Every finding on record at Spearfish Canyon Healthcare

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, and interview, the provider failed to ensure one of one sampled resident (1) remained free from verbal abuse by one of one certified nurse aide (CNA) D.Findings include:1. Review of the provider's 9/16/25 submitted SD DOH FRI report regarding resident 1 revealed that at 6:30 a.m. on 9/16/25, CNA C and CNA D were conducting walking rounds (a process where outgoing and oncoming staff complete a handoff report regarding resident care information at each resident's bedside) on the 400 Hall. Resident 1 exited her room and asked for assistance. CNA D replied to resident 1, I don't have time for your [expletive word]. CNA C intervened by assisting resident 1 back into her room, and then directed CNA D to exit the facility. CNA C reported the incident to director of nursing (DON) B that same day at 8:30 a.m.DON B suspended CNA D from working on 9/16/25 pending the outcome of the facility's investigation of the above incident. She interviewed other staff members who were near CNA C, CNA D, and resident 1 on 9/16/25, when the incident occurred. Those staff members confirmed hearing the above verbal interaction by CNA D to resident 1. DON B ensured that the resident's medical provider and her power of attorney (someone designated on a legal document to act on behalf of a resident) were notified of the incident.2. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances and anxiety (anticipation of future changes or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). Her 9/17/25 Brief Interview for Mental Status (BIMS) assessment score was 10, which indicated her cognition was moderately impaired. On 1/9/26, resident 1 transitioned to hospice services.3. Observation on 4/20/26 at 10:15 a.m. of resident 1 revealed she was asleep in her bed and unable to be interviewed. 4. Review of CNA D's personnel file revealed she was hired at the facility on 6/25/25. On that same date, she completed education on resident abuse and neglect reporting, residents' rights, and the provider's grievance policy and procedure. She signed off on her understanding of the provider's abuse policy on 6/28/25. CNA D's CNA certification was current, and there were no known disciplinary actions associated with that certification. Her background check was completed on 6/18/25 and had no remarkable findings.5. The provider's implemented actions to mitigate the likelihood of the deficient practice from reoccurring were verified on 4/20/26 after record review, and interview with administrator A and DON B revealed that the facility had followed its quality assurance (QAPI) process regarding verbal abuse towards residents by interviewing resident 1 on 9/16/25 regarding the above incident. Resident 1 voiced no concerns regarding her care. Her psycho-social well-being was assessed and determined to be at baseline according to DON B. They monitored and documented resident 1's behavior and her psycho-social well-being following the incident. They ensured resident 1's care plan was reviewed and updated related to her impaired cognition and her history of behavioral concerns. Changes to resident 1's mood-altering medications were monitored, and her medical provider was kept informed of any resulting changes in resident 1's physical and mental health. Resident 1's family and power-of-attorney participated in care plan meetings and were informed of pertinent changes in the resident's physical and mental health.In addition, a sample of residents were interviewed between 9/17/25 and 9/18/25 regarding any care concerns they had, how staff interacted with them, and their feelings of safety. No issues were identified. CNA D was terminated from employment on 9/22/25. All staff were educated (9/30/25) regarding the process of de-escalating residents with challenging behaviors. The incident was brought to the facility's Quality Assurance and Performance Improvement meeting for further review by that interdisciplinary team.Based on the above information, non-compliance at F600 occurred on 9/16/25, and based on the provider's corrective action plans that were initiated on 9/16/25 and implemented for the deficient practice confirmed on 4/20/26, the non-compliance is considered past non-compliance.

Based on observation, record review, interview, and policy review, the provider failed to ensure follow standard food safety practices to ensure:*One of one low-temperature dishwasher's temperature was consistently monitored and documented to ensure it met the required minimum wash temperature for sanitation of items used to prepare and serve food to the residents.Findings included:1. Observations on 8/26/25 at 10:32 a.m. and 10:37 a.m. in the kitchen revealed: *The logs for the dishwasher temperatures for August 2025 were hanging on the wall and included:-Columns to record Temp (temperature) for B (Breakfast), L (Lunch), and D (Dinner), Sanitizer Concentration (PPM) (parts per million), and Initials.-Those temperature columns had documented temperatures that ranged from 110 to 126 degrees F (Fahrenheit)--Thirty-six of those documented temperatures were not at the minimum required temperature of 120 degrees F.-For July 2025:-The dishwasher temperatures documented in the columns titled Temp (temperature) for B (Breakfast), L (Lunch), and D (Dinner).-ranged from 110 to 130 degrees F.--Five of those temperatures were not at the minimum required wash temperature of 120 degrees F.-There were had 41 out of 93 opportunities in July 2025 that did not have documented dishwasher temperatures. 2. Interview on 8/26/25 at 10:45 a.m. with dietary supervisor (DS) J revealed she:*Had been employed with the facility as the DS for only a short time.*Was unaware of the dishwasher's low wash temperature readings.*Stated she would call the service department that they lease the dishwasher from to schedule maintenance.-She was unsure of the last time the leased dishwasher had been serviced. 3. Interview on 8/27/25 at 1:55 p.m. with dietary aide K revealed she ran the dishwasher three times after breakfast before the water temperature reached 120 degrees F. 4. Further interview on 8/27/25 at 2:10 p.m. with DS J revealed she:*Had been employed with the facility as the DS since 6/25/25.*Called the service department that they lease the dishwasher from, and they informed her that they would only service the dishwasher if they had problems with the chemicals, not the water temperature.*Had the maintenance technicians inspect the dishwasher that day, and they advised her that the kitchen staff would need to run the dishwasher multiple times to get the water temperature to 120 degrees F.*Agreed there were several unrecorded temperatures on the dishwasher temperature logs.*Had been training new staff, and had forgotten to check the dishwasher logs. 5. Interview on 8/28/25 at 8:32 a.m. with maintenance technician E revealed he:*Informed the DS that the kitchen staff would need to run the dishwasher multiple times to reach the required temperature of 120 degrees F.*Was unaware of the dishwasher's low wash temperature readings before the DS informed him. *Had not been asked to perform maintenance on the dishwasher in the past few months. 6. Interview on 8/28/25 at 8:40 a.m. with administrator A revealed:*She was unaware of the dishwasher's low wash temperature readings.*She expected the kitchen staff to have notified the DS of the dishwasher's low wash temperature readings.*There had been no gastrointestinal outbreak in the facility. 8. Review of the provider's 6/15/25 Dishwasher Temperature policy revealed: It is the policy of this facility to ensure dishes and utensils are cleaned under sanitary conditions through adequate dishwasher temperatures. 4. For low temperature dishwashers (chemical sanitization):a. The wash temperature shall be 120 degrees F.b. The sanitizing solution shall be 50ppm (parts per million) hypochlorite (chlorine) on dish surface in final rinse.

