with the required 14-day usage order stop date, two of two sampled residents (4 and 43) were evaluated by a healthcare provider within the required 14-day timeframe to renew their PRN (as needed) antipsychotic medication orders and that the indication for administration was documented for an as-needed (PRN) anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restless or irritability) medication that was administered to one of one sampled resident (10).Findings include: 1. Review of resident 43's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 8/20/26 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated her cognition was moderately impaired. Her diagnoses included depressive disorder, delusional disorder (a mental health condition where a person has false beliefs), and anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). She had a 5/28/26 physician's order to be given haloperidol 0.5 mg (milligrams) tablet four times daily PRN for nausea. The physician's order had a usage stop date of 7/23/26. She had a 7/23/26 physician's order to be given haloperidol 0.5 mg tablet four times daily PRN for nausea. The physician's order had a usage stop date of 9/17/26. Resident 43 was seen by a healthcare provider on 7/23/26 and again on 8/11/26, which was 19 days between provider visits to renew her PRN antipsychotic medication. 2. Review of resident 4's EMR revealed he admitted to the facility on [DATE]. His 7/22/26 BIMS assessment score was 1, which indicated his cognition was severely impaired. His diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with anxiety and other behavioral disturbances, and post-traumatic stress disorder ((PTSD) a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). He had a 6/25/26 physician's order for olanzapine (an anti-psychotic medication) 5 mg to be administered every 24 hours as needed for anxiety or agitation. Resident 4 was seen by a physician on 7/23/26, and his physician's order for his as needed olanzapine prescription was reordered. On 8/13/26 resident 4's physician's order for his as needed olanzapine was renewed without being seen by a physician. On 8/18/26 resident 4 was seen by a physician and his physician's order for his as needed olanzapine was reordered, 26 days since his last physician's visit. 3. Review of resident 10's EMR revealed she admitted to the facility on [DATE]. Her 8/6/26 BIMS assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included schizoaffective disorder (a serious mental illness with symptoms of impaired reality perception, mood swings, disorganized thinking, and altered behavior), anxiety, and major depressive disorder (lasting and deep feeling of sadness, emptiness, and loss of interest in normal day activities). She had a 6/26/26 physician's order for lorazepam (an anti-anxiety medication) 0.5 mg to be administered every 8 hours as needed for anxiety. Her August 2026 medication administration record (MAR) indicated that on 8/1/26 at 1:12 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/2/26 at 12:44 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/5/26 at 11:37 a.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/7/26 at 3:55 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/14/26 at 12:36 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/16/26 at 5:42 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/25/26 at 12:45 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. On 8/26/26 at 12:34 p.m. resident 10 was administered 0.5 mg of lorazepam. There was no documentation of what the lorazepam was administered for or if non-pharmacological interventions were attempted before she was administered the lorazepam. Her 8/27/26 care plan indicated the non-pharmacological interventions that were to be attempted were, Find out what helps to calm her when she is feeling anxious. She does like music, Intervene before anxiety increases, identify potential triggers and remove. Speak in reassuring calm tone. Actively listen to resident needs as she understands her needs. Clearly communicate, address concerns and follow up with requests. Encourage resident to slow breathing to help self calm while providing support. Reduce stimulation (dim lights, reduce noise), and Review behaviors/interventions and alternate therapies attempted and their effectiveness as per facility policy. 4. Interview and record review on 8/26/26 at 2:40 p.m. with director of nursing (DON) B revealed that she was aware that residents with a physician ordered as needed antipsychotic required a physician visit every 14 days for the medication to be reordered by the physician. She was aware the physician's visits to renew the as needed antipsychotic medications for residents 4 and 43 had occurred between July and August 2026. She stated it was because of a change in mental health providers. She acknowledged that the physician visit was not required to be a mental health provider and that resident 4 and 43's primary care physician could have seen them. DON B verified that resident 10 had no progress notes in her August 2026 EMR to indicate what her behaviors were that required the administration of her as needed lorazepam or what non-pharmacological interventions were attempted before the as needed lorazepam was administered. DON B expected non-pharmacological interventions to be attempted before an as needed medication was administered and the resident's behaviors and non-pharmacological interventions were documented in a progress note within the resident's EMR. The provider did not have a policy related to psychotropic medications. 5. Interview on 8/27/26 with DON B revealed the physician was responsible to ensure physician's visits were completed every 14 days for residents who were prescribed as needed antipsychotics.

Based on observation, interview, record review, and policy review, the provider failed to ensure four of four sampled residents (6, 7, 15 and 26) were screened for a history of trauma upon their admission to the facility.Findings include:1. Interview on 8/12/25 at 9:36 a.m. with resident 6 in her room revealed: *She was dressed and sitting in her recliner with a blanket and a stuffed cat on her lap. *Her room is decorated with lots of pictures and paintings of butterflies. She stated she enjoyed painting. *She stated that sometimes she would get “really mad,” and then she’s “not the nicest girl.” *She said, “I had a father, who you wouldn't call a father, because he would come home and he would use me. He would have his fun with me, and he would laugh about it. He was a mean man. But I got over it, I don't know how.” *Later in the interview, when asked about the food at the facility, she stated, “I should eat more, I want to be strong. I want to be strong because I don't ever want anyone touching me again, that's not supposed to be.” Review of resident 6’s electronic medical record (EMR) revealed: *She had a 7/9/25 Brief Interview for Mental Status (BIMS) assessment score of 6, which indicated she had severe cognitive impairment. *She had a 6/27/22 initiated care plan intervention to “Monitor for s/s [signs/symptoms] of depression, previous history of childhood abuse/PTSD [post-traumatic stress disorder] possible symptoms. Behavioral Health and her Physician have been made aware of this past history. Give her time to talk/express any feeling. Notify her Charge Nurse if symptoms persist.” *She did not have a diagnosis of PTSD (a mental health condition that can develop after experiencing a traumatic event) or depression, and had not been screened or assessed for trauma triggers. Interview on 8/13/25 3:08 p.m. with social services manager (SSM) E revealed: *She stated, “I do the MDS, [Minimum Data Set assessment] (a tool used to evaluate a resident’s health status and to develop an individualized care plan to manage the resident’s care needs), and if I notice a resident is depressed, I let the physician’s nurse know. I believe [medical director K] makes the referral for mental health services.” *She did not have a specific assessment to have screened residents for trauma history or to have addressed trauma triggers. *She stated, “Is that something we're supposed to be doing? We are not screening every resident for trauma. Is that something that is supposed to be done on admission?” Interview on 08/13/25 3:56 p.m. with lead resident care manager (LRCM) C revealed: *Psychiatry would screen all residents who have a psychotropic medication prescribed. *She stated, “We are not screening all residents for trauma now, but we will be in the future.” *Residents who did not have a mental health diagnosis were not being screened for a history of trauma. *She stated, “Trauma-informed care has never been a part of the training curriculum here, so we had to add it, and now everyone will be getting that training.” 2. Review of resident 7's electronic medical record (EMR) and comprehensive care plan revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 5, which indicated she had severe cognitive impairment. *She had diagnoses of anxiety disorder, major depressive disorder (a mental condition characterized by a persistently depressed mood and loss of pleasure or interest in life), and Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions). *She was taking medications daily to treat her depression, anxiety, and mood. *She had a history of abuse and trauma from her ex-husband. -She was hospitalized numerous times during their marriage. *She had a difficult time adjusting to her admission into the facility and being away from her son. *There was no documentation to support that she was screened for a history of trauma upon her admission to the facility. *She had a 4/22/24 initiated care plan with no identified focus that specifically addressed her trauma. 3. Interview on 8/14/25 at 2:00 p.m. with LRCM C and medical provider J regarding resident 7 revealed: *They both confirmed the resident had a history of trauma and abuse by her ex-husband during their marriage. *Resident 7 received therapy from medical provider J every two weeks. *Resident 7 experienced delusions and hallucinations, and medication management with adjustments was necessary. *LRCM C confirmed that no trauma screening was completed upon resident 7's admission. *LRCM C and medical provider J both agreed that trauma screenings should have been completed upon admission with residents with a history of abuse or trauma. *LRCM C confirmed that there was no current process in place for screening residents for trauma history on admission. *Interview with social service manager (SSM) E was attempted on 8/14/25 at 3:06 p.m., but she was unavailable due to scheduled resident care conference meetings. 4. Observation and interview on 8/12/25 at 10:39 a.m. with resident 26 revealed: *She was lying in bed with her knees bent and the blankets pulled up over them. *She stated she had been at the facility for two weeks. *She stated she had PTSD (post-traumatic stress disorder) from the Oklahoma City bombing. *She had seen a psychiatrist, but that was 20 years ago. Record review of resident 26's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 15, which indicated her cognition was intact. *She was scheduled to see medical provider J on 8/14/25 to set up a scheduled psychiatric plan. *She had diagnoses of PTSD and hypertension (high blood pressure). *There was no documentation to support that she was screened for PTSD upon admission to the facility. *Her care plan had not mentioned her PTSD or any interventions. 5. Observation and interview on 8/12/25 at 11:20 a.m. with resident 15 revealed: *He was in his closet sorting his clothes. *He was clean-shaven and well-dressed. *He stated he had been at the facility for seven and half months. *He had PTSD and was seeing a psychiatrist at the local VA (United States Department of Veterans Affairs). Record review of resident 15 EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was a 15, which indicated his cognition was intact. *He had diagnoses of bipolar disorder (a disorder with episodes of mood swings) and PTSD. *There was no documentation to support he was screened for trauma for PTSD upon admission to the facility. *His care plan had mentioned his PTSD. Review of the provider's 2001 Trauma-Informed Care and Culturally Competent Care policy revealed: Purpose: To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident Screening: 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. 3. Screening may include information such as: a. trauma history, including type, severity and duration; b. depression, trauma-related or dissociative symptoms; c. risk for safety (self or others); d. concerns with sleep or intrusive experiences; e. behavioral, interpersonal or developmental concerns; f. historical mental health diagnosis; g. substance use; h. protective factors and resources available; and i. physical health concerns. 4. Utilize initial screening to identify the need for further assessment and care.

Based on record review and interview, the provider failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were routinely completed to evaluate for signs of adverse effects of antipsychotic medication use as a means to potentially reduce the risk for adverse outcomes for five of the five sampled residents (4, 7, 8, 22, and 31) who received antipsychotic medications.Findings included:1. Record review of resident 4's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He was diagnosed with type 2 diabetes (a condition involving disruptions in how the body regulates blood sugar), paranoid schizophrenia (a mental health disorder with symptoms of delusions and hallucinations), anxiety disorder, depression, and cognitive communication deficit. *His Brief Interview for Mental Status (BIMS) assessment score was a 15, which indicated his cognition was intact. *He was given one risperidone 0.25 milligrams (mg) tablet by mouth one time a day in the morning. Risperidone is an antipsychotic medication (a medication used to treat a variety of mental health conditions). *He was given two risperidone 0.25 mg tablets by mouth one time a day in the evening. *He was given one sertraline HCI 100 mg tablet by mouth one time a day for depression. *No documentation in his EMR indicated that an AIMS assessment had been completed. 2. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She was diagnosed with Alzheimer's disease (a progressive disease that destroys memory and other mental functions), anxiety disorder, major depressive disorder, and delirium (a sudden change in thinking that leads to confusion). *Her Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment. *She was given one olanzapine 5 milligrams (mg) tablet by mouth, an antipsychotic medication, every evening and every twelve hours as needed. *She was given one lorazepam 0.5 mg tablet by mouth, a benzodiazepine medication (a medication used to slow activity in the brain to produce a calming effect), every eight hours as needed. *No AIMS assessment had been completed. 3. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *He had a diagnosis of dementia (a group of symptoms affecting memory, thinking, and social abilities). *His BIMS assessment score was 3, which indicated he had severe cognitive impairment. *He was given one-half of a 25 mg (12.5 mg) quetiapine fumarate tablet by mouth, an antipsychotic medication, at bedtime through his gastrostomy tube (a feeding tube inserted through the abdomen into the stomach). *No AIMS assessment had been completed. 4. Review of resident 22's EMR revealed: *She was admitted on [DATE]. *She was diagnosed with vascular dementia (problems with memory, thinking, and behaviors caused by disruption of blood flow to the brain) with agitation, and depression. *Her BIMS assessment score was 3, which indicated she had severe cognitive impairment. *She was given one quetiapine fumarate 50 mg tablet by mouth at bedtime, one 25 mg tablet at bedtime, and one-half of a 25 mg tablet (12.5 mg) by mouth at noon. *She was given one fluoxetine hydrochloride 20 mg tablet by mouth, a selective serotonin reuptake inhibitor (SSRI) medication (a medication used to treat a variety of mental health conditions), once daily. *Her last AIMS assessment was completed on 9/28/23. 5. Review of resident 31's EMR revealed: *She was admitted on [DATE]. *She had a diagnosis of Alzheimer's disease. *Her BIMS assessment score was 99 because she did not answer the questions, and the staff interview was completed. -She had memory impairment and severe difficulty with daily decision-making. *She was given one-half of a quetiapine fumarate 25 mg tablet (12.5 mg) by mouth daily at noon and bedtime. *Her last AIMS assessment was completed on 3/5/24. 6. Interview on 8/13/25 at 8:30 a.m. with lead resident care manager (LRCM) C revealed: *Residents who received psychotropic medications should have had an assessment completed routinely to monitor for adverse side effects. *She stated, AIMS assessments should have been completed upon admission, quarterly, and with any significant change in status for residents. *AIMS assessments should have been completed by MDS coordinator D to assess residents for psychotropic medication side effects. *She verified that she was unable to find recently completed AIMS assessments for residents on psychotropic medications. *She stated that the facility currently had no psychotropic medication policy and was unable to provide a related policy for review. 7. Interview on 8/14/25 at 11:25 a.m. with MDS Coordinator D revealed: *She confirmed that she had not completed any resident AIMS assessments upon admission or during the Minimum Data Set (MDS) process.

Based on interview, observation, record review, and policy review, the provider failed to ensure that one of one sampled resident (3) who received dialysis (a treatment for kidney failure that removes waste and excess fluid from the blood), received services consistent with professional standards of practice by not having documented the resident's care needs and not having provided documented evidence that the resident was monitored for complications or significant changes in clinical status, including bleeding and hypotension (low blood pressure).Findings include:1. Interview on 8/12/25 at 9:16 a.m. with resident 3 in her room revealed:*She was lying in her bed, covered with a blanket.*She stated she received dialysis on Monday, Wednesday, and Friday mornings.*She was transported from the facility to receive her dialysis treatments.*On dialysis days, she had breakfast at the facility and was provided with a sack lunch to take with her to dialysis.*The staff would sometimes check her vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) when she returned after dialysis.*She stated, You have to be patient when you ask for help. You usually have to wait a long time. 2. Interview on 8/13/25 at 11:33 a.m. with certified medication aide (CMA) H about the process followed when resident 3 returned from dialysis revealed:*There was no formal process to follow when a resident returned from dialysis.*There was no post-dialysis assessment completed for resident 3 when she returned to the facility after dialysis.*It was up to resident 3 to decide what happened when she returned from dialysis. If she wanted to stay up after dialysis, they would help her into her chair, and if she preferred to lie down, they would assist her into her bed. 3. Interview on 8/13/25 at 11:38 a.m. with registered nurse (RN) I about the process followed when resident 3 returned from dialysis revealed:* She usually tells us what she wants to do when she gets back.*Resident 3 usually said she was hungry and wanted to eat her sack lunch when she returned.*There was no formal process for assessment or documentation of clinical status after dialysis. 4. Interview on 8/13/25 at 4:31 p.m. with lead resident care manager (LRCM) C about the process revealed:*The dialysis center would send a communication form back to the facility with resident 3.*She would expect the staff to be checking resident 3's vital signs and looking at the dressing over her port (a type of dialysis access surgically placed under the skin that allows for repeated needle access for dialysis treatments) to make sure the dressing was clean, dry, and intact.*She stated that it depends on what she [resident 3] wants. If she wants to go straight to the dining room, it may be later that day, after we get her back to her room and in bed before vital signs are checked.*She confirmed that without checking resident 3's vital signs and dressing after dialysis, it would be difficult to monitor for changes in her clinical status.*She stated there was room for improvement with that process. 5. Review of resident 3's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a 5/23/25 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated her cognition was intact.*She had a 9/9/24 initiated care plan goal of The resident will have immediate intervention should any s/sx [signs/symptoms] of complications from dialysis occur through the review date.*The 9/9/24 care plan interventions associated with that goal included:-Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis three times a week; Monday, Wednesday, and Friday.-Monitor/document/report PRN [as needed] any s/sx of infection to access site: Redness, Swelling, warmth or drainage.-Work with resident to relieve discomfort for side effects of the disease and treatment.*Resident 3's blood pressure and heart rate documentation from January through July of 2025 indicated:-In January, her blood pressure and heart rate were documented once, on 1/25/25.-In February, her blood pressure and heart rate were documented on 2/14, 2/15, 2/16, and 2/28.-In March, her blood pressure and heart rate were documented on 3/8, 3/14, and 3/22.-In April, her blood pressure and heart rate were documented on 4/2, 4/5, and 4/19.-In May, her blood pressure and heart rate were documented on 5/3, 5/4, 5/17, 5/18, 5/19, 5/24, and 5/31.-In June, her blood pressure and heart rate were documented on 6/7, 6/14, and 6/21.--There were only twenty-one days from January through July 2025 that had a blood pressure and heart rate documented.---Only 5 of those twenty-one days were scheduled dialysis days. 6. Interview on 8/14/25 at 12:48 p.m. with chief nursing officer (CNO) B revealed:*They had just identified that they needed a post-dialysis assessment tool or form to clarify the expectations for vital sign monitoring and assessment of residents who received dialysis.*Staff had not received any dialysis-specific training.*She confirmed that without assessing a resident after dialysis, it would be difficult to monitor for changes in clinical status. 7. Review of the provider's 2001 End-Stage Renal Disease, Care of a Resident with policy revealed:*Policy Statement-Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.*Policy Interpretation and Implementation-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.-Education and training of staff includes, specifically:--the nature and clinical management of ESRD (including infection prevention and nutritional needs);--the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis;--signs and symptoms of worsening condition and/or complications of ESRD;--how to recognize and intervene in medical emergencies such as hemorrhages and septic infections;--timing and administration of medications, particularly those before and after dialysis;- The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.