Based on observation, interview, record review, and policy review, the provider failed to ensure a homelike environment for one of one sampled resident (39) due to the noise level in his room and that one of one sampled resident (61) had a hand towel available to dry himself after he had used his handwashing sink. Findings include: 1. Observation on 8/26/25 at 3:50 p.m. in resident 61's room revealed: Certified nurse aide (CNA) L assisted the resident in his bathroom after he had used the toilet. The resident used a grab bar beside the toilet to hold himself up while CNA L completed his peri-care, helped him with his clothing, and transferred him to his wheelchair with assistance from the resident's wife. There was a wall-mounted soap dispenser and paper towel dispenser near the resident's hand washing sink. It was just outside of his bathroom. CNA L had used that sink to wash and dry her hands after she exited the bathroom. She had not reminded or assisted resident 61 to wash his hands after he had exited the bathroom. There were no cloth towels on the towel rack that was mounted on the side of the countertop sink. There was a wadded-up washcloth that sat on top of the sink counter. Interview on 8/26/25 at 4:00 p.m. with resident 61 and his spouse revealed that the spouse had asked staff at different times for a clean washcloth and hand towel to be left on the towel rack for the resident to use, but that request was inconsistently accommodated. The resident confirmed he was able to independently use his handwashing sink. He was able to reach the paper towels and the soap dispenser. He preferred using cloth towels rather than paper towels because he had used cloth towels at home. Observations on 8/27/25 at 8:30 a.m. in resident 61's room revealed that same used washcloth observed above remained on the sink's countertop. There were no cloth towels on the towel rack. At 1:50 p.m., the used washcloth had been removed and not replaced with a clean one. There were no cloth towels on the towel rack. Interview on 8/27/25 at 2:05 p.m. with CNA L revealed it was her responsibility to ensure resident 61 had a clean washcloth and hand towel on his towel rack to use. That had not occurred. Interview on 8/27/25 at 2:15 p.m. with director of nursing (DON) B revealed she had not known that resident 61's washcloths and hand towels were not consistently placed on the resident's towel rack for him to use as he preferred. His preference for using cloth towels to wash and dry his hands was not accommodated, but it should have been. Review of the provider's revised 6/10/25 Safe and Homelike Environment policy revealed 4. The facility will provide and maintain bed and bath linens that are clean and in good condition. Based on observation, interview, record review, and policy review, the facility failed to provide a homelike environment for one of one resident (39) due to a very loud pressure valve release noise from bulk oxygen tanks placed directly outside the wall of the resident’s room. 2. Observation and interview with resident 39 in his room on 8/26/25 at 5:03 p.m. revealed: *He was the only occupant of the room. *He preferred to lie flat in his bed for much of the day due to chronic thoracic (middle section of the spine) pain. *He liked to listen to books on tape but would also watch television sometimes. *His bed was placed with the long side against the exterior wall of the room. *Approximately 11 large bulk oxygen tanks were grouped along the exterior wall of the room. *The tanks intermittently released pressure with a loud, aggressive hissing noise. -Each tank release noise lasted from 5 to 15 seconds. -The noise level interrupted the ability to converse or hear the television. *He wore headphones a lot to help block the noise. *He said the tanks’ release noises interrupted his thoughts, activities, and disturbed his sleep. *He felt the tanks’ release noise increased his anxiety and caused him to be startled frequently. *He stated he hated the noise and it was often louder than the one experienced at that time. *The noise had been present since he admitted to the facility last year. *He had not asked for a different room as he was grateful to be there. *He felt that the noise aggravated his anxiety and negatively affected his mental health. Observation on 8/27/25 from 9:30 a.m. to 9:45 a.m. outside of resident 39’s room revealed: *There was no pattern to how often the tanks’ release noise would occur. *The tanks’ release noise occurred three times during approximately 15 minutes of observation. -The tanks’ release noise level varied but could be heard and clearly identified in the hall 30 feet from resident’s room with the room door closed. Review of the resident 39’s electronic medical record (EMR) revealed: *Resident 39 was admitted on [DATE]. *His admitting diagnoses included: *Generalized Anxiety Disorder (a chronic mental health condition characterized by excessive and persistent worry and anxiety that is difficult to control.) *Post-traumatic stress disorder (PTSD) (a mental health condition that’s develops after experiencing or witnessing a traumatic event.) *Schizotypal disorder (a mental disorder characterized by thought disorder, paranoia, and social anxiety.) *Other schizoaffective disorder (a mental health condition marked by a mix of symptoms such as hallucinations and delusions, and mood disorder symptoms such as depression.) *He had a Basic Interview for Mental Status (BIMS) assessment score of 14, which indicated his cognition was intact. Review of resident 39’s care plan revealed: *Resident 39 had screened positive for PTSD related to prior Vietnam war service. *Resident had triggers identified to a history of trauma that included excessive or prolonged television (TV) viewing, especially TV programming with action scenes. *Resident 39 experienced stressful or startled responses when others walked quickly or stomped behind him. Interview on 8/27/25 at 9:30 a.m. with Social Services Designee H regarding oxygen tank release noise levels in resident 39’s room revealed: *She was not aware of the noise made by the bulk oxygen tanks releasing pressure. *She agreed that his PTSD and anxiety could be aggravated by that noise Interview on 8/28/25 at 8:40 a.m. with maintenance technician E revealed: *He was aware of the noises from the oxygen tanks releasing pressure. *He had not heard it from inside the resident 39’s room. *He had not thought about if the noise was disturbing resident 39. *He thought residents would “probably get used to it.” Interview on 8/28/25 at 8:48 a.m. with certified medication aide (CMA) F revealed: *She was not aware of the oxygen tanks’ release noise in resident 39’s room. *She stated she “was probably used to it.” *She wouldn’t want a resident to be constantly disturbed. Interview on 8/28/25 at 9:30 a.m. with registered nurse (RN) G revealed she was not aware of the tanks’ release noises in resident 39’s room. Interview on 8/28/25 at 9:50 a.m. with resident 39 revealed: *The social worker had come to visit him about the tank noise on 8/26/25. *He had told her that the noise was extremely startling, increased his stress and anxiety, and interrupted his activities and thoughts. *The tank released while he was talking, startling both resident and this surveyor. *He was grateful to have a roof over his head, but was very happy to be moving to a new room away from the noise. Interview on 8/28/25 at 12:20 p.m. with administrator A revealed: *The bulk oxygen tanks had been placed in that location prior to her return to the facility approximately two years ago. *Now aware of the noise, they intended to move the tanks away from resident rooms. *They would not have a resident reside in that room until the tanks were moved. Review of the providers safe and homelike environment policy revealed: *”In accordance with residents’ rights, the facility will provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible.” *”Comfortable sound levels” was defined to mean “levels that do not interfere with resident’s hearing, levels that enhance privacy when privacy is desired, and levels that encourage interaction when social participation is desired.”