Based on observation, record review, South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and policy review, the provider failed to identify and implement interventions to prevent one of one sampled resident (2) from having been burned by a baseboard heater. Findings include: 1. Observation on 6/25/25 at 11:15 a.m. of the lounge area next to the nurses' station revealed: *An open area with large windows that extended from the ceiling to close to the floor. *Beneath the bottom of the windows were two separate metal baseboard heating units. They were cool to the touch. -There were temperature control knobs for each unit that were accessible and able to be adjusted by turning the knobs. -Stickers on the top of each of those heating units read: Caution: High Temperature. Review of resident 2's electronic medical record (EMR) revealed: *Her admission date was 3/25/25 and her primary diagnoses included pain related to malignant colon cancer, diabetes, and heart disease. *Her 3/31/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. *A 6/12/25 nurse progress note: Resident complained of right hand pain. This writer approached resident and hand was red and swollen, outer layer of skin was flushed. I asked resident why she got so close to the baseboard heater, she replied that her hand was cold. -The medical provider was notified of the incident and recommended a cold pack be applied to the affected area for ten minutes on then ten minutes off and the resident's hand was to remain elevated for eight hours. *Resident 2 was transferred to the attached emergency department during the early morning hours of 6/13/25 for a medical condition unrelated to the burn. She has discharged from the facility on 6/17/25. Interview on 6/25/25 at 11:30 a.m. with certified nurse aide (CNA) E regarding resident 2 revealed: *The resident was always cold. -She often sat in front of the windows by the baseboard heaters in the lounge area next to the nurses' station to warm up. *The resident was able to move her wheelchair independently to and from that area. *CNA E had not known of any other instances of the resident having been burned by the baseboard heaters except for the 6/12/25 incident. *Resident 4 sat in his wheelchair and resident 5 sat in a recliner in that same area on a regular basis. -CNA E had not known of any instances of them or other residents having been burned by the baseboard heaters. Interview on 6/25/25 at 12:45 p.m. with director of environment services (EVS) C revealed: *There was a primary heat source for the lounge area next to the nurses' station. The baseboard heaters in that lounge were able to supplement the primary heat source if that was needed. *There was unrestricted access to the temperature control knobs on the baseboard heaters to have turned them on and adjusted the temperature. *He had not known until after the 6/12/25 incident how hot the metal around those baseboard heaters was capable of reaching after they were turned on. -Using an infrared heat gun with the temperature knob turned to 50%, the temperature of the metal on the baseboard heater had reached 100-115 degrees Fahrenheit (F). With the knob turned to 75%, the temperature of that metal had reached 130 degrees F. --Temperatures above 120 degrees F were capable of causing burns. *The baseboard heater units should have been, but had not been identified as an accident hazard prior to the 6/12/25 incident for resident 2. Telephone interview on 6/25/25 at 1:40 p.m. with licensed practical nurse (LPN) D regarding resident 2 revealed: *The resident often sat in her wheelchair in front of the large windows in the lounge area next to the nurses' station because there were baseboard heaters beneath those windows. She regularly had stated that she was cold. *On the evening of 6/12/25, LPN D said the resident sat in the above location after dinner until 8:30 p.m. She was awake and alert. -LPN D had observed the resident leaning forward in her wheelchair during that time, but had thought nothing of it. *At 8:30 p.m. the resident reported to LPN D that her hand hurt. She had been warming her hands up on the baseboard heater. *LPN D observed the resident's hand and found it was red and swollen. *He had not known: -The baseboards had posed a burn hazard to someone who had been in close proximity to them. -The heaters had accessible knobs that regulated the temperature. -If resident 2 or any other resident had ever been burned by those baseboard heaters prior to the 6/12/25 incident. Interview on 6/25/25 at 2:00 p.m. with lead resident care manager (CM) B revealed: *In the year that she had been employed by the facility, the baseboard heaters had not been used in the above lounge area. -Nothing had been done proactively to identify or prevent an accident from having occurred related to those heaters because the [baseboard] heaters had never been an issue [before 6/12/25]. *When she felt the baseboard heaters the morning of 6/13/25, they were still warm. She had notified Director of EVS C and the breakers to those baseboard heaters were turned off and remain off to prevent further incidents from occurring. On 6/25/25 at 3:15 p.m. an Accident Prevention and Resident Safety policy was requested from lead resident CM B. At 4:45 p.m. Chief Nursing Officer A and lead resident CM B provided an Accident and Incidents Investigating and Reporting policy. The provider did have the policy that had been requested.

Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the provider failed to protect the resident's right to be free from verbal abuse by one of one cook (J) during the supper meal for one of one sampled resident (3). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 5/8/25 SD DOH FRI revealed: *During the supper meal on 5/8/25, resident 3 was seated at her table in the dining room using her tablet when she noticed cook J looking at her. She asked what, and cook J responded in a tone and attitude resident 3 found inappropriate. Resident 3 expressed that she would not eat due to his attitude. *Cook J then used vulgar language and told her to starve. *Resident 3 left the dining room table and had seen certified nursing assistant (CNA) G and told her what had happened. CNA G reported it to licensed practical nurse (LPN) D. *LPN D spoke with cook J, who denied directing vulgar language specifically at resident 3 but admitted to using vulgar language. LPN D then informed the lead resident care manager (CM) B about the incident. *CM B notified the director of environmental services (EVS) C, who was cook J's supervisor and he responded by terminating cook J's employment and escorted him from the facility on 5/8/25. EVS C also apologized to resident 3 and informed her that cook J was no longer employed at the facility. *Following the incident, dietary supervisor F initiated education with all dietary staff on verbal abuse towards residents. 2. Review of resident 3's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. 3. Interview on 6/26/25 at 11:06 a.m. with resident 3 revealed: *She reported that while she was seated at the table during supper, using her tablet, she believed her tablemates were ordering. *Upon looking up, she noticed cook J was looking at her. She asked what and stated that cook J responded with an inappropriate tone and attitude, she expressed she did not like his attitude, he then used vulgar language and told her to starve. *Following the incident, she left the table and informed CNA G about the incident with cook J. *She expressed to staff that she did not want to eat any food prepared by cook J. Staff went downtown and had gotten a chicken salad for her for supper. *She indicated this was not the first time cook J had used an inappropriate tone with her. 4. Interview on 6/26/25 at 1:30 p.m. with CNA G regarding the 5/8/25 FRI for resident 3 revealed: *Resident 3 had informed her of the incident with cook J right after it happened. *CNA G had offered to get resident 3 a room tray for supper that evening, but the resident declined. *Resident 3 requested CNA G not to report the incident, but CNA G knew that was verbal abuse by cook J and she needed to report the incident. *CNA G reported it to LPN D, charge nurse on duty that night. 5. Phone interview on 6/26/25 at 1:39 p.m. with LPN D regarding the 5/8/25 FRI for resident 3 revealed: *He had been informed about the incident of cook J towards resident 3 by CNA G. *He initially went to visit with resident 3, but she was upset, he chose instead to speak with cook J. *Cook J admitted to using vulgar language that evening but denied directing any directly at resident 3. *Later that evening, LPN D spoke with resident 3 who reported that cook J had used an inappropriate tone and language toward her and told her to starve. 6. Interview on 6/26/25 at 1:58 p.m. with director of EVS C regarding the 5/8/25 FRI for resident 3 revealed: *He had received a call from CM B informing him of the incident involving cook J. *He entered the facility through the kitchen's backdoor, approached cook J, and informed him that his employment was terminated. [NAME] J was then escorted out of the building. *Upon exiting the building, cook J directed vulgar language toward director of EVS C. *Following the incident, EVS C apologized to resident 3 and informed her that cook J was no longer employed at the facility. 7. Interview on 6/26/25 at 2:09 p.m. with dietary supervisor F regarding the 5/8/25 FRI for resident 3 revealed: *He completed the education that included how to talk to residents for the all dietary staff on 5/13/25. *He continued to visually monitor staff interactions with residents to ensure appropriate conduct. *He was bringing all relevant information to the QAPI (Quality Assurance and Performance Improvement) meetings. *Prior to the incident with resident 3 cook J had received multiple write-ups for other violations including smoking on the premises, inappropriate behavior toward staff and management, and call-ins. 8. Review of cook J's personnel file revealed: *His pre-employment background checks identified no areas of concern. *He had received abuse and neglect, patient rights, and service excellence trainings on 12/11/24. *On 2/23/25 he received a written warning for smoking on campus. *On 4/3/25 he received a written warning for not being courteous to another caregiver or the supervisor/manager. *On 4/17/25 he received a final warning for refusal to follow the policy for call-ins. *On 4/21/25 no warning but a write-up for refusal to follow directions from management. *On 5/8/25 was his last day of employment. 9. Interview on 6/26/25 on 3:30 p.m. with CM B regarding the 5/8/25 FRI for resident 3 revealed: *She had received a call from LPN D that evening informing her of the incident with cook J. *She contacted director of EVS C, who stated he would address the situation. *Director of EVS C later called back to inform her that cook J's employment had been terminated and that he had been escorted out of the facility. *CM B stated LPN D completed an internal incident report, which was used for safety and QAPI meetings. *She conducted an all-staff meeting on 5/14/25, which included education on recognizing and reporting all forms of abuse. The provider implemented actions to ensure the deficient practice does not recur was confirmed after record reviews and interviews revealed the facility had followed their quality assurance process, education was provided to all staff regarding recognizing and reporting abuse. Dietary staff education was provided on how to speak to residents, 10 strategies for communication with nursing home residents, and professional conduct. Monitoring of staff interactions with residents to ensure appropriate conduct. Observation and interviews revealed staff understood the education provided. Based on the above information, non-compliance at F600 was determined on 5/8/25, and the provider's implemented 5/14/25 corrective actions for the deficient practice confirmed on 6/25/25, the non-compliance is considered past non-compliance.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Proper hand hygiene, glove use, containment of soiled linen, and disinfection of a mechanical lift, by two of two staff (M and N) during one of one sampled resident's (46) mechanical lift transfer and personal hygiene care. *Proper hand hygiene, glove use, containment of soiled linen, and suprapubic catheter (connected through the abdomen to the bladder) care by one of one medication aide (Q) during one of two sampled resident's (1) catheter care observations. *Proper hand hygiene and glove use by two of two dietary aides (O and W) while assisting two of two residents (8 and 11) during two of three dining room observations. *Oxygen tubing was changed according to facility policy for two of four (43 and 51) sampled oxygen-dependent residents. *Cleaning and sanitization of five of six multi-use facility recliners and one of one couch located in the memory care unit. Findings include: 1. Observation on 7/23/24 at 10:29 a.m. with nurse aide (NA) M and certified nurse aide (CNA) N during a mechanical lift transfer and personal hygiene care of resident 46 revealed: *A multi-resident use mechanical lift was removed from the hallway and brought into resident 46's room. *NA M and CNA N sanitized their hands, applied clean gloves, and transferred resident 46 onto her bed using a sling attached to the mechanical lift. -Her open-backed skirt was partially wet with urine, was removed by NA M and placed directly onto the floor. *CNA N removed the resident's urine-soaked incontinence brief and cleansed the resident's genital and rectal areas. -Using those same gloved hands, he applied a barrier cream to the resident's rectal area first and then her genital skin folds. *NA M removed his gloves and without cleansing his hands he: -Opened the resident's closet door and obtained a clean incontinence brief and clothing. -Applied a clean pair of gloves and assisted CNA N while they applied the resident's incontinence brief and clothing. -Removed the trash and placed her soiled clothing in a plastic bag for transport. *They both removed their gloves and without cleansing their hands they: -Adjusted her bed linens. -Touched the bed's remote and adjusted the bed height. -Moved the overbed table closer to her bed and placed her drink cups within her reach. -Opened the hallway door, removed the mechanical lift from the room, and placed it in the hallway. *They then sanitized their hands in the hallway, but had not sanitized the mechanical lift. Interview on 7/23/24 at 10:50 a.m. with NA M and CNA N regarding resident 46's personal hygiene, hand sanitization, glove use, and mechanical lift cleaning revealed: *CNA N stated he was a contract CNA and had been working for the provider for about three months. -Stated he was trained by other staff while working on the floor. -Verified he had some new hire orientation but was unable to recall what it was. *NA M stated he was taught hand hygiene and glove use during his new hire orientation. *They both stated hand hygiene and glove use should have been performed before and after resident care. -Neither one had identified hand hygiene and glove use when going from a dirty task to a clean task. *NA M identified he had placed the resident's soiled linen directly on the floor and stated he was, Sorry about that. -He stated he thought the mechanical lift should have been sanitized after each resident use, but was not sure if that was what they were supposed to do. 2. Observation on 7/24/24 at 2:10 p.m. of medication aide (MA) Q during resident 1's suprapubic (SP) urinary catheter care revealed: *Resident 1 was on enhanced barrier precautions due to having an indwelling SP urinary catheter. *MA Q stated the resident had a bowel movement and had requested to be cleaned up before the surveyor's entrance into the room. -The soiled bed linens were folded and lying directly on the floor next to the bed. *MA Q sanitized her hands and applied a disposable plastic gown and clean gloves. -She removed a split gauze dressing that was located around the SP tubing insertion site on the resident's lower abdomen. -She cleansed the skin and catheter tubing around the insertion site with a specialized disposable wipe made for that purpose. *With those same gloved hands, she: -Opened a cabinet door, removed a clean split gauze dressing package, opened it, and applied the gauze dressing to the catheter tubing insertion site. -Adjusted the resident's dressing gown over the site and pulled up the bed linens to cover the resident. -Retrieved a urinal from the bathroom, opened the catheter bag's drainage port, and drained the urine into the urinal. -Returned the drainage port into a plastic holder on the catheter's drainage bag without having cleansed the drainage port. -Emptied the urinal's contents into the toilet, then turned on the sink's faucet handle and rinsed the urinal with water, and again dumped the urinal contents into the toilet. -Flushed the toilet. *She removed her gown and gloves then touched that same faucet handle to wash her hands. *With ungloved hands she: -Removed the soiled linen off the floor and placed it into a plastic transport bag. -Removed the resident's garbage bag for transport. -Opened the resident's hallway door and carried those items to a soiled linen closet located in the hallway. Interview on 7/24/24 at 2:20 p.m. with MA Q regarding the above observation of resident 1's SP catheter care revealed: *She identified she had not cleansed the catheter bag's drainage port after emptying the urine into the urinal stating, I missed that. *She was not aware she had missed the following hand hygiene and glove use opportunities: -When she moved from a dirty task to a clean task during the resident's SP catheter dressing change. -When she touched the resident's clothing cabinet, clean dressings, SP tubing, clothing, bed linens, faucet handle, and toilet handle with soiled gloves. -When she placed soiled linens directly onto the floor and when she handled those soiled linens without wearing gloves. -When she opened the hallway door without sanitizing her hands after she handled the soiled linens. Review of the provider's 2009 Cleaning and Disinfection of Resident-Care items and Equipment revealed: *3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. *4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Review of the provider's 2010 Catheter Care, Urinary, policy revealed: *Infection control. -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. *The policy had not addressed the step-by-step procedure for routine emptying of the urine collection bag, SP catheter care, disinfection of the drainage port, or hand hygiene and glove use protocols during routine catheter care. Review of the provider's undated Hand Hygiene policy revealed: *Procedure -1. All employees will perform hand hygiene before: b. Administering patient care. -2. All employees will perform hand hygiene after: a. Toileting self or assisting patients. b. Handling body secretions. c. Giving care to patient or handling equipment. d. Removing gloves. -3. b. Gloves will be changed after each patient/resident encounter. *The policy had not addressed hand hygiene and glove use when moving from a dirty procedure to a clean procedure when providing resident care. 47416 3. Observation on 7/22/24 at 5:15 p.m. of certified nursing assistant (CNA) O during the dinner meal revealed she: *Removed a glove from her right pants pocket. *Put that same glove on without sanitizing her hands. *Wiped her face with the back of her gloved hand. *Then wiped her face, wiped resident 11's mouth, touched another resident's straw, moved her hair behind her ear, and assisted resident 8 with eating, all with the same gloved hand. Observation on 7/23/24 at 12:10 p.m. of CNA W during the noon meal revealed she: *Had gloves on, removed them and started to feed residents. *Did not sanitize her hands and touched resident utensils. *Touched resident 8's hand with her unclean. Resident 8 then put her hand in her mouth. Review of the provider's undated Hand Hygiene policy revealed: *2. All employees will perform hand hygiene after: d. Removing gloves. *3. All employees providing direct patient care will: a. Use gloves since gloves reduce hand contamination by 70-80%, prevents cross contamination and protects, patients/residents and staff from infection. 4. Observation and interview on 7/23/24 at 8:56 a.m. to 7/25/24 at 8:21 a.m. with resident 51 in her room revealed: *She was on oxygen therapy and used a nasal cannula (tubing that delivers oxygen into the nose). *She did not know when it was last replaced. *Tape was applied to the nasal cannula (NC) tubing and had the date 7/01/24 written on it. Observation and interview on 7/23/24 at 9:29 a.m. with resident 43 in his room revealed: *He was on oxygen therapy and used NC tubing. *The NC tubing had a piece of tape with the date 6/2/24 written on it. *He did not know when it was last replaced. Record review of both resident 43's and resident 51's revealed, there was no documentation of when the nasal cannula had been replaced. Interview on 7/24/24 at 4:55 p.m. with licensed practical nurse (LPN) K regarding NC tubing replacement revealed: *The NC tubing were replaced monthly and documented in the treatment administration record (TAR). *She was not able to find documentation in the TAR for NC tubing replacements for resident 43 or resident 51 nor able to produce the policy for NC tubing replacement. Interview on 7/25/24 at 8:33 a.m. with LPN L revealed she: *Thought that NC tubing replacements were documented in the TAR. *Was not able to find any documentation of NC tubing replacement for residents 43 or 51. Interview on 7/25/24 at 9:46 a.m. with LPN H revealed he: *Placed the tape on resident 8's nasal cannula with the date 7/1/24. *Assumed the tubing was replaced at the beginning of the month but was not certain. *Said the changes were notated in the TAR. *Was not able to find documentation for the nasal cannula changes for either of the above residents. *Was not able to produce a policy for when nasal cannula or oxygen tubing was to be changed. Interview on 7/25/24 at 11:59 a.m. with RN/ infection control coordinator U revealed she: *Was not sure when nasal cannulas or oxygen tubing was to be changed. *Did not know about any policy involving tubing changes. *Said that staff should not touch their face or hair prior to resident cares. *Said staff are trained annually on proper hand hygiene. Interview on 7/25/24 at 2:01 p.m. with assistant director of nursing (ADON)/ resident care manager (RMC) C revealed: *Her expectations were that staff would conduct proper hand hygiene and change oxygen tubing in accordance with the facility policy. *She said that nasal cannula tubing was to be changed at the beginning of the month. Interview on 7/25/24 at 10:59 a.m. with administrator A revealed: *Oxygen tubing was to be changed at the beginning of the month. *He could not find the facility policy for oxygen tube changing. Review of the provider's February 2006 Nasal Cannula in Audit provided by administrator A revealed: *He provided a copy of the adjacent hospital's nasal cannula audit. *Infection Control: - Nasal Cannulas should be changed every 14 days or if visibly soiled. 47780 5. Observation on 7/22/24 at 4:30 p.m. in the memory care unit revealed: *Two of the three recliners had dark brown discoloration on the headrest and the armrest. *One of those recliners had a worn-down discolored spot on the headrest and was worn-down along the seams at the armrests. *Two high-back chairs had multiple spots on the seat and the back cushions of the chairs. *One of one couch had multiple unidentified light brown stains on the armrest and down the front of the armrest and multiple light brown spots on the seat and back cushions. Interview on 7/25/24 at 9:30 a.m. with the environment service supervisor G revealed: *He had been the manager for nine years. *The housekeepers have a cleaning checklist that they completed daily. *The housekeepers should have done a deep clean immediately when they saw the stains on the chairs and couch. *He would have expected the housekeepers to have notified him that one of the recliners had a worn-down discolored spot on the headrest and was worn-down along the seams at the armrests. -He would have discarded that recliner immediately. A review of the provider's housekeeping daily cleaning checklist revealed: *They wiped down the chairs in the day room daily. *There was no mention of cleaning the couch in the day room. *There was no mention of deep cleaning the chairs or the couch in the day room. An undated Standard Precautions Policy revealed: F. Environmental Control 1. See Environmental cleaning procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces, and manager is to ensure that these procedures are being followed. Interview on 7/25/24 at 4:30 p.m. with RN/infection control coordinator U about hand hygiene and glove use revealed she: *Had been doing monthly audits. *Had identified hand hygiene was an issue. *Had opened a performance improvement project (PIP) for hand hygiene as a priority and planned to have opened a glove use PIP.

Based on South Dakota Department of Health (SD DOH) complaint report review, interview, record review, and policy review, the provider failed to ensure prompt identification of loss or potential diversion of controlled (high risk for addiction and dependence) medications and prompt identification of medication errors. Failure to accurately monitor controlled medications and medication errors may have placed the residents at increased risk of adverse effects of not receiving medications as ordered, such as increased pain. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the identification of the incident. Findings include: 1. Review of the 6/27/24 SD DOH complaint report revealed: *Resident 1 had not received her Fentanyl (a controlled medication for severe pain) medication as ordered by her physician. -She was supposed to have received a new Fentanyl topical patch every 72 hours (3 days). -She had a new patch applied on 6/8/24 and it had not been replaced until 6/21/24. Four applications were missed over thirteen days. -She had increased pain and migraine headaches during that time. 2. Interview on 7/23/24 at 9:23 a.m. with resident 1 revealed: *She confirmed the above medication error had occurred and stated she had suffered from increased pain and migraine headaches because of the medication error of not receiving that medication. *She stated while a nurse was speaking to her about the medication error, an aide was also in her room and informed her there was another resident (15) who had the same problem with her Fentanyl patches. -She stated the nurse had told the aide to be quiet and leave the room. She was unable to recall the aide's name. -She stated resident 15 had dementia and was unable to communicate her needs and she was worried about medication errors happening to other residents who were unable to defend themselves. 3. Review of the provider's January through July 2024 medication error tracking log revealed: *There were 100 medication errors with approximately 60 of those errors related to controlled medications including oxycodone, Tramadol, morphine, Percocet, hydrocodone, Fentanyl (all pain relievers), and Ativan (antianxiety medication). -The Summary of occurrence area of the tracking log showed many of those errors were identified as Pulled med but not documented on Mar. -The number of medication errors had decreased in July of 2024 with only five documented errors. 4. Interview on 7/25/24 at 9:00 a.m. with assistant director of nursing (ADON)/resident care manager (RCM) C revealed: *The pharmacy tracked the medication errors, and she received their Omnicell (an automated medication dispensing machine) medication error summary reports weekly. -She reviewed every medication error report and tracked them for any trends. -She provided staff reminders in stand-up meetings about medication documentation and accuracy. *She identified one medication aide (MA) as having numerous medication errors. That MA was placed on a performance improvement plan (PIP) and was closely monitored. 5. Interview on 7/25/24 at 9:40 a.m. with medication aide (MA) Y revealed: *All scheduled and as-needed (PRN) controlled medications are retrieved individually from the Omnicell at the time of administration. -There were no controlled substances kept in the medication carts. *Both the nurses and the medication aides had access to the Omnicell to remove controlled medications. 6. Interview on 7/25/24 at 10:30 a.m. with pharmacist F regarding the above findings revealed: *He was aware of the facility's medication errors because he wrote the medication error reports. *He felt many of those errors were documentation errors and not actual medication errors. *He stated he used to only write up error reports on actual medication errors (i.e. wrong med, wrong dose, wrong patient) but within the last month he wrote medication error reports on all the Omnicell discrepancies, including missed documentation, so the discrepancies could be tracked and monitored for diversion more closely. *He stated he provided those reports to the nurse supervisors, and they would have decided what actions were to be taken with the staff. -He stated, We are now tracking every narcotic medication error and writing up each one. -He identified narcotics (medications for severe pain) retrieved for hospice patients were the medications most frequently not documented on the MARs and he felt the immediate need of the patient likely caused a delay in or absence of documentation. *The pharmacy had increased the monitoring of medication errors from monthly to weekly and included nursing administration, quality assurance, and the safety team, in all reports. *He stated the quality assurance and safety team had been discussing the re-implementation of a medication error committee for increased focus on medication and documentation errors. 7. Review of the provider's 2/7/12 Medication Error Prevention Plan policy revealed: *3. All medication errors will be reported to the quality assurance, process improvement team for recommendation. *4. Disciplinary Action may occur after 3 consecutive medication errors in 3 months and/or after any significant medication error. LTC management may decide to implement a Performance Improvement Plan prior to disciplinary actions being taken. The provider's implemented systemic changes to ensure the deficient practice does not reoccur was confirmed on 7/25/24 after record review revealed the facility had followed their quality assurance process, followed their policy, provided staff education, and implemented a PIP. Interviews revealed changes had recently occurred that included increased monitoring and of medication documentation and medication errors. Based on the above information, non-compliance at F755 occurred on 6/11/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/25/24, the non-compliance is considered past non-compliance.

Based on observation, interview, and record review, the provider failed to ensure two of two sampled residents (11 and 27) who received a specialized diet were served the correct portion sizes and nutritional values for one of three observed meal services. Findings include: 1. Observation on 7/23/24 from 11:45 a.m. through 12:35 p.m. of the memory care unit lunch meal revealed: *The menu for lunch that day consisted of spaghetti, a lettuce salad, and bread with an alternate meal of chicken and rice soup. *Residents 11 and 27 were served an approximate one-half cup round scoop of ground spaghetti centered in the middle of their plate. -No other food items were served with their meal. *Administrator A was present in the dining room and an unidentified aide notified him of their meal portions. -Resident 27's husband was visiting during the meal and administrator A offered more food items to which the husband responded he would wait and see if she ate the spaghetti first. -Resident 27 ate the spaghetti and a prepackaged cup of pudding the husband had offered. *Resident 11 showed little interest in eating her spaghetti. *By the end of the lunch meal, no further offers of food items were made to resident 11 or 27. Interview on 7/23/24 at 11:50 a.m. with resident 27's husband while he sat with her in the memory care dining room revealed: *He stated his wife had lost nearly 60 pounds since she had been sick with COVID-19 and her dementia had worsened. -He stated because of her weight loss and dementia her dentures no longer fit correctly, and she would have refused to wear her dentures even when they did fit. -He stated his wife liked eating soup, but it was rarely offered to her. -He stated she was able to eat soft foods without difficulty and had not understood why they gave her pureed food as she did not like it. Interview on 7/23/24 at 5:00 p.m. with registered dietitian (RD) D and administrator A regarding the above observed meal service revealed: *RD D stated she worked for the provider as a consultant. *RD D agreed the meal served to residents 11 and 27 was not visually palatable, accurate in portion size, or nutritionally balanced. *Administrator A agreed the full nutritional menu was not served to those residents. -He stated dietary cook R was hired within the last 90 days and he expected the dietary manager (DM E) to have ensured cook R had been educated on serving sizes and specialized diets. -He stated that DM E was newly hired around the same time as cook R and he (DM E) was working on obtaining his dietary manager's certificate. *Their expectation was for all the food groups listed on the menu, or a nutritionally equal substitute, was to have been served in the correct portion sizes. *They both confirmed they had not observed a meal service to ensure the meals were proportioned correctly and served appropriately. Interview on 7/24/24 at 1:30 p.m. with DM E revealed: *He stated he was hired as a cook in January of 2024 and became the DM around March of 2024. -He stated he had not worked as a DM in a long-term care facility before this employment and he was currently working on his dietary manager's certificate. *He stated the past DM had resigned in March of 2024 and the DM training he received from her was slim to none and lasted about four days in total. -She had shown him how to order supplies, complete the Minimum Data Set (MDS), and fill out the dietary staff schedules. -He stated he had no training on specialized diets, portion sizes, or the required education he needed to provide to his dietary staff. *He thought dietary cook R had been trained by dietary cook S on specialized diets and portion sizes. Interview on 7/24/24 at 2:30 p.m. with dietary cook S revealed she: *Had worked as a cook for about one and a half years. -Had been trained on serving sizes by dietary cook T and had not received any formal training from a DM or a dietitian. *Stated she had trained cook R for nearly two weeks and had provided her with some training on plate presentation, serving sizes, recording temperatures, and specialized diets. *Was unable to identify the portion sizes for ground or pureed foods and stated she usually filled up a bowl until it would look like a four-ounce portion. -Stated there were no guides on portion sizes for specialized diets located in the kitchen. *Stated, Some people don't eat as much so we give smaller portions to them. -Was not aware if the dietitian had been notified of this practice. *Stated, We need more education on this (portion sizes). Interview on 7/24/24 at 2:40 p.m. with RD D regarding the above dietary staff interviews revealed: *She stated she was not aware the current DM and cooks had not been properly trained on portion sizes or dietary types and was not aware there were no serving guides available to staff. *She was not aware the cooks were serving smaller portions to those who did not eat well and had initiated a review of each resident's diet and food consistency orders. -She stated the only time residents should have been served smaller portions was if they had a specific order for smaller portions. *She agreed there was a need for further food service monitoring and dietary staff education. Review of resident 11's medical record revealed: *She received Hospice services and had a diagnosis of a major neurocognitive disorder due to Parkinson's disease with behavioral disturbance. -She had a brief interview for mental status (BIMS) of 99, which indicated she was severely cognitively impaired and was unable to participate in the assessment. *Her diet order was for an NDD3 (National Dysphagia Diet level 3) texture that omitted dry, hard, crispy foods. *She was to receive an Ensure nutritional supplement drink three times a day. *On 01/23/2024, the resident weighed 117 lbs. On 07/20/2024, the resident weighed 95.5 pounds which was an -18.38 % weight loss. -A decrease of 10% or greater in 180 days was considered a significant weight loss. Review of resident 27's medical record revealed: *She was diagnosed with a major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance, anxiety, depression, and hallucinations. *She had a BIMS of 04, which indicated she had a severe cognitive impairment. *Her diet order was for a regular diet as tolerated with mechanical texture, regular consistency, gravy on meat, pureed vegetables, and finger foods. -She also had an order for a nutritional supplement drink three times a day. *On 01/22/2024, the resident weighed 134 lbs. On 07/22/2024, the resident weighed 116 pounds which was an -13.43 % weight loss. -A decrease of 10% or greater in 180 days was considered a significant weight loss. Review of the provider's 2012 Weight Assessment and Intervention policy revealed: *The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. -2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss. For example: f. Increased need for calories and/or protein; i. Inadequate availability of food or fluids. Review of the provider's initial hire and annual dietary training revealed DM E, cook S, and cook R, had not received training on the following topics: Food Safety, Serving/Distribution, Leftovers, Time/Temp Controls, Nutrition/Hydration, and Sanitation.

Based on South Dakota Department of Health (SD DOH) complaints report review, interview, and record review, the provider failed to correctly administer narcotic (pain relieving) medications as ordered for two of two sampled residents (1 and 15). Failure to administer narcotic medications as ordered may have contributed to residents 1 and 15 having increased pain, discomfort, and side-effects of narcotic withdrawal. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the discovery of the medication errors. Findings include: 1. Review of the two 6/27/24 SD DOH complaint reports revealed: *Resident 1 had not received her Fentanyl (a controlled medication for severe pain) medication as ordered by her physician. -She was supposed to have received a new Fentanyl topical patch every 72 hours (3 days). *Her Fentanyl patch was applied on 6/8/24. -It had not been replaced from 6/8/24 through 6/21/24. *She did not receive four doses. -She had increased pain and migraine headaches during that time. *She had called a friend and was reported to have been crying because of her increased pain and migraine headaches. 2. Interview on 7/23/24 at 9:23 a.m. with resident 1 revealed: *She was receiving hospice care for end-stage kidney failure. *She stated, I started having pain and looked at the calendar and found out it (Fentanyl patch) hadn't been changed in several weeks. It was supposed to be changed every three days. -She stated she had increased back pain and severe migraine headaches during that time. -She stated, It was a doozy for a few days. It was a hell of a migraine. *She stated a hospice nurse told her the Fentanyl patch medication was prescribed correctly to indicate it would be replaced every 72 hours (three days), but the pharmacy had changed it to be replaced every 72 days. *She stated that while a nurse was speaking to her about the medication error, an aide was also in her room and informed her there was another resident (15) who had the same problem with her Fentanyl patches. -She stated resident 15 had dementia and was unable to communicate her needs and she was worried about medication errors happening to other residents who were unable to defend themselves. 3. Review of resident 1's electronic medical record (EMR) and June 2024 medication administration record (MAR) revealed: *She had received hospice services that had begun in April of 2024 for stage 5 renal failure. *She had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. *She had an order for: Fentanyl Transdermal Patch 25 mcg/hr [micrograms per hour]. Apply 1 patch every three days. Remove patch after 72 hours (3 days) and fold in half and dispose of according to facility procedures. -Her MAR indicated the Fentanyl order had been changed on 6/8/24 to Apply one patch transdermally one time a day every 72 days. *She had a new patch applied on 6/8/24 and it had not been replaced until 6/21/24. Four applications were missed over thirteen days. 4. Review of resident 15's EMR and May 2024 MAR revealed: *She was on hospice care for terminal breast cancer. *She had a BIMS score of 4, which indicated she had severe cognitive impairment and was non-interviewable. *She had an order for: Fentanyl Transdermal Patch 25 mcg/hr. Apply 1 patch transdermally one time a day every 72 hours. -Her May 2024 MAR indicated the Fentanyl order had been changed on 5/9/24 to state Apply one patch transdermally one time a day every 72 days. -She had a new patch applied on 5/9/24 and it had not been replaced until 5/16/24, missing two applications over seven days. 5. Interview on 7/23/24 at 3:24 p.m. with licensed practical nurse (LPN) H and LPN I revealed: *The pharmacy entered medication orders into the EMR's MAR in Point Click Care (PCC). -If the pharmacy was closed, the nurse would have entered the order into PCC and the order would have been verified by the night nurse. 6. Interview on 7/25/24 at 9:00 a.m. with assistant director of nursing (ADON)/resident care manager C revealed: *The Fentanyl orders had been entered into PCC incorrectly and indicated staff were to have applied a patch every 72 days and not every 72 hours as prescribed. The MARs on the computer only showed what was to be given each day, according to what had been entered into PCC, so those Fentanyl orders had not appeared on the daily MAR screen to be given and were missed. *She stated that when the Fentanyl medication errors had been identified, pharmacist F implemented two secondary order verification systems. -All medication orders were verified by a second person in the pharmacy and a MAR was printed to verify the accuracy of new orders. -All Fentanyl orders had a daily patch monitor prompt to be signed off on the daily MAR which was separate from the MAR's Fentanyl order. *She was included in all the pharmacy medication error reports and medication errors were reviewed by the pharmacy and nursing administration every week. They were also reviewed by a multidisciplinary team during the monthly quality assurance and safety meetings. -All medication aides and nurses were educated on the new Fentanyl patch monitoring process on 7/1/24. 7. Interview on 7/25/24 at 10:30 a.m. with pharmacist F regarding the above findings revealed: *The physicians would enter their orders in an EMR system called EPIC and the pharmacy staff would enter those orders into PCC. *Both Fentanyl orders were entered incorrectly by pharmacist X. When that repeated medication error was discovered, the two-party verification, printing of MARs, and daily patch monitoring systems were implemented. *The pharmacy had increased the monitoring of medication errors from monthly to weekly and included nursing administration, quality assurance, and the safety team, in all reports. *He stated the quality assurance and safety team had been discussing the re-implementation of a medication error committee for increased focus on medication and documentation errors. The provider's implemented systemic changes to ensure the deficient practice does not reoccur was confirmed on 7/25/24 after record review revealed the facility had followed their quality assurance process, education was provided to the pharmacy and nursing staff regarding the two-person order verification process, pharmacy printing and double checking the MARs for correctness, daily monitoring of resident's Fentanyl patches, and a review of the medication error report revealed no further Fentanyl medication errors had occurred. Based on the above information, non-compliance at F760 occurred from 5/9/24 through 5/16/24 and again from 6/8/24 through 6/21/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/25/24, the non-compliance is considered past non-compliance.