Based on observation, interview, record review, and policy review, the provider failed to implement a process that ensured an accurate accounting of daily fluid intake for one of one sampled resident (4) on dialysis with a physician-ordered fluid restriction. Findings include:1. Observation and interview on 8/27/25 at 8:15 a.m. with resident 4 revealed she was returning to her room from the dining room after breakfast. She was not available for an interview on 8/26/25 because she had been at dialysis for most of that day. She dialyzed on Tuesdays, Thursdays, and Saturdays. There were 13 bottled waters, a six-pack of soda, and a lidded cup with water inside it in her room. She had opened one of those bottled waters and drank from it during the interview. She stated her medical provider had told her she should be trying to get rid of fluid, and avoid drinking a lot of fluids. Review of resident 4's electronic medical record (EMR) revealed a 4/17/22 physician's order for: Fluid Restriction: 1500 cc [cubic centimeters] per day. Dietary: 320 cc 3 X [times]/day [per day]. Nursing: 120 cc 3x/day med [during medication] pass: 60 cc 3x/day. Interview on 8/27/25 at 3:20 p.m. with licensed practical nurse (LPN) R regarding resident fluid restrictions revealed that a Huddle Book was kept at the nurses' station. The huddle book was referred to by caregivers for resident-specific information, including which residents had fluid restrictions. Resident 4's name was on that fluid restriction list. Regarding the excessive number of fluids available to the resident in her room, LPN R stated a bottled water and a lunch were sent with the resident on her dialysis days. The resident often had not consumed the bottled water at dialysis and brought it back with her to her room. LPN R stated that those unused bottled waters should have been removed from the resident's room when the nurse had completed the resident's post-dialysis assessment. On 8/27/25 at 4:20 p.m., a copy of resident 4's fluid intake documentation for one week was requested from director of nursing (DON) B. Interview on 8/27/25 at 5:20 p.m. with DON B revealed that when a resident had a physician-ordered fluid restriction, that restriction was to be added to the resident's treatment administration record (TAR). Daily fluid intakes were to be documented, calculated, and monitored on that TAR to ensure compliance with the physician's order. Resident 4's fluid restriction order information had not been added to her TAR. Her daily fluid intake had not been calculated or monitored to determine if her fluid restriction was being followed as ordered. Review at that same time with DON B of the communication tool used between the provider and the dialysis unit revealed no noted concerns by either entity regarding the resident having potentially not followed her fluid restriction. DON B agreed that failing to follow the provider's processes for accounting for resident 4's fluid restrictions and not removing unnecessary fluids from the resident's room had placed that resident at risk for potential harm. Review of the provider's revised 5/2/25 Fluid Restriction policy revealed:1. The breakdown of a resident's fluid intake will be recorded on the medication record or other format as per facility protocol.4. Water will not be provided at the bedside unless calculated into the daily total fluid restriction or unless specifically ordered by the physician.

Based on observation, interview, record review, and policy review, the provider failed to ensure:The whiteboard communication board in one of one sampled residents' rooms (61) was updated to reflect the amount and type of caregiver assistance required for him to safely transfer from his toilet to his wheelchair. The safety of one of one sampled resident (61) who was not transferred by one of one certified nurse aide (CNA) L as directed in the resident's care plan and the provider's huddle book (a communication tool that informs caregivers of residents' care needs), which may have increased his risk for falling and/or injury. Findings include: 1 Observation on 8/26/25 at 3:50 p.m. in resident 61's room revealed a wall-mounted whiteboard with the following information written on it: 7/17[/25]: SPT [stand pivot transfer-a staff person assists the resident to a standing position, and the resident then turns their body to move to another surface] w/FWW [front wheeled walker] assist X1 [assisted by one staff person]. There was a folded mat propped against the wall at the foot of the resident's bed.Continued observation revealed CNA L was with resident 61 inside his bathroom, assisting him off the toilet. Without first putting a gait belt around the resident's waist (a waist strap gripped by the caregiver and used as support for safe mobility and transfer), she lifted up on the resident's pants and verbally cued him to use the wall-mounted grab bar next to the toilet to help pull himself up off the toilet to stand. The resident had repeatedly stated he was too weak to pull himself up to stand. He called out for his wife to help.After hearing the resident call for her help, the resident's spouse entered the bathroom with a gait belt and handed it to CNA L. CNA L then placed the gait belt around the resident's waist. The gait belt enabled CNA L to provide the support resident 61 needed to come to a standing position, pivot, and lower himself onto his wheelchair seat safely. Interview on 8/26/25 at 4:20 p.m. with CNA L regarding the above transfer revealed she was expected to have used a gait belt whenever she had assisted a resident with a transfer. It was a standard safety and fall prevention intervention. She stated she referred to the information on the whiteboards in residents' rooms to know how to properly transfer the residents. She had not known who was responsible for updating the information on the residents' whiteboards.Interview on 8/26/25 at 4:30 p.m. with resident 61 and his spouse revealed that he had been awake early and had been busy throughout that day with therapy and outpatient appointments. His physical stamina was diminished. He had fallen since he was admitted to the facility. His bed was lowered at night, and the fall mat observed above was to be placed along the side of his bed at night, related to his risk for falling. Review of resident 61's electronic medical record (EMR) revealed his admission date was 4/17/25. His diagnoses included a right femur (upper leg/thigh) fracture and chronic obstructive pulmonary disease (a chronic breathing disorder).An 8/18/25 event note indicated: CNA stated she was attempting to transfer resident [61] from his bed to his wheelchair for toileting, his right leg slid forward causing [the] resident to be lowered to the floor onto his buttocks. There was no injury to the resident as a result of that fall. An 8/19/25 Fall Assessment-Post Incident score was 18. That indicated the resident was at high risk for falling.Review of resident 61's current care plan initiated on 4/18/25 revealed a focus area of Transfers/Bed Mobility/Ambulation. A revised 6/19/25 intervention for that focus area indicated resident 61 required extensive assistance of 1 staff