Based on interview, record review, and policy review, the provider failed to ensure four of twenty-four sampled residents' (13, 24, 43, and 50) Advanced Directives had been: *Completed upon admission and available in the medical record. *Periodically reviewed with the resident or the resident's representative. Findings include: 1. Review of resident 13's medical record revealed: *Her admitted was 5/3/22. *Her Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment. -Her husband was listed as the Power of Attorney (POA) for healthcare decisions. *Her admitting physician ordered her code status to have been 'do not resuscitate' (DNR) on 11/30/21. *There was no documentation in the medical record that indicated the Advanced Directive had been addressed with the POA upon the resident's admission to the facility or periodically thereafter. 2. Interview on 5/8/23 at 9:06 a.m. with resident 43 and review of his medical record revealed: *His admitted was 5/19/22. *His BIMS score was 11, indicating moderate cognitive impairment. -His daughter was listed as the POA for healthcare decisions. *He had been unable to understand questions about Advanced Directives and said his daughter handled all his stuff. *His admitting physician had ordered his code status to have been 'full code' cardiopulmonary resuscitation on 5/19/22. *There was no documentation in his medical record that indicated the Advanced Directive had been addressed with the POA upon the resident's admit to the facility or periodically thereafter. 3. Review of resident 24's medical record revealed: *He was admitted on [DATE]. *His BIMS score was 5, indicating severe impaired cognition. *Admission physician's order was signed on 1/11/23, indicating the resident's code status was DNR. *Resident 24's medical record did not have an Advanced directive acknowledgment form. *The DNR status was not addressed in his care plan. 4. Review of resident 50's medical record revealed: *She was admitted on [DATE]. *Her BIMS score was 6, indicating severely impaired cognition. *Admission physician's order was signed on 3/14/23, indicating the resident's code status was DNR. *The resident's medical record did not have an Advanced Directive acknowledgment form. On 5/9/23 at 8:30 a.m., a request was made to the director of nursing (DON) B to provide a copy of residents' 13, 24, 43, and 50's Advance Directives. On 5/9/23 at 10:00 a.m. DON B indicated there were no copies of the above residents Advance Directive in their medical records. Interview on 5/9/23 at 1:28 p.m. and again at 4:45 p.m. with DON B regarding the above findings revealed: *In the resident admission packet, there was an Advanced Directive form for the resident or the POA to have completed and signed. -The admitting nurse was expected to have completed the Advanced directive form with the resident or the POA upon admission. *They [copies of resident advance directives] are not there, and why is because it was sent home with family and never returned. *Agreed Advance Directives should have been in the residents' medical records and periodically reviewed with the resident or POA. Review of the undated Advance Directives policy revealed: *Purpose: -To provide an atmosphere of respect and caring and to ensure that each patient's ability and right to participate in medical decision making is maximized during care . *Procedure: -During admission process Advance Directive Acknowledgement form is completed and placed in the front of the residents chart. -It is the Provider's responsibility to ensure that the patient, significant other or agent understand the provided advance directive information -All education and interaction with the patient, significant other or agent will be documented in the medical record by the provider.

Based on observations, interviews, record review, and policy review, the provider failed to ensure one of one resident (3) who was at nutritional risk received ongoing monitoring of nutrition and revisions in care as her nutritional status changed. Findings include: 1. Observations on 5/9/22 at 3:56 p.m., on 5/10/22 at 8:04 a.m. and at 1:35 p.m. of resident 3 revealed she appeared thin and weak. Review of resident 3's medical record revealed: *An admitted [DATE]. *Her diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . *She was diagnosed with COVID-19 on 1/21/22. *She had been admitted to hospice on 4/27/22 with an admission diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *Her weight on: -1/4/22 was 117 pounds. -2/10/22 was 104.5 pounds. -2/15/22 was 108 pounds. -3/9/22 was 106 pounds. -3/17/22 was 103 pounds. -4/3/22 was 95.5 pounds. -4/21/22 was 89.5 pounds. -4/29/22 was 89.5 pounds. *She had lost 27.5 pounds which was 23.5% of her body weight in 4 four months. Review of resident 3's 2/1/22 quarterly Minimum Data Set (MDS) assessment revealed she had: *Short and long-term memory impairment. *Been able to feed herself with set-up assistance. *No problems swallowing. *Weight of 105 pounds. *Five percent or more weight loss not prescribed by a physician. Review of resident 3's dietary intakes revealed from 1/27/22 through 4/30/22: *1/27/22 through 2/9/22: -She had not eaten or refused 171 out of 282 meals. -33 meal intakes had not been documented. -She had not eaten or refused 82 bedtime snacks. -16 days of bedtime snacks had not been documented. -There was no documentation for an afternoon snack being offered. Review of resident 3's interdisciplinary progress notes revealed on: *2/10/22 she had been seen by a physician. There was no note indicating if he was aware of the resident's weight loss. *2/10/22 a plan of care meeting was held and the resident's daughter had attended via phone. Her low mealtime intakes and weight loss had been discussed. No nutritional interventions had been discussed with the daughter. *2/18/2022 at 2:35 p.m. a dietary note indicated that she had weight loss in the last month. She had refused to drink Boost or Ensure supplement. It stated [resident's name] will eat [NAME] Buddys from the snack trays between meals. *4/28/22 at 10:38 a.m. a dietary note was entered by the registered dietician(RD) stating: RD - Hospice care Wt [weight]: 89.5# [pound] (4/21/22) Diet order: regular, regular texture & consistency. Medical problems/history: [CONDITION(S)] [[CONDITION(S)]], chronic right heart failure, NSTEMI MI [non-ST-elevation [CONDITION(S)]], Alzheimer's disease, dementia, weakness. Assessment: Resident is hospice care. Resident has poor intake - she declines most meals. Of meals consumed she has 30% average of foods 232cc/ [cubic centimeter per]meal of fluids. No eating problems. No [CONDITION(S)]. Skin is intact, thin, fragile & [and] pale. She unintentionally lost 27.5# since 1/4/22 and 6# in the past 3 weeks. Continued wt loss is expected with poor intake. Nutrition interventions: Resident will be provided foods, fluids and supplements that she requests, enjoys and tolerates to provide comfort and maintain dignity during her passing. Review of resident 3's physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] . -Weight listed in the note was 117 pounds. -Weight loss was not addressed in the note. *4/14/22 she had been seen for a 60 day visit. -Weight listed in the note was 95.8 pounds. -Assessment/Plan included: --Diagnoses: [MEDICAL RECORD OR PHYSICIAN ORDER] . --Patient continues to be bedridden, dementia appears to be getting worse. Staff reports that since patient had COVID that she had been deteriorating at a more rapid pace. Review of the provider's Nutrition/Skin Workgroup Minutes revealed they had met on: *2/15/22 and resident 3 was not discussed for her weight loss. *3/15/22 and resident 3's weight loss was discussed as new business. -The food service supervisor was listed as the process owner. -They did discuss that she did not care for supplements but did like [NAME] Buddy bars and ice cream between meals. -For follow up they were going to continue to monitor. *4/19/22 and resident 3's weight loss was again discussed. -The food service supervisor was listed as the process owner. -Resident had agreed to adding Boost at meal times. -Stated she liked [NAME] Buddy Bars. -For follow up they were going to continue to monitor. Review of resident 3's 2/12/21 care plan revealed: *The goals were: -To eat 75 to 100 percent of her lunch and supper meals. *Interventions included: -Encouraging her to get up out of bed for lunch, or provide her a room tray. -Avoid activities that involve bending, lifting. -Avoid lying down for at least 1 hour after eating. Keep HOB [head of bed] elevated. Encourage to stand/sit upright after meals. -If she is hungry at night there are [NAME] pot pies in the freezer in activities, or provide something from the HS [hour of sleep] snack tray. -Provide Boost or ensure pudding at meals to aid in receiving extra protein when [resident's name] does not eat. --This had been added on 3/22/22. *It had not addressed weight loss. *It had not addressed offering snacks between meals. Interview on 05/11/22 at 4:51 p.m. with director of nursing (DON) B regarding resident 3's weight loss revealed: *Supplements were added to the care plan on 3/22/22. *The interdisciplinary team did not catch the weight loss timely. *The resident had COVID-19 in January and had a health decline. *Provider held monthly nutrition meetings. *Did not know how often the registered dietician reviewed and documented on each resident. Interview on 5/11/22 at 4:55 p.m. with food services supervisor D regarding resident 3's weight loss revealed: *She had tried to review all residents' weights weekly. *She was responsible to update the registered dietician if a resident was having weight loss or nutritional concern. *Resident was on the snack list on the snack tray to receive a snack during the afternoon and evening snack pass. *Agreed she had not found the weight loss when it first started. *She had tried to offer resident 3 supplements prior to March 2022 but the resident had stated she did not want them. *She did not know she should have documented what interventions had been tried and residents refusals of those interventions. Continued interview on 5/12/22 at 8:45 a.m. with food services supervisor D revealed: *She was responsible to update nutrition care plans for all residents. *She did not update a care plan when a resident had weight loss. *Intake of nutritional supplements were not documented to monitor if a resident was drinking them. *She had stated the care plan should have been updated to reflect the residents' current needs. Phone interview on 5/12/22 at 10:45 a.m. with RD E regarding resident 3's weight loss revealed: *Resident 3 had just decided to quit eating. *The meal and snack intake records indicated she was refusing to eat. *She was in the facility one time a month. *She received a list of residents who needed to be reviewed each month from food services supervisor D. *She had been aware resident 3 was losing weight but she was not sure how long she had known about the weight loss. *She thought there had been different interventions tried but did not know if they would have been documented. *She knows it is not an excuse, but she [resident 3] just doesn't want to eat. *She had spoken with resident 3's daughter about the weight loss but had not documented the conversation. Interview on 5/12/22 at 11:01 a.m. with DON B, assistant director of nursing (ADON) C, and food services supervisor D regarding resident 3's weight loss revealed: *The ADON noticed the weight loss when doing MDS assessments in April 2022. *Food service supervisor did not notify RD E about the weight loss until the end of April 2022. *Did not have documentation of doctor, family, or RD notification of the weight loss. Review of the provider's July 2017 Resident at Nutritional Risk policy revealed: *Policy: Residents at nutritional risk will be identified and provided nutritional care unless contrary to the resident's, their family's wishes, or physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *1. The CDM/DSM [certified dietary manager/dietary service manager] will keep a current list of those at nutritional risk. Information will be obtained from nursing, from attending care conference and other meetings, from personal observations, and the Registered Dietitian. All residents who meet the following criteria will be included: -a. Weight down - 5% [percent] in 1 month or 10% or more in 6 months unless resident is expected to have weight loss. -b. Resident is below Ideal Body Weight Range. *3. Nursing will be asked to weigh the nutritional At Risk resident weekly (all other residents monthly or more as requested), and will be asked to reweigh resident with a gain/loss of 5 pounds or more in a week's time. *4. Dietary will visit the resident to offer suggestions for food substitutions, nutritious snacks or supplements. The first choice of increasing intake will be offering regular foods and snacks whenever possible and appropriate

Based on observation, interview, record review, job description review, and policy review, the provider failed to: *Arrange for timely behavioral health follow-up after one of one sampled residents (31) hospitalization for an opioid overdose. *Identify, implement, and evaluate interventions for caregivers to follow for one of one sampled resident (31) who had: -Recently returned to the facility after a fall in her home and now required long term care. -A history of mental illness diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Multiple medical diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: 1. Observation and interviews on [DATE] at 4:02 p.m. and [DATE] at 10:45 a.m. with resident 31 revealed she: *Had been in her room lying in her bed. -Was alert, oriented, and able to verbally engage in conversation. *Got along well with her roommate and they visited throughout the day. *Enjoyed books, watching television, and reading devotions to other residents. *Had been practicing Buddhism since she was nine or ten years old. -Used the strand of beads on her nightstand for meditation. -Used an online forum to connect with other Buddhists. *Practiced transcendental meditation. *discharged home from the facility the end of February 2022, but had a subsequent fall at her home, required hospitalization , and returned to the facility for long term care in early [DATE]. *Had been hospitalized since her return to the facility but declined to explain the reason why. *Stated two years ago in March her youngest son had died unexpectedly. -The month of March was an especially difficult time for her. -Had been meeting with a therapist since early [DATE] to help her manage unprocessed grief related to that death. *Had also been referred to a psychiatrist in early [DATE]. -Felt no benefit from having seen that provider. Review of resident 31's care record revealed: *Admission physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] *Her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . *She was hospitalized on [DATE] after an opioid overdose and readmitted to the facility on [DATE]. *On [DATE] she had an initial consultation with a licensed clinical social worker (LCSW) T outside of the nursing home that specialized in behavioral health. -Had received counseling from that social worker regularly since that time. *On [DATE] she had a psychiatric evaluation completed. Interview on [DATE] at 3:15 p.m. with director of nursing (DON) B regarding behavioral health follow-up after resident 31's [DATE] hospital return revealed: *The resident had been referred to a behavioral health nurse practitioner in the clinic attached to the nursing home after her [DATE] admission, but the resident had requested to see a different provider. *DON B had contacted that same behavioral health clinic by e-mail on [DATE] and on [DATE] requesting a behavioral health appointment for the resident with a different provider. *On [DATE] the resident had indicated to DON B she was willing to see a behavioral health provider not affiliated with the attached behavioral health clinic. -No referrals outside of the attached behavioral health clinic had been made. *On [DATE] DON B sent an e-mail to the LCSW in the attached behavioral health clinic requesting an appointment for the resident. -That appointment with the LCSW occurred on [DATE]. *On [DATE] an appointment with a behavioral health physician in the attached clinic was made. *DON B expected resident 31 had not waited over a month to receive psychiatric follow-up after her [DATE] hospital return. -She was unable to explain why that appointment had been delayed. Interview on [DATE] at 9:30 a.m. with administrator A regarding behavioral health follow-up after resident 31's [DATE] hospital return revealed: *We dropped the ball. -Struggles between medical and behavioral health providers within that facility's healthcare system had stalled the ability to get resident 31's behavioral health services sooner. *That was a process that the healthcare system was actively working on. *An appointment with a different behavioral health provider should have been arranged. 2. Review of resident 31's interdisciplinary progress notes between [DATE] and [DATE] revealed: *Repeated entries throughout that time regarding that resident's need for pain and anxiety medication. -No description of how that anxiety had manifested itself. *The first nurse documentation related to resident 31's mood state was on [DATE]. -Psych/Social: States that she likes to be a hermit but is quite social when out with others for activities or at meal times. *One social service note on [DATE] stated: - .she possibly attempted suicide one time here-that is why she ended up in the hospital so her Physician knows as well as Behavioral Health. No behaviors present. *Her [DATE] PHQ-9 (patient health questionnaire) depression scale score was 6 indicating mild depression. -Mood indicators included appearing depressed, tired, and feelings of letting herself down. *Her [DATE] PHQ-9 score was 4 indicating minimal depression. -Mood indicators included trouble staying asleep and feeling tired daily. *A [DATE] interdisciplinary care team meeting note. *None of the documentation referred to above had comprehensively described the status of resident 31's current or ongoing mood state since her [DATE] nursing home readmission. Review of resident 31's revised [DATE] care plan revealed mood interventions that included: *Monitor/document/report as needed any signs or symptoms of depression including hopelessness, anxiety, sadness, [CONDITION(S)], anorexia, verbalizing negative statements, repetitive anxious or health-related complaints, and tearfulness. *The resident needs time to talk. Encourage the resident to express feelings. *A list of her preferred leisure activities that were last updated on [DATE] during a prior nursing home stay. *Inclusion of the anti-depressant and anti-anxiety medications she had taken along with their potential side effects. *That care plan had not been updated and revised to reflect: -Her receipt of ongoing behavioral health services. -The association of the month of March as it related to her mood state. -The significance of the death of her son and the unresolved grief continued to experience. -The importance of her unique religious and spiritual beliefs and practices. -The strong relationship she had with her roommate. Interview on [DATE] at 10:22 a.m. with unlicensed assistive personnel (UAP) I regarding resident 31 revealed: *She had not been informed of any updates or changes to resident 31's plan of care after her [DATE] hospital return. *Mood documentation was completed on interdisciplinary progress notes or on a behavioral symptoms checklist. -Both were in the resident's electronic medical record. *She was unaware of any triggers that might negatively impact that resident's mood state. Interview and review of resident 31's [DATE] through [DATE] daily behavioral symptoms documentation on [DATE] at 9:05 a.m. with UAP R revealed: *Behaviors on that checklist included observed: repetitive movement, yelling/screaming, kicking/hitting, pushing, grabbing, pinching/scratching/spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, and care rejection exhibited by the resident. -Frequent crying was the only mood symptom on that checklist. -She considered isolation and infrequent talking as mood symptoms too. *Throughout the time referred to above the tool had been marked none of the above referring to those behavioral symptoms and the single mood indicator. Interview on [DATE] at 9:15 a.m. with licensed practical nurse (LPN) S regarding resident 31's care record documentation revealed: *Nurses' documentation that described the status of that resident's mood state after her [DATE] hospital return was minimal. -There was no indication any staff had regularly spoken with the resident about whether she felt her depression and anxiety had improved or worsened, what interventions she used to manage her symptoms of depression and anxiety, and if those interventions had been effective or not. *LPN S had been responsible for ensuring thorough and complete resident documentation was evidenced in that care record and that had not occurred. Interview on [DATE] at 2:20 p.m. with social services director (SSD) N regarding resident 31 revealed she: *Knew that resident was at risk for a decline in her psycho-social well-being related to her mental health history, medical diagnoses, recent hospitalization for an opioid overdose, new need for long term care, and unresolved grief issues related to the death of her son. *Stated monitoring and assessing that resident's mood state was her responsibility. -That was accomplished by reviewing behavioral symptom charting, reviewing interdisciplinary progress notes, resident, family, and staff interviews, updating the plan of care as needed and ensuring staff understood that plan of care. *Had not reviewed and assessed resident 31's behavioral symptom charting since she returned to the facility on [DATE] but should have. -Had not realized that documentation tool had not accounted for mood symptoms that would have been pertinent to resident 31. *Had only documented one social services progress note since [DATE]. -Thought she had spoken with the resident several times since her hospital return, but had not documented those encounters and should have. -Incorrectly documented resident 31 had attempted suicide. *Said the interdisciplinary team usually met daily throughout the week to discuss pertinent resident issues. -Had not made a point of bringing up that resident during those meetings to solicit team members' input that could have been used in assessing her psycho-social status. *Had not reassessed and updated the care plan to include mood triggers or individualized non-pharmacological approaches the resident used to manage her mood symptoms, but should have. *Felt most of her time was spent coordinating new resident admissions. Interview on [DATE] at 3:15 p.m. with DON B regarding the interdisciplinary team's response after resident 31's [DATE] hospital return revealed: *She expected regular and detailed interdisciplinary progress notes after the [DATE] hospitalization that demonstrated the resident's mental health status had been monitored, identified and addressed any new concerns, and described how she had been coping. -That had not occurred. Refer to F609 [DATE] at 4:46 p.m. continued interview with DON B. Interview on [DATE] at 9:30 a.m. with administrator A regarding the interdisciplinary team's response after resident 31's [DATE] hospital return revealed: *Care plan interventions had not been individualized or revised to identify the resident's coping mechanisms. *There was a lack of documentation and a lack of appropriate documentation that demonstrated ongoing monitoring and review of the resident's psycho-social well-being. -As a result, there had been no assessment of the resident's mood state to determine if plan of care changes had been indicated. -SSD N was the most appropriate person to assume ownership of that assessment process, but he was not sure she had the time to do that. Review of the undated Resident's Rights revealed: As a resident of Seven Sisters Living Center, you have certain rights and protections under Federal law that help ensure you get the care and services you need. Review of the [DATE] Social Worker job description revealed: *Role Overview: -The Social Worker provides the social services necessary to meet the psychosocial, mental, environmental, emotional and behavioral needs of the residents to maintain their optimum levels of wellness, serving as the resident advocate ad family liaison. *Essential Functions: -4. The position maintains progress notes and documentation on any changes in the resident's condition and other pertinent information and reviews similar documentation prepared by other caretakers. Review of the revised [DATE] Charting and Documentation policy revealed: *Policy: -All services provided to the resident, or any changes in the resident's medical or mental condition, is to be documented in the resident's medical record.

Based on observation, interview, and policy review, the provider failed to ensure professional standards of practice were followed for: *Administration of as-needed medications by one of one unlicensed assistive personnel (UAP) (F) for one of one observed resident (23). *Eye drop administration by one of one UAP (J) for one of one observed resident (22). *Nasal spray administration by one of one UAP (J) for one of one observed resident (22). Findings include: 1. Observation, interview, and review of medication administration record (MAR) on 5/10/22 at 5:57 p.m. of registered nurse (RN) O for resident 23 revealed: *Resident 23 had complaints of back pain. *She had told the resident she would see if there was pain medication available. *The MAR had shown UAP F had administered a [MEDICATION(S)]-acetaminophen 5/325 milligrams (mg) tablet at 4:47 p.m. *She indicated she had not directed UAP F to administer the medication. *Another nurse may have directed her to administer the medication but she was not sure. *UAPs were to ask a nurse before administering any as-needed medication to residents. Interview on 5/10/22 at 6:05 a.m. with UAP F regarding the as-needed medication for resident 23 revealed she: *Did not ask a nurse before administering as needed medications to resident 23 because she asked for the pain medication every day around the same time. *Only asked a nurse if she could administer as needed medications if it was not a normal request for the resident. Review of resident 23's MAR and interdisciplinary progress notes revealed: *UAP F had administered: -[MEDICATION(S)]-acetaminophen 5/325 mg one tablet twenty times in April 2022 and nine times in May 2022. -[MEDICATION(S)] 25 mg one capsule five times in April 2022 and one time in May 2022. *No progress notes that a nurse had been notified prior to administration. Interview on 5/11/22 at 5:24 p.m. with director of nursing B regarding UAPs administering as needed medications revealed: *She had expected UAPs to ask a nurse before administering as needed medication to any resident. *UAPs were educated to ask a nurse prior to administering any as needed medications. Review of UAP F's 7/7/21 Medication Aide Skills Competency revealed it had not addressed administration of as needed medications. Review of the provider's 7/12/18 Standard of Medication Administration policy revealed it had not addressed UAP's role in medication administration. Review of the provider's October 2014 Medication Aide job description revealed the UAP should only administer as-needed medication under the direction of a nurse. 2. Observation and interview on 5/10/22 at 8:00 a.m. of UAP J administering three separate eye drop medications for resident 22 revealed: *All three medications were administered by UAP J into the inner most corner of the resident's eyes. *An old nurse showed her how to instill eye drops that way. *Had not known the accepted standard of practice for eye drop administration was to pull the center of the lower eyelid down and drop the medication into the mid lower eyelid. 3. Continued observation and interview on that same date and time with UAP J administering nasal spray for resident 22 revealed she: *Administered that spray without first having that resident clear her nasal passage by blowing her nose. -Knew she should have had her blow her nose before administering that spray, but she had not done that. Interview on 5/11/22 at 3:05 p.m. with DON B revealed she: *Confirmed professional standards of practice for eye drop and nasal spray administration had not been followed by UAP J. *UAP J's 7/9/21 medication aide skills competency checklist included medication administration observations for oral, topical, and inhaler routes. Review of the revised 7/12/18 Standards of Medication Administration policy revealed: *Eye Drops: -Gently pull the lower eyelid down. Instruct the resident to look up. -Drop the medication into the mid lower eyelid [fornix]. *Nasal Spray Administration: -c. Ask Res [resident] to blow nose gently before using the spray.

Based on observation, interview, and policy review, the provider failed to implement a consistent process to document and safely dispose of unused medications for one of one observation. Findings include: 1. Observation on 5/11/22 of unlicensed assistive personnel (UAP) I passing medications revealed at: *7:44 a.m. she had given resident 48 her medications. -Resident had accidentally dropped her aspirin tablet and it fell into the crack in her recliner. -UAP I was unable to locate the aspirin. -She did not document the dropped dose or tell a nurse she had dropped the dose. *8:07 a.m. she had given resident 10 her medications. -Resident only wanted to take half tablet of the fiber supplement. -UAP I had taken the other half tablet and threw it into a sharps container sitting on top of her medication cart. -She did not document the disposal of the half tablet or inform the nurse. -The sharps container was not affixed to the medication cart, it was just sitting on top of it. Interview on 5/11/22 between 7:44 a.m. through 8:10 a.m. with UAP I revealed: *When she dropped a dose of medication she did not document that anywhere or tell a nurse. *When a resident refused a medication, she did not document where she put the refused medication or tell a nurse. *She would destroy the medication by putting it into a sharps container unless it was a controlled medication. *If the medication was a controlled medication then she had to tell and nurse and two people had to destroy the medication. Interview on 5/11/22 at 8:42 a.m. with director of nursing B regarding destroying medications revealed: *When a medication was destroyed a slip for the pharmacy should be filled out and the medication should be wasted in a sharps container. *If the medication was a controlled medication it was destroyed by two nurses. Sometimes it was put into a sharps container and sometimes is was put into the Omnicell [an automated dispensing system for medications] for the pharmacy to destroy. *She had expected the UAP to notify a nurse if a medication needed to be destroyed. *She agreed the sharps containers were not affixed to the medication carts. -They had been unable to order sharps containers that fit into the sharps container holders on the sides of the medication cart. Interview on 5/11/22 at 9:15 a.m. with registered nurse H regarding destruction of medications revealed: *Staff had not documented destruction of refused or dropped doses unless they were controlled medications. *Controlled medications were to be wasted in the sharps containers. *She did not feel like it was safe to put the controlled medications into the sharps container so, she would put them down the sink drain. Interview on 5/11/22 at 2:40 p.m. with registered pharmacist (RPh) M revealed: *Staff were able to put all medications that needed to be destroyed into the Omnicell and then the pharmacy would have destroyed them. *Agreed staff put medications that were destroyed at the facility into a sharps container. Requested a policy medication destruction from director of nursing B on 5/11/22 at 10:30 a.m. Received a 2/8/19 Controlled Substances Distribution and Administration policy from RPh M on 5/12/22 at 10:00 a.m. that revealed: *Unused controlled substances could be returned to the Omnicell return bin. *It did not address where medications were to be wasted.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were maintained for: *Storage and handling of medications by one of one unlicensed assistive personnel (UAP) (J) during one of one observed medication pass for one of one observed resident (22). *Cleaning of mechanical lifts by three of three observed UAPs (K, L, and T) after use by two of two observed residents (24 and 40). *Handling and cleaning of a glucometer by one of one UAP (F) during use for two of two observed residents (4 and 23). *Hand hygiene by one of one UAP (F) performing blood sugar monitoring for two of two observed residents (4 and 23). *Hand hygiene by one of one UAP (G) while passing meal trays for four of five observed residents (10, 30, 36, and 48). Findings include: 1. Observation on 5/10/22 at 8:00 a.m. of UAP J preparing to administer resident 22's medications revealed she: *Performed hand hygiene, opened the medication cart drawer, and removed her three bottles of eye drops and one nasal spray from a designated section of that cart. -An uncapped tube of antibiotic eye ointment also belonging to that resident was stored with those eye drops and nasal spray. *Placed the three eye drop bottles and nasal spray into her front smock pocket then entered the resident's room. -A ring of keys was also inside that pocket. *Reached in and out of that pocket to remove each bottle, administer that medication, then return that bottle to her pocket after use. Interview on 5/10/22 at 9:23 a.m. and 2:07 p.m. of UAP J regarding the above medication pass revealed: *Medication bottles should have been carried into the room with her clean hands and not placed inside her unclean smock pocket. *The antibiotic ointment had been without a cap for about a week. -It was administered daily during the evening shift. *That ointment should have been given to a nurse for destruction at the time its cap was noted to have been missing. *The contents of that tube had been compromised and posed a contamination risk to the resident. 2. Observation on 5/10/22 at 7:50 a.m. of UAPs K and T transferring resident 40 with a mechanical lift revealed: *After transferring that resident from a chair to her bed, UAP K removed that lift from the room, and placed it in a common sitting area across the hallway from an activity/small dining area in the west hall living unit without cleaning it. Observation on 5/10/22 at 11:17 a.m. of UAP L revealed: *She exited resident 24's room with a mechanical lift after assisting her off the toilet. -Placed that lift in a common sitting area across the hallway from the activity/small dining area in the west hall living unit without cleaning it. Interview on 5/10/22 at 11:22 a.m. with UAPs K and L revealed: *Cleaning mechanical lifts after use was not a part of their usual routine. -Lifts were cleaned if they were visibly soiled. *Agreed lifts should also have been cleaned between resident use. Interview on 5/11/22 at 3:05 p.m. with director of nursing (DON) B revealed: *Resident medications were not expected to be transported inside staffs' unclean pockets. *The uncapped antibiotic ointment should have been immediately discarded when it was discovered that way and replaced with an unopened tube. *Mechanical lifts were expected to be cleaned between resident use and when visibly dirty. Review of the revised 7/12/18 Standards of Medication Administration policy revealed: *1. Oral Medication Administration: -Place medications on the bedside table or tray if necessary prior to administering that medication. *4. Instillation Administration Eye Ointment: -Wipe off the tip of the ointment tube with a clean gauze pad and replace the cap. A Cleaning of Critical and Non-Critical Medical Equipment policy was requested of DON B on 5/11/22 at 8:15 a.m., but she indicated there was none. The revised July 2021 Lifting/Transferring policy was provided instead. Review of that policy revealed no lift cleaning expectations. 3. Observation on 5/10/22 of UAP F performing blood sugar monitoring revealed: *At 4:40 p.m. she was in resident 23's room: -She had set the glucometer, glucose strips, and a white plastic container on the bedside table without a barrier under them. -With a pair of gloves on she obtained the blood sugar reading, removed her gloves, threw them away, and returned to the cart with the above supplies. -She set the glucose strips and the white container on the medication cart. -Went into the soiled utility room and retrieved a PDI Sani Cloth from a container on the edge of the sink, then walked back to her med cart. -She wiped the glucometer with a PDI Sani Cloth and set it on top of the medication cart. --She did not ensure the glucometer had stayed wet for two minutes. -She removed the keys from her shirt pocket and unlocked the medication cart. -She put the strips and the glucometer in the plastic container and set it into the top drawer of the med cart. -She used the hand sanitizer on the medication cart to sanitize her hands. *At 5:30 p.m. she entered resident 4's room: -She set the glucometer, glucose strips, and plastic container on the bedside table without a barrier under them. -Put on a pair of gloves and obtained the blood sugar reading. -Removed the gloves, threw them away, collected the supplies from the bedside table, and walked out of the room without performing hand hygiene. -She entered the dirty utility room and retrieved a PDI Sani Cloth. -Put the cloth around the glucometer and set it on top of the medication cart. -Removed the keys from her shirt pocket and unlocked the medication cart. -She then sanitized her hands, removed the wipe from the glucometer, and put the supplies into the top drawer of the medication cart. --She did not ensure the glucometer had stayed wet for two minutes. Interview on 5/10/22 at 5:33 p.m. with UAP F regarding the above observations revealed she: *Did not know she should have used a barrier under the blood glucose supplies. *Agreed that the bedside tables in residents rooms could be contaminated. *Agreed after removing her gloves she should perform hand hygiene before touching other surfaces. *Was not aware of the contact time required for the PDI Sani Cloth. Interview on 5/11/22 at 8:42 a.m. with DON B revealed: *Staff had been expected to use a barrier under the blood sugar monitoring supplies. *When cleaning the glucometers with a PDI Sani Cloth the surface of the glucometer needed to stay wet for two minutes. -The staff either needed to wipe the glucometer the entire two minutes or wrap the glucometer in the wipe for two minutes. Review of the provider's 5/27/21 Glucose Monitoring/Glucometer Cleaning policy revealed: *Staff should wash hand after removing their gloves. *The glucometer should be cleaned with a PDI Sani Cloth. -One cloth was to be used to remove any heavy soil and a second cloth was to be used to wet the surface. *The surface of the glucometer was to remain wet for 2 minutes. 4. Observation on 5/9/22 at 5:17 p.m. of UAP G passing meal trays to residents 10, 30, 36, and 48 revealed she had a cart with meal trays on it in the hallway and she: *Entered, set down meal tray, exited, and shut doors of residents 10, 30, 36, and 48's rooms. *Pushed cart back down hall to dining room, set down resident 35's meal tray, assisted her with set up and then returned to medication cart. *UAP G did not perform hand hygiene during any of the above observations. Interview on 5/9/22 at 5:42 p.m. with UAP G revealed she should have sanitized her hands when going in and out of resident rooms. Interview on 5/12/22 at 8:42 a.m. with DON B revealed staff should be performing hand hygiene when entering and exiting resident rooms. Review of the provider's 6/24/21 Hand Hygiene policy revealed: *All employees would wash hands before preparing food. *All employees would wash hands after handling equipment. *It had not addressed hand hygiene after touching potentially contaminated surfaces.