person with bed mobility, transfers and ambulation. That intervention was revised again on 7/21/25 by director of rehabilitation C and indicated Assist X 2 [by two staff persons] stand pivot transfer [a staff member assists the resident to a standing position, and the resident then turns their body to move to another surface] with FWW [a front-wheeled walker] and [the use of a] gait belt. Interview on 8/27/25 at 9:30 a.m. with director of nursing (DON) B revealed the whiteboards in residents' rooms were to be maintained and updated by the therapy department. If the whiteboard was updated, those changes were documented on a Therapy to Care Plan-Communication Tool. Copies of that tool were distributed to the provider's Minimum Data Set (MDS) Coordinator, the DON, and the nurses' station. Nursing staff were to communicate those resident-specific changes to caregivers during shift changes. Copies of those tools were placed in a Huddle Book that contained resident-specific care information and was kept at the nurses' station for the caregivers to reference. Review of the above Huddle Book revealed a 7/17/25 Therapy to Care Plan-Communication Tool, signed by physical therapist Q, had indicated resident 61 required a 2 person stand pivot transfer with FWW and gait belt.Interview on 8/28/25 at 10:25 a.m. with physical therapy assistant (PTA) P regarding the 7/17/25 expectations for transferring resident 61, and the transfer information documented on his whiteboard revealed that the information on his whiteboard was outdated and not accurate. She confirmed resident 61 had required the assistance of two staff persons and the use of a gait belt when he was transferred. Physical therapist Q was not available to interview.Interview on 8/28/25 at 11:30 a.m. with director of rehabilitation C regarding resident 61 revealed that the process used to ensure caregivers were informed of and educated on changes in resident 61's transfer needs failed. Caregivers referred to the transfer information on a resident's whiteboard to know how they were expected to transfer that resident. That failure placed resident 61 at a higher risk for having been injured and/or falling when he was transferred. PT Q was should have updated resident 61's whiteboard at the same time she completed her 7/17/25 Therapy to Care Plan-Communication Tool that included the resident's updated transfer recommendations. Review of the provider's revised 5/15/25 Resident Handling/Transfers policy revealed 13. Staff members are expected to maintain compliance with safe handling/transfer practices. 14. Resident lifting and transferring will be performed according to the resident's individual plan of care.

Based on observation, interview, and policy review, the provider failed to ensure two of two observed medication refrigerators had not contained expired vaccines that were available for administration to the residents. Findings include: 1. Observation on 8/28/25 at 1:45 p.m. of the medication room refrigerator in the [NAME] Hall revealed: *Ten influenza vaccines had expired on 6/30/25. *One pneumococcal 13-valent vaccine had expired on 4/2025.Interview immediately after having identified the above expired vaccines with registered nurse (RN) G revealed:*She had thought that the night nursing staff had been checking for expired vaccines and medications.*She was unsure if there had been any other staff who were responsible for checking for expired vaccines and medications.2. Observation on 8/28/25 at 2:15 p.m. of the medication room refrigerator in the green hall revealed:*Three influenza vaccines had expired on 6/30/25.*One pneumococcal 13-valent vaccine had expired on 4/2025. Interview immediately after having identified the above expired vaccines with licensed practical nurse (LPN) I revealed:*She thought the pharmacist checked for outdated medication once a month.*She was not aware that those expired vaccines had been in the refrigerator.*She was unsure if the night nursing staff had been checking for expired medication. Interview on 8/28/25 at 2:30 p.m. with director of nursing (DON) B regarding the expired vaccines in the two medication room refrigerators revealed:*She was not aware there was expired vaccines in the two refrigerators.*She stated the consultant pharmacist was to check for expired medications and vaccines once a month.*All staff that administered vaccines should have checked the expirations dates.*The expired vaccines should have been removed and sent back to the pharmacy for drug destruction. Review of the provider's June 2025 Hazardous Waste Pharmaceuticals revealed:*Facility staff with approved access to pharmaceuticals will store, administer, and discard pharmaceuticals in accordance with relevant facility procedures.*Expired medications sent for drug destruction.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were followed by:One of one observed certified medication aide (CMA) (M) who did not clean one of one sampled resident's (76) inhaler after it was used for medication administration.One of one observed certified nurse aide (CNA) (N) who did not complete hand hygiene (handwashing) during a transition in cleaning urine from the floor and handling one of one sampled resident's (63) catheter urine collection bag valve.One of one observed CNA (L) who had not reminded or assisted one of one sampled resident (61) to perform hand hygiene after he had used the bathroom.Findings include: 1. Observation and interview on 8/26/25 at 11:37 a.m. with CMA M after she had administered resident 76's medication through an inhaler revealed:Without first cleaning the mouthpiece of the inhaler, CMA M placed the uncleaned inhaler back into its box inside the medication cart.The box top was opened and stored with other residents' medications.She stated that she should have used an alcohol pad to clean the mouthpiece after it was used to mitigate the resident's risk of infection or cross-contamination, but she had not done that. 2. Observation and interview on 8/26/25 at 12:21 p.m. with CNA N in resident 63's room revealed:Resident 63 was seated in his recliner. There was a large amount of urine on the floor in front of and to the side of his recliner.After CNA N lifted the resident's pant leg, CNA N stated the valve of the resident's urinary catheter bag was not properly tightened and that caused the urine inside the catheter bag to leak out and onto the floor.CNA N performed hand hygiene, then put on a gown and a pair of gloves. He used cloth towels to absorb the urine from the floor. With those same gloved hands, CNA N adjusted the resident's urinary catheter bag valve and resumed cleaning the floor.CNA N stated he was not sure at what point in the above observation that he should have removed his gloves, performed hand hygiene, and put on a clean pair of gloves. He agreed that using unclean gloves while handling the catheter bag valve had increased resident 63's risk for infection. 3. Observation and interview on 8/26/25 at 3:50 p.m. with resident 61, after CNA L had assisted him to use the bathroom, revealed:CNA L exited the bathroom, removed and discarded her gown and gloves. Outside of the bathroom, there were wall-mounted paper towel and soap dispensers near the handwashing sink that she used to perform hand hygiene. She had not reminded or assisted the resident to perform hand hygiene after he had exited the bathroom.Resident 61 confirmed he was able to independently use the handwashing sink to wash and dry his hands. He had not always remembered to perform hand hygiene after he used the bathroom without staff reminding him. Interview on 8/27/25 at 2:05 p.m. with CNA L regarding the above resident observation revealed she had not reminded or assisted resident 61 to wash his hands after he had used the bathroom, but she should have. She agreed that resident hand washing after bathroom use was an important infection prevention intervention. Interview on 8/28/25 at 2:07 p.m. with Infection Preventionist O regarding the above observations revealed that she confirmed the above observed staff missed opportunities to mitigate the risk of infection. Review of the provider's revised 5/20/25 Administration of Metered-Dose Inhaler (MDI) policy revealed: 18. When all the ordered inhalations have been administered, remove the spacer (if used) from the MDI, and wash the spacer and mouthpiece according to the manufacturer's instructions. Review of the provider's revised 4/10/25 Hand Hygiene policy revealed: 2. Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. That hand hygiene table included the following condition: When, during resident care, moving from a contaminated body site to a clean body site. A Glove Use policy was requested from administrator A on 8/28/25 at 3:10 p.m. At 3:45 p.m. on 8/28/25, administrator A stated the facility had no Glove Use policy.A Resident Hand Hygiene policy was requested from administrator A on 8/26/25 at 12:05 p.m. At 2:50 p.m. on 8/28/25, administrator A stated the facility had no Resident Hand Hygiene policy.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, staff interview, and policy review, the provider failed to ensure an environment free of safety hazards for:*One of one sampled resident (4), who sustained a skin burn injury from hot liquid (broth) that was improperly prepared by cook (H) who did not follow the facility's established procedures for safe food preparation and service.*One of one sampled resident (1), who fell when CNA O assisted her to walk without the use of a gait belt.Findings include: 1. Review of the provider’s 3/25/25 SD DOH facility reported incident (FRI) revealed: *On 3/25/25 at approximately 8:24 a.m., physical therapist (PT) N answered resident 4’s call light. *Resident 4 reported to PT N that she had spilled her broth on her right leg. *PT N immediately notified licensed practical nurse (LPN) Q, who entered resident 4’s room at approximately 8:25 a.m. *With resident 4’s consent, LPN Q immediately assessed resident 4’s leg area and noted redness to the area on her right leg. Resident 4 had no complaints of pain at that time. *LPN Q gently dried the area, ensured resident 4’s comfort, and alerted director of nursing (DON) B of the situation. *Silvadene was applied to the area to treat the skin and prevent further damage. *The doctor and the power of attorney (POA) were notified. *On 3/25/25, resident 4 was seen by a physician assistant for increased lethargy and decreased alertness that had been noted on 3/24/25. She was also evaluated for the burn at that time. *On 3/25/25, LPN Q noted that resident 4 was awake and visiting with staff before breakfast. *On 3/25/25, cook H prepared the broth using water from the stovetop kettle. -The stovetop kettle was normally used to make hot cereal. *Education was completed with all dietary workers to ensure that hot beverages are made from the coffee machine, which also dispenses hot water, at a reduced temperature of 135°F to 140°F. *Hot liquid safety evaluation audits were conducted for all residents in the facility to ensure accuracy. *Facility education was provided to nursing and dietary staff to ensure that: -Nursing staff assisted residents who choose to eat in their rooms with proper positioning prior to meals or beverages being served. -When hot liquids are served, dietary staff must ensure beverages are in a handled cup with a lid and must communicate with nursing staff to monitor residents in their rooms. *Audits were conducted to monitor the temperature of food and beverages, and no concerns were identified. 2. Review of resident 4’s electronic medical record (EMR) revealed: *She was admitted on [DATE] after surgical repair of a left hip fracture that resulted from her fall at an assisted living facility (ALF) and had been discharged back to that ALF. *She had a Brief Interview for Mental Status (BIMS) assessment score of 13, which indicated she was cognitively intact. *Her diagnoses included a history of transient ischemic attack (TIA) (a “mini-stroke”), age-related macular degeneration (an eye disease typically associated with aging that can cause significant vision loss), fracture of neck of left femur (hip fracture), and tremor (involuntary muscle contraction causing shaking or trembling) unspecified (specific type or cause of the tremor not yet identified). *A 3/26/25 nursing note indicated “Assessed resident right thigh burn today, she has a 2.5 cm [centimeter] area where the blister opened, skin is beefy red with no s/s [signs/symptoms] of infection.” *A 4/11/25 discharge summary indicated resident 4 had skin issues described as “Burn to R [right] outer thigh- healing.” 3. Interview on 7/8/25 at 1:37 p.m. with certified medication aide (CMA) C revealed: *Dietary staff would deliver room trays to resident rooms. *Some residents routinely chose to eat in their rooms. *Room trays were delivered after the dining room meals were served. *Dietary staff would set up the meal tray for the resident in their room. *CMA C stated that staff had received education about how to safely position residents for eating in their rooms. *She stated that staff had received “a lot” of education about hot liquid safety. 4. Interview on 7/8/25 at 1:48 p.m. with Certified Nursing Assistant (CNA) E and CMA D revealed: *A few residents who chose to eat in their rooms by preference. *If there was a last-minute resident request to eat in their room, staff would call the kitchen to notify dietary staff. *Dietary staff delivered the cart with meal trays, after the dining room was served, to the residents in their rooms. *Nursing staff were only involved in meal service if a resident required assistance. *They confirmed receiving education about the safe positioning of residents for meals and hot liquid safety. *Nursing staff had access to a thermometer that was kept near the microwave in case food or beverages needed to be warmed by nursing staff. 5. Interview on 7/8/25 at 2:35 p.m. with dietary aide F revealed: *Dietary aides delivered trays to residents in their rooms. *If a resident was in bed when a tray was delivered, she would turn the call light on to notify nursing staff that the tray had been delivered. *Coffee and hot water were dispensed from the coffee machine into carafes and kept on the cart for room meal trays. *If a resident requested coffee or hot water for tea, she would pour the beverage into a coffee cup, place a lid on it, and bring the covered cup into the resident’s room. *She stated she had received education as recently as “a couple of days ago” about hot liquid temperatures and safety. 