Based on interview, record review, provider's incident review, and policy review, the provider failed to report to the South Dakota Department of Health (SD-DOH) an incident that required emergency medical treatment outside of the facility for one of one sampled resident (31). Findings include: 1. Interview on 5/9/22 at 4:02 p.m. with resident 31 revealed she: *discharged from the facility to her home at the end of February 2022, fell at home, and required hospitalization after that fall. -readmitted to the facility from the hospital for long-term care in early March 2022. *Had returned to the hospital since her readmission in early March 2022, but declined to discuss the nature of that hospital stay. Review of resident 31's care record revealed her diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of 3/7/22 interdisciplinary progress notes revealed: *At 9:45 a.m. she was found in bed by staff unresponsive. *At 9:50 a.m. a registered nurse assessment: -The resident's eyes would open intermittently and her pupils were pinpoint bilaterally. -She had no purposeful response to verbal or tactile stimuli. *She was transferred to an emergency department for medical care. Review of resident 31's 3/8/22 Inpatient Discharge Summary revealed a discharge diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] Interview and review of the provider's 3/7/22 Incident Report/Investigative Report on 5/11/22 at 4:26 p.m. with director of nursing (DON) B revealed: *DON B stated someone had brought resident 31's purse from her home into the facility the morning of 3/7/22. *Oxycodone pills and [MEDICATION(S)] tablets had been found in that purse after she was transferred to the emergency roiagnom on [DATE]. -Those were the same medications she had been discharged home with in February 2022. *The incident had not been reported to the SD-DOH but should have been. -That had been her responsibility. Review of the 3/1/17 Abuse policy revealed: *g. Injuries of Unknown Origin: An injury should be classified as an injury of unknown source when both of the following conditions are met: -i. The source of the injury was not observed by any person or the source of the injury could not be explained by the resident/patient; -ii. The injury is suspicious because of the extent of the injury or the location of the injury or the number of injuries observed at one particular point in time or the incident of injuries over time. *Reporting and Response: -It is the policy of this facility that abuse allegations (abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident/patient property) are reported per Federal and State Law.

Based on interview, record review, and policy review, the provider failed to ensure care plans were updated and revised to reflect residents current needs for one of fourteen sampled residents (31). Findings include: 1. Interviews on [DATE] at 4:02 p.m. and [DATE] at 10:45 a.m. with resident 31 revealed: *Spirituality was important to her. *She had tears in her eyes when she spoke about the death of her son. *She had a new roommate and they got along well. Review of resident 31's medical record revealed she: *Was found unresponsive in her room the morning of [DATE]. -Was transferred to the emergency department, treated for [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of resident 31's care plan last revised on [DATE] revealed: *That care plan had not been individualized and updated to reflect: -The unresolved grief she had related to her son's death. -Her heightened sense of sadness during the month of March when he died . -Her participation in individual therapy sessions related to her depression, anxiety, and complicated bereavement. -Her unique religion and how she maintains her connection with it through on line formats, individual practices, and through a current staff member who also shared those beliefs. -Her use of transcendental meditation to achieve inner peace. -The close relationship she has established with her current roommate. Interview on [DATE] at 4:26 p.m. with director of nursing (DON) B regarding resident 31's care plan revealed she: *Agreed it had not identified specific interventions, supports, and strategies that resident utilized to help manage her depression, anxiety, and grief. -It was the responsibility of each interdisciplinary team member to have updated and revised that care plan as needed to ensure it was accurate and complete. *Knew the resident also enjoyed lifelike dolls she kept in her room, but that was not mentioned in the care plan either. Review of the providers [DATE] Care Planning Policy revealed: *3. The Plan of Care will be individualized, based on the diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] -Incorporate identified problem issues; -Incorporate risk factors associated with identified problems; -Build on the resident's strengths; -Reflect treatment goals, timetables and objectives in measurable outcomes; -Aid in preventing or reducing declines in resident's functional status and/or functional levels. *8. The Care Planning/Interdisciplinary Team is responsible for the review and updating of care plans: -When there has been a significant change in the resident's condition; -When the desired outcome is not met; -When the resident has been readmitted to the facility from a hospital stay; and -At least quarterly.

Based on observation, interview, record review, and document review, the provider failed to ensure one of two sampled residents (4) had not acquired an avoidable pressure ulcer (area of skin breakdown, where something keeps rubbing or pressing against the skin) after admission to the facility as evidenced by an ineffective care planning process and failure to follow the skin/wound preventative program. Findings include: 1. Observation on 6/9/15 at 7:30 a.m. revealed the resident was in bed. He did not have his foam heel boots on at that time. The nursing assistants had put them on when they had gotten him up. Observation and interview on 6/9/15 at 4:55 p.m. revealed: *Licensed practical nurse (LPN) (D) examined resident 4's right heel. *There had been a scabbed area on the outer aspect of that heel. *The LPN had not measured the area but agreed it had been approximately two centimeters (cm) in diameter. *She had applied [MEDICATION NAME] ointment and a dressing to the heel after she had examined it and found no dressing present on the area. *She stated a dressing was to have been on the scabbed area until it had healed. *The resident's foam boots had not been on while he had been in bed. Observation on 6/9/15 at 5:45 p.m. revealed: *Two certified nursing assistants assisted the resident to the bathroom. *The resident's coccyx had no dressing in place. *The skin on the resident's coccyx had no open areas present. *They had put his foam boots on when they had gotten him up. Review of resident 4's June 2015 treatment administration record (TAR) revealed: *Wound care-coccyx apply [MEDICATION NAME] and cover with [MEDICATION NAME] Border (a dressing). (Observation above revealed no dressing was in place over the coccyx, and it appeared healed at that time.) -Wear foam boots at all times. -Change on bath days, Monday and Thursday. -Change as needed. *Change small [MEDICATION NAME] with Border dressing on mid-back area on bath days (Monday and Thursday) and as needed until healed. *There had been no treatment listed for the right heel yet observation above revealed LPN D had applied a dressing to that heel. Review of the resident's physician's orders [REDACTED]. *On 12/2/14:Wound care consult. Air overlay mattress. *New orders that same day Wound care: Auto turn bed rather than air overlay. Cover wound on coccyx with [MEDICATION NAME] change Monday et (and) Thursday. *On 12/2/14 DC twin mattress apply air overlay. *On 2/9/15 Wound care wound to coccyx apply [MEDICATION NAME] nickel thick then cover with [MEDICATION NAME] border. Change on bath days. *On 2/17/15 Wound care to coccyx, continue [MEDICATION NAME] nickle thick, covered with [MEDICATION NAME], change on bath days and PRN (as needed) if soiled. *On 3/6/15 Wound care consult on resident's heels Bil (bilateral). *On 3/9/15 Wound care: Wound to R (right) outer heel cover with collagense ([MEDICATION NAME]) the [MEDICATION NAME] border. Wound to L (left) inner heel cover with [MEDICATION NAME] border. Wound to coccyx cover with [MEDICATION NAME] then [MEDICATION NAME] border. Change on bath days. Wear foam boots at all times. *On 3/26/15 Wound care. DC (discontinue) wound care to L inner heel. Wound is heeled (healed). *On 5/26/15 DC wound care to R (right) heel Wound is healed. Review of the resident's 9/3/14 Nursing Admission Screening/History form/documentation revealed: *The resident's right and left legs were normal in color and temperature. *Section L Skin had been left blank. *The resident had required staff assistance for transfers, ambulation, locomotion (moving about), toileting, bathing, and hygiene. *No skin breakdown had been noted on admission. Review of his Braden Scale for Predicting Pressure Sore Risk assessments from 9/3/14 through 5/18/15 revealed he had been at risk for developing pressure ulcers. Interview on 6/10/15 at 9:20 a.m. with the director of nursing (DON) confirmed the revised 2/23/15 Physician Protocols 2015, the September 2010 Wound Assessment,Prevention,Treatment,Documentation, and the 2/10/12 Braden Scale Worksheet were used to determine how to prevent and treat a pressure ulcer. Review of the provider's 2/10/12 Braden Scale Worksheet revealed if a stage II (shallow open area in the skin) or greater pressure ulcer developed: *The care plan was to have been updated. *The EZ graph wound assessment was to have been completed and continued weekly. *The physician was to have been notified. *The wound protocol was to have been initiated. *When it was healed the care plan was to have been updated. Review of the resident's last revised 6/9/15 care plan revealed: *A goal that the resident had a potential for skin tears, skin breakdown, and ulcers related to his dementia (memory problem) and being wheelchair bound. *The goal had been the resident would be free from skin tears through the review date. *Areas of skin breakdown and ulcers were to have been monitored and documented. *The resident was to have foam boots on. *It had not addressed the areas of present or previous breakdown. *It had not stated when the resident was to have worn the foam boots. *It had not listed any treatments or prevention for the resident's coccyx or heels other than the foam boots. Review of the September 2010 Wound Assessment,Prevention,Treatment,Documentation guidelines revealed: *Nursing was to have documented weekly on all wounds. *Those guidelines stated the following was to have been documented: -The location of the wound. -The size to include the length, width, and depth. -Any undermining, tunneling, or sinus tracts. -Any drainage and the amount. -The odor. -The tissue type. -The wound edges. Review of a sampling of the resident's progress notes from 10/7/14 through 6/10/15 revealed the nurses had not documented as expected in the above 2010 Wound Assessment,Prevention,Treatment,Documentation guidelines as stated below as examples demonstrate: *On 11/28/15 the resident had developed an open area on his coccyx the size of a nickel. -The area had slight bloody drainage and redness around the area. -A [MEDICATION NAME] dressing was applied. *On 12/7/14 the resident had two open areas on his coccyx. -One had been bleeding and the other had slough (dead off-color tissue) present. -The wound was red and irritated. *On 12/25/14 the wound was described as being the size of a quarter. *On 1/1/15 the coccyx had slough in the wound bed. *On 1/8/15 the wound appeared to be resolved. -Pink skin had appeared where the wound had been. *On 1/22/15 the wound on the coccyx had re-opened. -No treatment was documented as being completed for the wound. *On 1/30/15 the wound on the coccyx had been the size of a dime. -Bloody drainage was present. -It was recovered with a [MEDICATION NAME] dressing. *On 2/5/15 the open area on the coccyx had foul, purulent (pus laden) drainage. -There had been eschar (dead dark tissue) in the middle of the wound and slough surrounding that to the borders of the wound. *On 3/6/15 the resident had skin breakdown on the outside of his right heel that had been open and quarter sized. *His left heel had a nickel sized area that had not opened yet. *[MEDICATION NAME] and foam boots were applied to both heels. -The physician and family were notified of the above. -Wound consultation had been ordered for the resident's heels. *On 3/13/15 it had been documented the [MEDICATION NAME] was soiled, so a new one was applied. -It had not stated where that dressing was located. *On 3/30/15 the coccyx was healed. -The right heel had no dressing and had been scabbed over. *On 4/3/15 the coccyx and right heel had drainage present. -Dressings and ointment had been applied. -The wound on the coccyx was about the size of a dime. *On 4/16/15 the coccyx was healed. Interview on 6/10/15 at 9:20 a.m. with the DON confirmed: *The nurses aides cardex in Point Click Care had not directed when or for how long the resident was to have worn the foam boots. *She stated they were to have been on at all times. *She had expected wound documentation to include wound measurements to have been completed every seven to ten days by the wound care nurse. *The other nurses working the floor were expected to document drainage and how the resident tolerated the treatment. (Examples of the nurses documentation above revealed that had not occurred.) *She had not expected them to measure the pressure ulcers. Review of the resident's assessments and documentation by the wound care nurse for his coccyx and heels on the EZ graph Wound Assessment system form from 12/2/14 through 5/20/15 revealed: *It had been documented on 12/2/14 and then not again until 2/12/15. -That had been seventy-two days between documentation. *The next documentation had been on 2/25/15, an interval of thirteen days. *The next documentation had been on 3/9/15, an interval of twelve days. *The next documentation had been on 3/19/15, an interval of nine days. *The other documentation had been seven days or less until 4/1/15 through 4/15/15, and interval of fourteen days. *No documentation regarding the coccyx had been documented on the EX graph by the wound care nurse after that date. *The orders for the treatment to the coccyx had not been discontinued, and the treatment was still present on the June 2015 TAR. *Documentation for his heels revealed: -Nine days elapsed between documentation from 3/9/15 through 3/18/15. -Fourteen days elapsed from 4/1/15 through 4/15/15. -Sixteen days elapsed from 4/15/15 through 5/1/15. *The left heel was not documented as healed until 3/26/15 and the right heel until 5/26/15, yet no documentation had occurred after 5/1/15.

Based on the current survey and and review of the previous survey deficiencies, the provider failed to sustain and enhance the residents environment and quality of life as revealed by: *Observation of the facilities overall cleanliness and maintenance of the environment. *Staff daily duties, responsibilities, and professional standards. *High water temperatures, dirty and broken equipment, and uncleanable surfaces. *Interviews with residents, staff, and family members regarding the facility and residents. *Medical record reviews of 30 random residents who resided at the facility. *Monthly maintenance and environmental audit reviews completed by administration. *Resident medical and treatment care plan reviews were incorrect, missing documentation, and not followed according to orders. *Provider's policies and procedures were not followed regarding the overall environment, staff, and care and condition of residents. *Last survey results review dated 1/12/12. *Job description reviews for all staff, administrator, and medical director, randomly dated with the earliest of 5/6/01 for the administrator, and 3/22/13 for the medical director, revealed responsibilities were not enforced or adhered to. Findings include: 1. Review of the previous survey revealed: *F253 (housekeeping) had been cited. *F309 (quality of care) had been cited. *F314 (pressure ulcers) had been cited. *F323 (accident hazards) had been cited. *F332 (medication errors) had been cited. *F371 (sanitary kitchen conditions) had been cited. *F441 (infection control) had been cited. *F514 (nursing documentation) had been cited. Refer to: F224, F241, F252, F253, F279, F280, F281, F309, F314, F323, F329, F332, F361, F368, F371, F428, F441, F463, F466, F490. F493, F501, F514, and F520.

Based on observation, interview, and policy review, the provider failed to ensure resident's 1, 5, 23, 24, 25, 27, 28, 29, and 30's physical, emotional, and activity needs had been met by staff. Findings include: Preceptor: 1. Interview on 2/26/13 at 3:30 p.m. with resident 24 revealed: *He turned his call light on at approximately noon that day to get help to use the bathroom. *Ten minutes later a certified nursing assistant (CNA) had come into his room and turned off the call light. *That CNA told him she would be back in a few minutes to help him use the bathroom. *He stated he waited for two hours to get help to the bathroom. *He had a care-planned activity that afternoon called bell choir. *He stated that he was so upset by having to wait two hours to use the bathroom that he quit bell choir. *He said he was not the type of person to say that he was upset about something. *Instead, he quit his only activity that he enjoyed doing, which was bell choir. *He stated he frequently waited a half hour to an hour to two hours to go to the bathroom. *He stated he does not have staff come and ask him to go to the bathroom per a toileting schedule. *He stated "The aides and nurses don't care." Interview on 3/26/13 at 8:10 p.m. with resident 24 revealed he had been in the bathroom, seated on the toilet, for twenty-five minutes after turning on his call light for assistance. He had just been assisted out of the bathroom at that time. Review of the 3/26/13 bowel and bladder chart detail report, shift charting by CNA E for resident 24 at 2:25 p.m. revealed: *Incontinent briefs were used. *Resident was incontinent. Review of resident 24's care plan dated 1/24/13 revealed: *"To toilet upon rising, before and after meals, at bedtime, and during the night as needed." *"He enjoys participating in bell choir and some special events." Interview on 3/27/13 at 9:50 a.m. with the director of nursing (DON) confirmed resident 24 should not have had to wait up to two hours to be assisted to the bathroom. Surveyor: 2. Interview on 3/26/13 at 2:30 p.m. with resident 27, with a brief interview for mental status score (BIMS) of 15 (the highest score attainable to indicate the person is cognitively intact) revealed: *She whispered to this surveyor she had at times waited so long for her call light to be answered she had wet or soiled herself. *When asked by this surveyor why she had whispered about that event, she hung her head and whispered "because I was embarrassed." *She also revealed that her call light was at times placed out of her reach and she had to have her roommate call for help. 3. Interview on 3/19/13 at 2:30 p.m. with resident 5 confirmed: *Her toilet was hard to flush. *She was unable to do it herself. *She had believed the nurses had written a work order to have had it fixed in the past. *It had not improved from that time. Observation at the above same time revealed: *The toilet was difficult to flush. *This surveyor had to turn the handle many directions before it would flush. *It took over 10 seconds of trying before it would flush. Review of the resident's 2/7/13 care plan revealed: *A 2/5/13 physical therapy evaluation. *It had stated she had an increase in weakness. *She had been evaluated by physical therapy and a restorative program had been recommended. *The resident had complained of being frustrated as she had been unable to flush the toilet independently. *Nursing had told her that it had not been a problem and encouraged her to call if assistance had been needed to flush the toilet. *It had not addressed that the toilet had not worked correctly or that a work order had been written. Interview on 3/21/13 at 11:50 a.m. with the Minimum Data Set coordinator confirmed she: *Had never been in the resident's bathroom. *Had not known if the resident's toilet had been hard to flush. *Had not known if the restorative aide had worked with the resident to gain strength to flush the toilet. Interview on 3/21/13 at 11:55 a.m. with the restorative aide confirmed she had not been working with the resident on flushing the toilet. Further interview with the resident on 3/21/13 at 12:00 noon confirmed: *The toilet had not been that hard to flush when she had been admitted . *It was now difficult to flush. *She had believed something had been wrong inside of the toilet flushing mechanism. Interview on 3/27/13 at 7:50 a.m. with the maintenance supervisor confirmed: *He had repaired the toilet flushing mechanism before. *He thought it had been about two months ago. *He had no documentation to support when or if that had been completed in the past two months. *He had a work order for that toilet and had repaired it over the past weekend. Record review revealed a work order dated 3/17/13 that the toilet had been hard to flush again. Interview on 3/27/13 at 8:00 a.m. with the resident confirmed the toilet was now repaired and she had been able to flush it independently. Preceptor: 4. Random observation on 3/26/13 from 9:55 a.m. through 10:17 a.m. of resident 28 revealed: *At 9:55 a.m. she had been lying in bed. Her bed had been in the low position with a floor mat up next to the bed frame. Her call light had been within her reach. This surveyor put the call light on. . *At 9:57 a.m. the activities director (AD) had come into the room and took her roommate out for an activity. *At 10:00 a.m. the AD had returned to the resident's room to check on her. *The AD stated that she would check on the residents if their call lights were on to make sure they were fine. *"I can't do anything for them but will check on them." The AD left her room without turning off the call light. *At 10:05 a.m. the MA answered her call light. *The MA told the resident that she would be back to help her shortly. *The MA turned off the call light and went to help another resident. *The MA had informed an unidentified CNA the resident had turned on her call light. *At 10:17 a.m. an unidentified CNA went into her room to assist her. 5. Interview on 3/21/13 at 8:15 a.m. with a family member regarding resident 29 revealed: *She had recently been admitted to the facility on [DATE]. *Her dementia had gotten progressively getting worse and she had been hospitalized for [REDACTED]. *The transition to the nursing home had been hard. *She was a quiet person who did not complain. *She stated "It takes the staff a long time to answer her call light." *"The other night she had to go to the bathroom. She had put on her call light and it took half an hour for someone to respond." *The family member had informed the charge nurse that the resident needed help to go to the bathroom. *The charge nurse had told her she would find someone to help her mom. *The resident urinated in her pants and all over the floor trying to get to the bathroom on her own. *The family member had to help the resident change her clothes. *She had cleaned up the urine on the floor as she was concerned that her mom and her roommate would have slipped and fallen in the urine. 6. The group interview on 3/19/13 at 10:30 a.m. with six residents (1, 23, 24, 25, 27, and 30) revealed: *The residents stated many times their call lights took a long time to be answered. *It could range from fifteen minutes to over an hour. *Many times the call light would be answered and staff would turn the call light off and say they would be back. *Staff usually did not come back until the call light was turned on again. *Resident 1 stated he had a staff member come into his room and shut his call light off when his back had been turned. *That staff person had not acknowledged his need for assistance. 7. Interview on 3/26/13 at 1:35 p.m. with resident 25 with a BIMS of 15 revealed she: *Did not think her room was cleaned very well. *Housekeeping only cleaned the room when she and her roommate were out of the room. *Used her call light numerous times daily. *Had her call light shut off by staff numerous times. *They would state to her they would be right back and would not return until she put it on again. Staff would come back and state "they forgot." *Usually waited one-half hour for the staff to answer her call light initially. *Or waited another half hour for the staff to come back if they had shut it off. *Would put her call light on for her roommate as the staff would put her roommates call light out of reach, so she did not use it to much. *Refer to finding 2 regarding resident 27. Surveyor: 8. Review of notes from an all staff bulletin from the DON dated 12/9/12 revealed: "We have had multiple family members and Residents c/o call lights not being answered. Please make sure you are always carrying a pager. Also make every attempt to answer call lights within 5 minutes. Please make sure you turn off call lights when you answer them. We will be running daily call light reports. WE will also be doing audits, we need to improve in this area ASAP." 9. Review of an undated care team meeting note revealed: "...daughter reported ________(resident 19) had an accident and the nurse aide gave her a hard time because she has to assist in cleaning her up." "___________(resident 19( and daughter feel she is neglected and that staff does not answer her call light in a timely manner. We need to answer call lights with in 5 minutes."