6. Interview on 7/8/25 at 4:00 p.m. with dietary supervisor G revealed: *She had been the dietary supervisor since 6/16/25. She had worked in the kitchen as a cook and a dietary aide before she began the dietary supervisor role. *She had received education on hot liquid safety and the proper procedure for preparing hot liquids using hot water from the coffee machine. *The coffee machine was calibrated to maintain coffee and hot water at a specific temperature throughout the day, which she thought was 132 or 134 degrees. *The coffee machine’s temperatures were to be checked twice daily, once in the morning and once in the afternoon. *Soups were served in bowls; if soup was included on a room tray, it was to be covered with a lid. *Soups served in the dining room did not have lids on them. 7. Interview on 7/9/25 at 10:37 a.m. with cook H revealed: *The day of the burn incident was only his second or third day working at the facility. *He had prepared the broth using water from the stovetop kettle rather than the facility’s established procedure of using hot water from the coffee machine. *He had not checked the temperature of the broth before it was sent out on a room tray. *He stated that they are now checking the temperatures of items such as soup that are heated in the microwave. *When temperatures are checked for items like soup after microwave heating, there was no formal log to record those temperatures, but the temperature was written on the resident’s meal ticket. 8. Interview on 7/9/25 at 11:40 a.m. with administrator A and director of nursing (DON) B revealed: *The meal tray delivery process was adjusted through the facility’s Quality Assurance and Performance Improvement (QAPI) program. Dietary staff were to deliver room trays to resident rooms and set the trays up for residents. They would notify nursing staff if a resident was not sitting up or needed to be positioned safely for meals. *Their audits indicated that revised practice was being followed by staff. *They reported experiencing significant turnover in the dietary department, including the dietary management team. *Administrator A confirmed that cook H had not followed proper procedure when he prepared the broth, and did not check the temperature of the broth before it was sent out on a room meal tray to be delivered to the resident. 9. Review of the provider’s October 2014 Safety of Hot Liquids Policy revealed: *Policy Statement -“Residents will be evaluated for safety concerns and potential for injury from hot liquids upon admission, readmission, and with any change of condition.” *Policy Interpretation and Implementation -“The potential for burns from hot liquids is considered an ongoing concern among residents with weakened motor skills, balance issues, impaired cognition, and nerve or musculoskeletal conditions. -Residents with these or other conditions may suffer from accidental burns and related complications stemming from thinner, more fragile skin that may burn quickly and severely and take longer to heal. -Residents who prefer hot beverages with meals (i.e., coffee, tea, soups, etc.) will not be restricted from these options. Instead, staff will conduct regular Hot Liquid Safety Evaluations as indicated, and document the risk factors for scalding and burns in the care plan. -Once risk factors for injury from hot liquids are identified, appropriate interventions will be implemented to minimize the risk of burns. Such interventions may include: --Maintaining a hot liquid serving temperature of not more than 155 degrees Fahrenheit; --Serving hot beverages in a cup with a lid; --Encouraging residents to sit at a table while drinking or eating hot liquids; --Providing protective lap covering or clothing to protect skin from accidental spills; and --Staff supervision or assistance with hot beverages. -Food service staff will monitor and maintain food temperatures that comply with food safety requirements but do not exceed recommended temperatures to prevent scalding.” 10. Review of the provider's SD DOH FRI submitted on 4/8/25 at 5:06 p.m. regarding resident 1 revealed: *Resident 1 fell on 4/5/25 at 5:30 a.m. when being assisted back from the bathroom by CNA O. *Resident 1 had verbalized that her knees were weak and then CNA O lowered resident 1 to the floor in a sitting position. -Resident 1 had no complaints of pain before or after she was sitting on the floor. -CNA O indicated that she guided resident 1 to the floor gradually by her waist. -CNA O had placed resident 1’s thoracic-lumbar-sacral-orthosis (TLSO) brace (a brace used to stabilize and limit motion in the back) prior to ambulating her to and from the bathroom. -Resident 1 had this brace prior to her admission to the facility related to her lumbar (lower back) 3 compression fracture (broken bone). -She was to always wear the TLSO brace when sitting upright and when she was out of bed doing an activity. -The TSLO brace could be removed when she was in bed. -No gait belt (a safety device used to assist resident's with walking) was used by CNA O when she assisted resident 1 with walking to and from the bathroom. -Resident 1 had her front-wheeled walker (FWW) for an assistive device when she was being assisted to the bathroom by CNA O. *Resident 1 was evaluated by the nurse and then three staff assisted her up off the floor. -Resident 1 had no complaints of pain after she was assisted up. *The physician and power of attorney (POA) were notified of the fall on 4/5/25 at 6:44 a.m. *Resident 1 used a portable assist lift (a medical device used to move residents with limited mobility) over the weekend related to her new acute weakness in her legs and pending a therapy consult. -Resident 1 was ambulating with a FWW prior to her fall on 4/5/25. *The therapy staff evaluated resident 1 on 4/7/25 and ordered continued use of the PAL lift related to resident 1’s leg weakness. *Resident 1 verbalized persisting pain to her right thigh after the incident on 4/5/25, which was not a new complaint for her. *Resident 1 had a neurosurgery follow-up appointment that was scheduled for 4/8/25 prior to her admission to the facility. -She had a history of a spontaneous lumbar 3 compression fracture that occurred prior to her admission to the facility. *On 4/8/25 resident 1 went to her neurology follow-up appointment. *Resident 1 was sent to the emergency department by neurology on 4/8/25 because of her increased radiculopathy pain. -The emergency room imaging results indicated she had a continued lumbar 3 compression fracture and a new acute (a new break in a bone) and/or subacute (a break in a bone that is between 5 and 13 days old) fracture of the lumbar 4 vertebral body. -Resident 1 was hospitalized on [DATE] for treatment of her bilateral lower leg weakness and the lumbar 4 vertebrae fracture. *Her POA, family, and the physician were notified of the above imaging results and her hospitalization. 11. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE] and currently resided at the facility. **Her diagnoses included wedge compression fracture of the 3rd lumbar vertebrae sequela, wedge compression fracture of the 3rd lumbar vertebrae, subsequent encounter for fracture with routine healing, age related osteoporosis without current pathological fracture, other abnormalities of gait and mobility, abnormal findings of diagnostic imaging of other parts of musculoskeletal system, and unspecified dementia. * Her 6/16/25 Brief Interview for Mental Status (BIMS) assessment score was 12, which indicated she had moderate cognitive impairment. * On 3/10/25 a fall risk assessment was completed which identified her as being at risk for falls. 12. Review of resident 1's 6/30/25 care plan revealed: *Her medications listed on the care plan included: “use of antidepressant, psychotropic, pain, and hypnotic medications which can contribute to gait disturbance and falls.” *I need assistance with my transfers, bed mobility and ambulation. -“I have limitations related to my lumbar fracture.” -“Assist [the resident] with one staff person for transfers, walking to/from the bathroom with FWW, and gait belt.” *”At risk for falls/injuries related to debility/generalized weakness, poor safety awareness.” -“Monitor [the resident] for increased weakness or instability.” -Refer [the resident] to physical/occupational therapy for strengthening exercises and gait training to increase mobility and safety awareness. *At risk for spontaneous and unavoidable fractures related to severe osteoporosis and history of spontaneous compression fractures.” -“Assess [the resident's] functional ability for mobility and note changes.” -Assist [the resident] with mobility as needed and using assistive devices e.g., --a. [NAME] or crutches, --b. Walker. -Provide and assist [the resident] with mobility by means of wheelchair, walker, crutches, canes as soon as possible. Instruct in safe use of mobility aids.” 13. The SD DOH FRI final report included further review of notes and imaging for resident 1 by the management team which revealed the following: *Resident 1 had a diagnosis of osteoporosis (a condition in which bones become weak and brittle) and a history of spontaneous lumbar fractures (bones in the lower back weaken and collapse, often without significant trauma) prior to her admission to the facility. -On 2/23/25 she had acute back pain in the lumbar vertebrae 4 and 5 areas, an x-ray (a medical imaging procedure) was obtained and was negative for fractures. -On 3/2/25 she had worsening back pain, increased weakness and pain to the right thigh, a computed tomography (CT) scan (a medical imaging procedure) was obtained and was positive for an acute compression fracture at lumbar 3 vertebrae. -On 3/2/25 a magnetic resonance image (MRI) (a medical imaging procedure) was obtained and showed a lumbar 3 vertebrae compression fracture and a lumbar 2 nondisplaced acute fracture. --No trauma was identified to cause those fractures. --The lumbar 3 was a spontaneous osteoporosis related fracture. -On 3/8/25 another MRI was obtained of the lumbar spine; this noted the severe lumbar 3 compression fracture. -On 3/10/25 resident 1 was admitted to the facility for rehabilitation with therapy services. -On 4/5/25 resident 1 had an assisted fall to the floor with no use of a gait belt. -On 4/8/25 a chair x-ray was obtained at the neurology department and deemed the lumbar 3 fracture worsened and she had a possible lumbar 4 fracture. -On 4/8/25 in the emergency department, an MRI was obtained and showed the lumbar 3 subacute and lumbar 4 acute/subacute fracture with 30% stature loss centrally. --It was noted that resident 1 had osteoporosis in the setting of the compression fractures. *On 4/8/25 resident 1’s physician provided a written statement regarding resident 1’s compression fractures. *On 4/9/25 at 8:34 a.m. the POA signed a bed hold (reserving the resident's bed for a temporary absence) for resident 1. *On 4/9/25 at approximately 9:30 a.m. a detective with the local law enforcement called the facility and stated that a family member had called and felt resident 1 had been improperly transferred which led to her fall on 4/5/25 and a report was filed. -No prior calls were received from family to the facility with concerns or questions about resident 1's fall on 4/5/25. *On 4/9/25 DON B and social services director (SSD) P called resident 1’s POA to follow up on the police report concerns. -The POA denied she made a report to law enforcement and denied any treatment concerns about resident 1’s care. -The POA inquired about gait belt use during the conversation. -The grievance and complaint procedures were reviewed with her. *On 4/10/25 resident 1 was re-admitted back to the facility. 14. Record review on 7/9/25 of resident 1’s physician letter revealed: *The above timeline and findings were confirmed and verified in his letter. *He referenced that resident 1 had not experienced any significant trauma to cause the lumbar fractures. *He referenced that with the combination of resident 1’s diagnosis of osteoporosis, poor bone density, and underlying bone fragility, resident 1’s fractures most likely occurred spontaneously. 15. Record review on 7/9/25 of CNA O’s written statements regarding resident 1’s fall revealed: *CNA O entered resident 1’s room at approximately 5:30 a.m. to find resident 1 sitting on the edge of her bed. *Resident 1 stated, “I need to pee”. -CNA O assisted her with applying her TLSO brace and walked with her to the bathroom while resident 1 used her FWW, no gait belt was applied. *After she used the bathroom, resident 1 and CNA O were walking back to resident 1’s bed, when she explained that her knees were weak, and she could not walk anymore. *Resident 1 was assisted to the floor by CNA O to a sitting position. - No gait belt was used by CNA O when assisting resident 1. -CNA O indicated that she assisted resident 1 down to the floor by guiding her by her waist. -Resident 1 received two skin tears to her right arm and one skin tear to her left arm from rubbing her arms on the recliner chair during the assisted fall to the floor. *CNA O called for help on her radio. -The floor nurse, and another CNA responded to the radio call. -CNA O indicated that resident 1 did not complain of pain before the incident, during toileting, during walking, or after the incident occurred. 16. Observation and interview on 7/9/25 at 11:43 a.m. with physical therapist (PT) I in hall 100 with resident 1 revealed: *She was ambulating with the use of her FWW with physical therapist (PT) I in the hallway. *Resident 1 was wearing a gait belt around her waist. *Resident 1 had her TSLO brace on. *PT I stated that the staff should always use a gait belt with residents with walking or transferring. *PT I stated that resident 1 walked approximately twenty-five feet with her assistance. -PT I stated that resident 1 had improved but her recent respiratory illness had set her progress back at that time. *Resident 1 denied pain when she walked with PT I. 17. Interview on 7/9/25 at 1:44 p.m. with CNA J regarding the use of a gait belts revealed: *Staff should use a gait belt for residents who needed assistance with walking or transferring. *Gait belts were stored in the resident rooms, behind the door on a hook or on the resident’s walker or wheelchair. -Staff could retrieve a gait belt from the storage room if unable to locate in a resident room. *Each resident had their own gait belt. *Staff had been trained on the use of gait belts. -Staff were trained at orientation and annually on gait belt use. 18. Interview on 7/9/25 at 1:51 p.m. with certified medication aide (CMA) C regarding the use of a gait belts revealed: *Gait belts were available for each resident who required assistance. *Gait belts were required for staff to use. *Staff received training on the use of gait belts during orientation and annually. -A registered nurse (RN) educator provided that training. 