A. Based on observation, interview, and record review, the provider failed to ensure residents' individual choices were met and/or encouraged for 9 of 25 (1, 5, 23, 24, 25, 26, 27, 29, and 30) sampled residents to enhance their identity. Findings include: Preceptor: 1. Interview on 3/26/13 at 3:30 p.m. with resident 24 revealed: *He had waited two hours that afternoon to be taken to the bathroom after pulling his call light. *He stated he had frequently waited half an hour to an hour to two hours to go to the bathroom. *He quit bell choir in retaliation of having to wait two hours to be taken to the bathroom. *He has not had staff offer to toilet him per his care planned toileting schedule. *He stated "the aides and nurses don't care." *Refer to 240 finding 1. Review of the Long-Term Care Facilities Resident's Bill of Rights, which was also the provider's dignity policy, revealed: *"When you enter a long-term care facility, you must be treated as an individual with respect, dignity and consideration." *"You have the right to privacy and confidentiality." *"Close your door and require others to knock before entering, except in an emergency." *"A facility must provide care and an environment that contributes to your quality of life." *"Maintenance or enhancement of your ability to preserve individuality, exercise self-determination and control every day physical needs." Preceptor: 2. Interview on 3/21/13 at 8:15 a.m. with a family member regarding resident 29 revealed: *She had recently been admitted on [DATE]. *Her dementia had gotten progressively worse. *She had been hospitalized for [REDACTED]. *The transition to the nursing home had been hard. *She was a quiet person who did not complain. *She stated "It takes the staff a long time to answer her call light." *"The other night she had to go to the bathroom. She had put on her call light, and it took half an hour for someone to respond." *The family member had informed the charge nurse the resident needed help to go to the bathroom. *The charge nurse had told her she would find someone to help her mom. *The resident had urinated in her pants and all over the floor trying to get to the bathroom on her own. *The family member had to help the resident change her clothes. *She had cleaned up the urine on the floor, as she was concerned her mom and her roommate would have slipped and fall in the urine. Surveyor: 3. Review of resident 26's medical record revealed a 3/6/13 physician's note that included the following."She is quite happy and ready to move closer to her family in a less controlled environment." Review of nurses medicare documentation sheets for resident 26 revealed: *3/8/13 Comments: "Lets needs be known." *3/9/13 Comments: "It was reported _______(resident's name) wants her room door kept shut. She was advised her roommate wasn't able to open the door by herself. Ambulatory." Social progress notes dated 3/18/13 revealed: "__________ (resident's name) has built a friendship with other residents and staff. We have had to remind ___________ (resident's name) that her roommate has difficulty opening the door, so she needs to keep it open when her roommate needs to go in and out." Dietary progress notes dated "WK(week) 6 - 12 March 2013" revealed: "As an HS snack ________ (resident's name) was to be offered juice and graham crackers, but she states would would like ice cream instead. Have placed diet ice cream on the HS snack sheet in place of juice and crackers." Registered Dietician notes dated 3/25/13 at 4:00 p.m. revealed "Plan: Honor food and fluid preferences." Review of the snack sheet dated 3/25/13 revealed resident 26 was to be offered graham crackers and milk. Interview with resident 26, who scored a 15 (highest attainable score to indicate person is cognitively intact) on her brief interview of mental status (BIMS), revealed: *She liked to play cards and be around people. *She stated in a direct tone "I want my door closed, but the aides told me to keep it open because my roommate can't open the door and to keep door open." *"I want my door closed at times, like when I change, take a nap, and get ready for bed." Interview on 3/27/13 at 1:05 p.m. with the restorative care aide revealed she was aware resident 26 liked her door closed and liked her independence. Interview at that same time with licensed practical nurse A revealed "________ (resident's name) shouldn't have been told that." 4. Interview on 3/19/13 at 2:30 p.m. with resident 5 confirmed: *Her toilet was hard to flush. *She was unable to do it herself. *She believed the nurses had written a work order to have it fixed in the past. *It had not improved from when she had reported it. Observation and testing at the above time revealed: *The toilet was difficult to flush. *The handle had to be turned many directions before it would flush. *It took over 10 seconds of trying before it would flush. Review of resident 5's 2/7/13 care plan revealed: *A 2/5/13 physical therapy evaluation. **It had stated she had an increase in weakness. *She had been evaluated by physical therapy and a restorative program had been recommended. *The resident had complained of being frustrated, as she had been unable to flush the toilet independently. *Nursing had told her that it had not been a problem and had encouraged her to call if assistance had been needed to flush the toilet. *It had not addressed the toilet had not worked correctly or that a work order had been written. Interview on 3/21/13 at 11:50 a.m. with the Minimum Data Set coordinator confirmed she: *Had never been in resident 5's bathroom. *Had not known if the resident's toilet had been hard to flush. *Had not known if the restorative aide had worked with the resident to gain strength to flush the toilet. Interview on 3/21/13 at 11:55 a.m. with the restorative aide confirmed she had not been working with the resident on flushing the toilet. Interview on 3/21/13 at 12:00 noon with the resident 5 confirmed: *The toilet had not been that hard to flush when she had been admitted . *It was now difficult to flush. *She had believed something had been wrong inside of the toilet flushing mechanism. Interview on 3/27/13 at 7:50 a.m. with the maintenance supervisor confirmed: *He had repaired the toilet flushing mechanism before and thought it had been about two months ago. *He had no documentation to support when or if that had been completed in the past two months. *He had a work order for that toilet and had repaired it over the past weekend. Review of a work order dated 3/17/13 revealed the toilet had been hard to flush again. Interview on 3/27/13 at 8:00 a.m. with resident 5 confirmed the toilet was now repaired, and she had been able to flush it independently. 5. The group interview on 3/19/13 at 10:30 a.m. with six residents (1, 23, 24, 25, 27, and 30) revealed: *The residents stated many times their call lights took a long time to be answered. *It could range from fifteen minutes to over an hour. *Many times the call light would be answered, staff would turn the call light off, and say they would be back. *Staff usually did not come back until the call light was turned on again. *Resident 1 stated he had a staff member come into his room and shut his call light off when his back had been turned. *That staff person had not acknowledged his need for assistance. 6. Interview on 3/26/13 at 1:35 p.m. with resident 25 with a BIMS score of 15 (highest attainable score to indicate person is cognitively intact) revealed she: *Did not think her room was cleaned very well. *Housekeeping only cleaned the room when she and her roommate were out of the room. *Used her call light numerous times daily. *Had her call light shut off by staff numerous times. *They would state to her they would be right back and would not return until she put it on again. Staff would come back and state "they forgot." *Usually waited one-half hour for the staff to answer her call light initially. *And waited another half hour for the staff to come back if they had shut it off. *Would put her call light on for her roommate as the staff would put her roommates call light out of reach, so she did not use it too much.

Preceptor: Based on observation, record review, interview, and policy review, the provider failed to update care plans related to a change of condition for pressure ulcer prevention and respiratory status upon readmission for two of two sampled residents (4 and 21). Findings include: 1. Review of resident 4's complete medical record revealed: *She had an admission date of [DATE] and a readmission date of [DATE]. *She had [DIAGNOSES REDACTED]. *Review of her Braden scale (form for predicting pressure ulcer risk) revealed there was no pressure ulcer score provided upon readmission until 2/5/13. She had been assessed at that time and had been given a score of fourteen. That score would have placed her at a moderate risk for pressure ulcers. *No pressure ulcer had been documented on her nursing physical assessment form on the readmission date of [DATE]. *On 1/4/13 it had been documented on her weekly skin assessment form of a pressure ulcer to her left medial (inside aspect) heel. Review of resident 4's initial care plan dated 12/26/12 revealed: *Under the focus area of positioning equipment it had been documented by hand with "air mattress". *Under the focus area of supports "cushion in w/c (wheelchair)" had been hand written in that area. *Under the focus area of mobility a nurse had marked the resident had required a wheelchair for mobility and the assistance of one staff member for transfers. *No documentation had been found on her initial care plan to indicate she: -Needed to be repositioned. -Was at high risk for pressure ulcers. - Required her heels to be floated. Review of resident 4's care plans dated 1/10/13, 2/28/13, and 3/02/13 revealed: *She had been at high risk for skin breakdown related to incontinence issues and to refer to POC (plan of care) in the bowel and bladder section. *The bowel and bladder focus area had not reflected her need to be repositioned or her heels floated. *On the care plan dated 2/28/13 she was to have worn foam boots to her feet as she tolerated. *No turning or repositioning schedule had been found in her care plans until 3/2/13. It stated she was to have worn the foam boots to her feet at all times. Her heels were to have been elevated while she was in bed. It had not specified how often she needed to be repositioned. Interview on 3/20/13 at 2:30 p.m. with the director of nursing (DON) revealed: *The care plans should have been updated with any change of condition. *There had not been any turning or reposition schedules put in place. *They had been concentrating on the resident's heels. *She had expected the resident to have been repositioned every two hours. No documentation to support that expectation had been found in any of the resident's three care plans. *She could not locate a Braden scale for the time of readmission. Interview on 3/21/13 at 9:00 a.m. with the Minimum Data Set (MDS) nurse revealed: *She only worked on Tuesdays and Thursdays. That was the only time she had to complete MDSs and care plans for all of the residents in the facility. *She stated the initial care plans are the first ones to be completed upon admission by the admitting nurse. *The comprehensive care plans had not been completed and put in place for the staff to use until after the completion of the MDSs. *Her information for the residents' care plans came from their chart review and the care team meetings only. She had not done any formal assessments on her own. *No repositioning schedule for the residents had been put in place on any of the care plans. *She would have expected to see some type of repositioning schedule for the resident. Review of the provider's MDS Coordinator's job description with a revision date of "6/08" revealed: *Was responsible for the development and total plan of care for each resident. *"Must have the visual and auditorial ability to assess resident conditions." *Should complete skin and physical assessments, and interview staff to determine the resident's care needs. Refer to F314 finding one. Preceptor: 2. Observation on 3/26/13 at 9:57 a.m. of resident 21 revealed: *She was lying flat on her back with oxygen tubing in her nostrils. *She had a persistent wet sounding cough and used accessory chest muscles for breathing. *The bed controls were out of reach at the foot of the bed, so she could not raise the head of her bed. *The call light was out of her reach down by her knees. *A surveyor raised the head of the bed and turned on the call light for assistance. *An unidentified certified nursing assistant answered the call light at 10:03 a.m. Record review revealed the resident had been recently hospitalized for [REDACTED]. *Review of the care plan dated 2/28/13 did not indicate what interventions should have been taken when the resident was having breathing difficulties. Review of the provider's 3/29/10 care planning policy revealed make revisions, corrections, and additions as appropriate.

Preceptor: Based on observation, record review, interview, and policy review, the provider failed to prevent the development of a pressure ulcer for one of one resident (4). Findings include: 1. Observation on 3/20/13 from 9:30 a.m. through 10:35 a.m. revealed: *She was lying on her back in the bed with the bed in the low position. *She had no foam heel protectors on her feet, and the foam wedge (device to help elevate legs to relieve pressure off her heels) was not in position. *At 10:10 a.m. charge nurse A and wound care nurse B did her pressure ulcer treatment. *At 10:35 a.m. charge nurse A put her foam heel protectors on and placed the foam wedge under her legs. Interview on 3/20/13 at 2:00 p.m. with the director of nurses (DON) on the above revealed: *She would have expected resident 4 to have her foam heel protectors on and the foam wedge in place. *She stated the resident's heels were to have been elevated everytime she was in bed and the certified nursing assistants (CNA) knew that. *She had expected the resident to have been repositioned every two hours. Review of resident 4's complete medical record revealed: *She had been admitted on [DATE] with a readmission date of [DATE]. *She had [DIAGNOSES REDACTED]. *Currently had a pressure ulcer on her left heel and was being seen by the wound care specialists, from outside the facility, every two weeks. That pressure ulcer had been identified on 1/4/13. *Her physical assessment form dated 12/26/13, had indicated she did not have a pressure ulcer at the time of readmission. *On 1/8/13 her wound had been identified by wound care nurse B as unstageable and measured 2.25 centimeters (cm) in length and 2.5 cm wide. *The only prevention measures that had been put in place by the nursing staff at the time of readmission were to provide an air mattress and a cushion to her wheelchair. *On 2/14/13 her care plan revealed she should wear heel foam boots at all times. *No turning or repositioning schedules had been put in place on any of the care plans dated 12/26/12, 1/10/13, and 3/2/13. *Her wheelchair had been her only source of mobility. *No Braden scale (a scoring method for predicting pressure ulcer risk) had been done for her upon readmission on 12/26/12 until 2/5/13. Her Braden scale on 2/5/13 was a fourteen putting her at moderate risk for pressure ulcers. *No documentation by the registered dietician (RD) or dietary manager (DM) since her readmission had indicated that the RD had known about the pressure ulcer. *No recommendations or monitoring of her pressure ulcer by the RD had been found. *On 1/26/13 the microbiology report had revealed she had an infection in the left heel pressure ulcer. An antibiotic had been ordered to treat the wound infection. Review of resident 4's dietary documentation on 1/31/13 and on 2/24/13 by the DM made no reference to the pressure ulcer or RD involvement. The last time time the RD had reviewed resident 4's chart had been on 1/3/13. Interview on 3/21/13 at 11:45 a.m. with charge nurse A revealed: *She would have notified the DON of the pressure ulcer. *The DON would have been responsible to report the wound to the DM in daily report. *The nurses would not have been responsible to report the wound to the dietary department. Interview on 3/21/13 at 11:50 a.m. with the RD revealed: *She could not remember having been informed of resident 4's pressure ulcer to her left heel. *She would have been notified of wounds by the DM or by chart review only. *She would not have been notified by the nursing staff of wounds or any change in a resident's condition. *She would review residents' charts that were new admits, had significant changes, and anyone having an annual review. A list had been provided by the DM of any additional charts that needed to be reviewed. Interview on 3/21/13 at 12:20 p.m. with the DON revealed the DM would have been notified right away in daily report of any wounds or pressure ulcers. They were in the process of updating their notification policy on pressure ulcers. Interview on 3/21/13 at 12:30 p.m. with the DM revealed: *She confirmed she would have been informed of any wounds and pressure ulcers in daily report with the department heads. *She could not remember if she had informed the RD of resident 4's pressure ulcer. *She agreed the RD should have been informed. *She agreed there had not been any charting by her or the RD to indicate that the dietary department had been involved with the healing process of the resident's pressure ulcer. *She had a dietary protocol for pressure ulcers and nutritional intake. Review of the provider's undated dietary protocol for pressure ulcers revealed: *Nursing was to have notified the dietary department of residents with an alteration in skin integrity. *Stage I through Stage IV pressure ulcers all required the RD to evaluate them monthly and document in the dietary progress notes. *No protocol for an unstageable pressure ulcer was found. Refer to F279, finding 1, and F361, finding 1.

Based on observation, interview, record review, and policy review, the provider failed to ensure adequate supervision and safety for two of six residents (3 and 15) who smoked. That failure created a situation of immediate jeopardy that had the potential for causing harm to residents who smoked and other residents of the facility. NOTICE: Notice of immediate jeopardy (IJ) was given verbally to the administrator, director of nursing (DON), assistant director of nursing (ADON) and social service director (SSD) on 1/11/12 at 2:00 p.m. The administrator was asked for an immediate plan of correction (POC) to ensure resident safety related to residents who smoked. PLAN: On 1/11/12 at 4:20 p.m. the administrator, DON, ADON, and SSD met with the survey team and provided an initial POC to remove the IJ to the residents in the facility. The written POC dated 1/11/12 included: *Initial plan where resident 15's room was checked on 1/11/12 by the administrator, DON, ADON, and SSD for smoking materials. *The above staff was to check the rooms of all other smokers on 1/12/12 for smoking materials. *The above staff was to review the provider's smoking policy and make changes with formal approval of the policy by the board of directors on 1/27/12. The revisions to the policy stated: ---All cigarettes and smoking materials were to be left at the nurse's station. Nursing staff were to escort each resident outside and light the smoking materials. ---Smoking by residents who required oxygen was strongly discouraged. No oxygen tanks were to be allowed in the smoking area. ---Resident and resident rooms were subject to be checked if there was suspected noncompliance. *A smoking log was created for each resident to log receipt and disposition of cigarettes. *A quality assurance (QA) document was created for weekly checks of each smoker's room for four weeks with monthly checks thereafter. *All scheduled staff were to be educated on the changes of the smoking policy and processes put into place on 1/12/12. *The ombudsman was to be contacted on 1/12/12 to review the changes in policy. *The smoking logs would be reviewed by nurses at the change of shifts and the SSD would review the log books weekly for an indefinite period of time and report findings to the QA/safety committee monthly. The survey team was verbally informed: *The on-duty staff had been informed of the policy changes. *A meeting with all smokers was to be held prior to supper on 1/11/12 to inform them of the change in policy. On 1/11/12 at 4:45 p.m. the written POC and supporting written documents were faxed to the state office for review by the state administrator. The state administrator was contacted at the above time by telephone and he gave informal approval to inform the provider's staff IJ had been removed. The administrator stated the written documents would be reviewed in greater detail and the survey team informed of formal approval of the POC prior to the team's exit from the facility. On 1/12/12 at 7:00 a.m. the survey team leader was informed by the long-term care advisor from the state office of requested changes in the immediate POC prior to formal approval being granted. The proposed changes included: *The paragraph in the revised policy referencing the state agency was to be removed. *The policy was to include review and signature of the smoking policy as a part of the admission process. *The word "search" where it was used within the POC was to be replaced with the word "inspected." On 1/12/12 at 8:15 a.m. the provider's administrator was presented the proposed changes. He agreed to the changes and submitted them by fax to the state office. On 1/12/12 at 9:20 a.m. the assistant administrator from the state office informed the team leader that formal approval of the revised immediate POC was accepted. During the survey on 1/12/12 the surveyor team confirmed removal of the IJ situation. Findings include: 1. On 1/10/12 resident 15 and CNA C were observed at: *4:45 p.m., As the resident approached the first floor nurse's station and asked CNA C for a cigarette. The CNA provided the resident a cigarette from the medication room. The resident wheeled himself part way down the hall and turned around, returning to the nurse's station. He then asked the CNA for a lighter. The CNA asked him if he had a lighter and he replied that he did not. The CNA then found a lighter and gave it to the resident. The resident wheeled himself down the hall toward the smoking area. *4:55 p.m., When resident 15 returned to the nurse's station he returned the above lighter to CNA C. She replaced it in the medication room. *5:00 p.m., As the resident was sitting in his wheelchair in the hall by the nurse's station he was holding a different cigarette lighter in his hand. He then placed the cigarette lighter in his jacket pocket and wheeled down the hall to the dining area. *5:10 p.m., As CNA C was at the nurse's station, this surveyor asked her if resident 15 was allowed to carry a lighter. She replied the resident was not allowed to do so. This surveyor explained he had observed the resident with a lighter in his jacket pocket. The CNA went to the dining area and obtained the above lighter from the resident. She then returned the lighter to the medication room. 2. Review of resident 15's nurses notes revealed: *On 10/1/11 with no time listed "Res.(resident) going outside to smoke with O2 (oxygen) turn on - reminded him he could not smoke with O2 on chair - was yelling and cussing in D.R. (dining room). Sat in DR until nurse left - he went outside after asking another res. for a smoke. CNA brought O2 back into building. Refuse to wear O2 at anytime when up in chair. Was told he could not have smokes if he would not comply - Notified S.W. (social worker) of this incident." *On 10/20/11 at 11:30 a.m. "Care team note - Res. angry can't smoke in room, can't keep cigarettes or lighter in his room, they are locked in med. (medication) room now." *On 10/29/11 with no time listed "Odor of cig. (cigarette) in pt. (patient) room - roommate smelled it as well as staff - Res. denied smoking in his room - a pkg (package) of cig. and lighter brought to the nurses station." *On 10/30/11 with no time listed "Has another pack of cigarettes - Is noncompliant." *On 11/4/11 at 1:30 p.m. "Res. was caught smoking in his room and bathroom - attempted to deny it - witness by CNA, LPN (licensed practical nurse), and DON (director of nursing) - notified S.W. and administrator - is not to smoke or have his cigarettes." *On 11/16/11 with no times listed "Out to smoke today. Never asking nurses for cig." *On 11/27/11 at 11:00 p.m. "Found lighter under pts. pillow, do not know for sure that pt. smoking in rm (room), but another pt. went to store for him to buy cigarettes." *1/3/12 at 2:30 a.m. "CNA caught resident smoking in his room. Removed 2 lighters et (and) 2 packs of cigarettes which were locked in the med. room. Instructed he was not to smoke in the facility et will need to see the charge nurse to get cigarettes." *1/5/12 at 11:00 a.m. "Res. has been caught smoking in his room. Cigarettes are now kept by nursing staff and locked up." Review of resident 15's social progress notes revealed no assessment that indicated he was safe to smoke independently or keep his cigarettes and lighter. There was also no documentation that addressed his smoking in his room. Review of resident 15's social service care plan initiated on 10/3/11 and updated on 1/2/12 revealed his cigarettes and lighter were to be kept at the nurse's station. An undated, unsigned handwritten note revealed "I have smoked in non-smoking areas and do not dispose of my butts (cigarette butts) correctly." Review of resident 15's 6/29/11 care plan revealed: *A problem with education and safety related to smoking habits. *The goal was for the resident to remain free from injury from smoking and would follow the smoking policy. *Approaches included: -No resident would be allowed to smoke tobacco products inside the facility. -Resident who requested permission to smoke upon admission would be assessed as designated to safely smoke on their own, or as an unsafe smoker who must be supervised. -Family and/or cognitive residents would sign the policy to state they acknowledge, understand, and would comply with the statements in the facilities smoking policy. -A physician's orders [REDACTED]. -Smoking for residents who required oxygen was strongly discouraged. Oxygen must be turned off. The cannula or mask and oxygen tank must be removed before lighting any smoking devices and during smoking. Review of resident 15's medical record revealed no smoking assessment or a signed smoking policy. Review of resident 15's medical record revealed a 7/29/09 physician's orders [REDACTED]. Interview on 1/10/12 at 2:45 p.m. with the social worker revealed the smoking policy was in the process of being revised after resident 15 was caught smoking in his room. She also stated other resident's would give or buy resident 15 cigarettes and lighters. Review of the provider's 2011 quality assurance meeting minutes revealed no documentation that smoking for the residents had been identified as a problem. 3. Review of resident 3's nurses notes revealed: *A late entry on 8/21/11 at 5:00 p.m. noted the resident was "seen outside with tank (O2) smoking." Resident stated he had forgotten about the O2 tank. *On 9/11/11 with no time noted "Res - went over safety when smoking and having O2 on the porch. Advise him to make sure to leave wheel chair and O2 in the breeze way when smoking. Safety 1st remind res." Review of resident 3's social progress notes revealed: *On 8/23/11 with no time noted "Res was observed smoking outside with oxygen tank. Spoke to res and he stated it was convenient. Res has been spoken to several times. Res will be spoken to and cigarettes will be kept at nurses station." *No assessment that indicated he was safe to smoke independently or to keep his cigarettes and lighter was found. Review of resident 3's social service care plan initiated on 11/15/11 to 2/13/12 revealed: *"I am a smoker and the smoking policy has been reviewed with me but I refused to sign." *An undated, unsigned handwritten note listed "I have been spoken to about smoking in non-smoking areas and with oxygen." Review of resident 3's medical record revealed no smoking assessment or a signed smoking policy. Review of resident 3's medical record revealed a 7/29/09 physician's orders [REDACTED]. Random observations from 1/9/12 through 1/11/12 revealed resident 3 had cigarettes in his shirt pocket.

Based on observation, interview, record review, and policy review, the provider failed to ensure the appropriate care and services were provided to maintain the highest practible physical well being for one resident (1) with pressure ulcers. Findings include: 1. Review of resident 1's medical record revealed he had facility acquired bilateral unstageable pressure ulcers to his heels. Due to these pressure ulcers he had a decline in his ability to ambulate and also had pain. Refer to F314.

Based on observation, record review, interview, and policy review, the provider failed to prevent bilateral heel pressure ulcers and maintain treatment to prevent further breakdown of those ulcers for one of one sampled resident (1). Findings include: 1. Observation on 1/9/12 at 5:45 p.m. of resident 1 revealed: *He was seated in a wheelchair in his room. *He had soft, quilted, heel protectors on both of his feet. *He was moaning and had facial grimacing. *He stated to registered nurse A that his feet hurt. Interview on 1/10/12 at 9:15 a.m. with resident 1 revealed:*He required more help due to the sores on his heels. *His heels hurt all the time since he developed the sores on his heels. *He used to walk occasionally with a walker, but not since he developed the sores on his heels. *He stated he mostly used his feet to propel his wheelchair. Random observation from 1/10/12 through 1/11/12 of resident 1 revealed: *Resident 1 had soft, quilted, heel protectors on both of his feet. *When he was laying on his bed, his heels were not relieved from pressure due to contact with his mattress. *He propelled his wheelchair by using his feet with a heel-to-toe motion. Review of resident 1's medical record revealed he had been admitted on [DATE]. He had [DIAGNOSES REDACTED]. Review of resident 1's 6/29/11 care plan revealed: *A problem for the potential for skin breakdown related to incontinence. *He was to receive interventions related to skin care for incontinence that included a toileting schedule and cleansing after any incontinent episodes. *On 10/6/11 a pressure relieving mattress was initiated. *On 11/15/11 heel wound care was initiated per physician's orders [REDACTED]. *A problem that he may require assistance with his activities of daily living. *An 11/15/11 intervention for transfers with a stand-up lift or a two person lift. Review of resident 1's 11/18/11 care plan revealed: *He had a problem listed for alteration in skin integrity related to his [DIAGNOSES REDACTED]. *The goal was his heel wounds to have been a stage 3 or less by 2/18/12. *Interventions included wound care, repositioning every one to two hours, a pressure relieving mattress, and to float the heels when in bed. *He had a problem listed for alteration in comfort related to his [DIAGNOSES REDACTED]. *The goal was he would verbalize his pain as less than a four (on a scale of one to ten) after as needed (PRN) medications had been given. *Interventions included an assessment of his pain every shift and PRN, repositioning every one to two hours and PRN, and to float the heels when in bed. Review of a 10/21/11 wound assessment for resident 1 revealed: *He had acquired right and left heel pressure ulcers. *The right heel pressure ulcer measured 2 1/2 centimeters (cm) in length by 3 1/2 cm in width. *The left heel pressure ulcer measured 3 cm in width by 3 1/2 cm in length. *There was a note stating "evolving deep tissue damage." *Both heels were listed as having black and purple coloration and the surrounding area was red. *His treatment goals had been listed as pressure redistribution, promoting circulation, and promoting granulation/contraction/re-[MEDICATION NAME] (the area would heal). Continued review of resident 1's wound assessments revealed: *On 10/24/11 the right heel measured 1.5 cm by 2.25 cm and the left heel measured 1.25 cm by 1.25 cm. Both had evolving deep tissue damage. *On 10/29/11 the right heel measured 1.25 cm by 1.0 cm and the left heel measured 1.0 cm by 0.85 cm. Both were probably evolving into eschar. Resident wore booties at night and non-skid slippers during the day. *There were no measurements between 11/5/11 to 11/15/11 because he was hospitalized . *On 11/17/11 the right heel measured 2.75 cm by 2.0 cm and the left heel measured 1.50 cm by 1.50 cm. *On 11/23/11 no measurements were documented. "Wound is ever evolving to black eschar. Area is worsened from time he left hospital to now. Patient has chronic [MEDICAL CONDITION], blind/no feeling in feet, can't walk on it. Healing prognosis poor." *On 11/27/11 the right heel had two areas of black eschar. Those areas measured 1.5 cm by 3.0 cm and 2.0 cm by 1.0 cm. The left heel measured 3.25 cm by 1.75 cm. "Wound is deteriorating at a rapid rate, another necrotic area is developing." *On 12/5/11 the two right heel pressure ulcers measured 1.5 cm by 3.5 cm with a macerated bloody area and 1.25 cm by 2.5 cm. The left heel measured 3.25 cm by 1.50 cm. *On 12/10/11 the two right heel pressure ulcers measured 1.5 cm by 3.5 cm with a macerated area and 1.0 cm by 2.0 cm. The left heel measured 3.25 cm by 1.50 cm. The physician was notified of the wound deterioration. *On 12/19/11 the two right heel pressure ulcers measured 1.8 cm by 3.5 cm and the second area was documented as being two different scabbed areas. The left heel measured 3.25 cm by 1.50 cm. *On 12/27/11 the right heel had one area measured 3.0 cm by 2.0 cm and the left heel measured 3.0 cm by 4.5 cm. Eschar areas were growing, the physician had been notified the wounds were not healing. *On 1/2/12 the right heel measured 2.5 cm by 3.5 cm and the left heel measured 3.75 cm by 6.25 cm. The physician was aware of the blackened heels, "but tonight resident complained of pain to right heel. Message left for physician about heel." Review of resident 1's physician's orders [REDACTED]. Do not wear shoes, use slippers of gripper socks during day and foam booties at night. Has evolving deep tissue damage to both heels." Those orders continued until 12/6/11. *12/6/11 new order to cleanse open areas gently with [MEDICATION NAME] solution, pat dry, dab a small amount of [MEDICATION NAME] ointment to open areas, secure with [MEDICATION NAME], and wrap with Kling wrap. Continue current heel protectors. *12/27/11 schedule for clinic visit for debridement of each heel. *1/5/12 at 3:00 p.m. resident 1 had a deep sharp debridement of his bilateral heels. He was placed on antibiotics and an order was received for [MEDICATION NAME] 5 milligram (mg)/325 mg one tablet every four hours PRN pain. Review of resident 1's Braden scale (scoring tool for predicting pressure sore risk) revealed his scores on 9/12/11, 9/21/11, and 11/5/11 were 17. Sensory perception was slightly limited, his skin was occasionally moist, he walked occasionally, his mobility was slightly limited, his nutrition was adequate, and he had a potential problem with friction and shear. His scores on 11/17/11, 11/28/11, and 12/7/11 were 16. His change on 11/17/11 was from walking occasionally to becoming chairfast. A total score of 15 - 18 was considered a mild risk. Review of resident 1's 9/27/11 annual Minimum Data Set (MDS) 3.0 assessment revealed:*He was at risk of developing pressure ulcers. *He had no pressure ulcers. *He had pressure relieving devices for his bed and chair. *He had no pain. *He required extensive assistance with ambulation with a walker. Review of resident 1's 11/18/11 significant change in status MDS 3.0 assessment revealed: *He was at risk of developing pressure ulcers. *He had two unstageable pressure ulcers. *He had a pressure relieving device for his bed. *He had pain frequently. *His pain was classified as moderate. *He limited his day-to-day activities due to pain. *He had received PRN medications for pain. *He had not ambulated. *A wheelchair was his primary mode of locomotion. Interview on 1/11/12 at 1:30 p.m. with the assistant director of nursing revealed: *She was aware resident 1 had acquired deep tissue injury pressure ulcers to his heels. *She agreed the booties he wore had not provided any pressure relief. *She agreed he propelled his wheelchair with his feet and heels. *She agreed he now had pain due to the pressure ulcers. *She agreed he was no longer ambulating with staff due to the pressure ulcers. Review of the provider's 3/7/06 pressure ulcer prevention, assessment, treatment, and documentation policy revealed all pressure ulcer occurrences would be analyzed to ascertain the cause. Review of the provider's September 2010 skin wound treatment standing orders policy revealed: *All residents were at risk for acquiring pressure sores. *Residents especially at risk for acquiring pressure sores were those with chronic illnesses such as diabetes, [MEDICAL CONDITION], and [MEDICAL CONDITION]. *Residents at risk were to adhere to the pressure ulcer prevention, assessment, treatment, and documentation policy. *Change positions every two hours. *Heel protectors and other pressure relieving devises would have been used as appropriate. *Documentation of the specific pressure relieving device used would have been done.