19. Interview on 7/9/25 with DON B regarding resident 1’s fall and gait belt use revealed: *The facility revised their “Use of a Gait Belt” policy on 5/13/25. -Directed staff were required to use gait belts with residents who “cannot independently ambulate or transfer” for the purpose of safety. -She stated the policy had stated before, that staff were to use gait belts with “anyone” who ambulated or transferred. *She indicated that CNA O was educated on gait belt use during her orientation. *She stated that resident 1’s fall on 4/5/25 was not a high impact fall and that it was an assisted fall to the floor. *CNA O put resident 1’s TLSO brace on her before she walked her to the bathroom. -She indicated that resident 1 was already up at the time and wanted to use the bathroom. -She explained there was a “time restraint” as resident 1 needed to use the bathroom, and CNA O was trying to get her to the bathroom to prevent an incontinent episode. -She added that CNA O and resident 1 used the FWW to walk to the bathroom. *DON B agreed that CNA O should have used a gait belt when she assisted resident 1 to and from the bathroom. *She confirmed that gait belt training and education was completed with all facility staff on 4/9/25. *Residents were to be assessed upon admission and periodically for fall risks. *Resident falls, facility reported, and non-facility reported incidents were tracked in the monthly quality assurance and process improvement (QAPI) meetings to discuss trends and audit findings. 20. Review of CNA O’s employment and training records revealed: *She was hired on 3/13/25. *She received orientation education on 2/28/25 from the provider which included: -Transfer Techniques. -How to lift and transfer without injury. -Gait belt use. -Types of Abuse. -How to report suspected or actual abuse. -Incident Reporting. *CNA O received re-education on 4/9/25. -Patient Handling. -What is a gait belt. -What is the purpose of a gait belt. -How to use a gait belt. -Choosing a gait belt. -Gait belt training and education. -Safe lifting and movement of residents. *CNA O voluntarily terminated her employment at the facility on 4/29/25. Review of the provider’s revised May 13, 2025, Use of Gait Belt policy revealed: *”Policy: It is the policy of this facility to use gait belts with residents that cannot independently ambulate or transfer for the purpose of safety.” *”Policy Explanation and Compliance Guidelines: -Gait belts will be available to all employees. -Applicable employees will receive education on the proper use of gait belt.” Review of the provider’s revised June 9, 2025, Fall Risk Assessment policy revealed: *”It is the policy of this facility to provide an environment that is free from accident hazards over which the facility has control, and provides supervision and assistive devices to each resident to prevent avoidable accidents.” *”Policy Explanation and Compliance Guidelines: -3. An “At Risk for Falls” care plan will be completed for each resident to address items identified on the risk assessment and will be updated accordingly.”

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, observation and policy review the provider failed to ensure the safety of one of one sampled resident (2) when the resident left the facility without staff knowledge or staff supervision (eloped). This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include:1. Review of the provider's 6/2/25 SD DOH FRI submitted at 6:50 p.m. to the SD DOH revealed:*On 6/1/25 at 6:52 p.m., camera footage showed that resident 2 was sitting in her wheelchair by the front entrance doors.*At 6:53 p.m., resident 3's spouse, who was visiting, opened the front entrance door, stepped aside, and held the door open as resident 2 exited the building. *At 6:54 p.m., certified medication aide (CMA) L observed resident 2 outside with other residents and with resident 3's spouse.-CMA L went outside and told resident 3's spouse that resident 2 needed staff supervision when outside.* At 6:54.12 p.m., CMA L brought resident 2 back into the facility. -Resident 2 was assessed for injuries by the nurse on duty and was not injured. *A Wander Guard bracelet (door alarm activating bracelet) was placed on 6/1/25 with the notification and consent of her son, who was her power of attorney (POA).*The director of nursing (DON B) and the physician were notified on 6/2/25 via HUCU (a secure healthcare communication platform).*Her 4/8/25 elopement risk assessment determined she was not at risk for elopement.*She had not demonstrated any recent exit seeking behaviors in the facility.*Letters were sent to family members educating them to ensure a staff member was asked prior to assisting residents out of the facility.*A sign was posted in the entry way that read the following:-Attention Visitors.--Please do not let a resident out without checking with a staff member first.---Make sure to look at your surroundings before exiting.*Her care plan was reviewed.*Elopement education and facility reporting education was completed with all facility staff. 2. Review of resident 2's electronic medical record (EMR) revealed:*She was admitted on [DATE].* Her 4/11/25 Brief Interview for Mental Status (BIMS) assessment score was 7, which indicated she was severely cognitively impaired.*She was assessed for elopement and wandering risks upon her admission to the facility, quarterly with her Minimum Data Set (MDS) and as needed with her resident monitoring activity. -Her 1/9/25 and 4/8/25 elopement risk assessments determined she did not exit seek, and was not at risk for elopement. -Her 1/9/25 wandering risk assessment determined she had wandering behavior, a Wander Guard bracelet was indicated, and consent had been obtained. -Her 1/23/25 and 4/8/25 wander risk assessments determined she did not wander, and a Wander Guard bracelet was not indicated.*A Head-Toe skin evaluation and a pain assessment were completed for resident 2 on 6/1/25 at 6:50 p.m.*A wandering risk assessment was completed for resident 2 on 6/1/25, it determined she needed a Wander Guard bracelet since she exited the front entrance door of the facility.*Her physician orders were updated on 6/2/25 for the use of the Wander Guard bracelet.-Nursing staff were to check the Wander Guard bracelet twice daily for it's placement and functioning. 3. Review of resident 2's current care plan dated 4/24/25 revealed:*She used a wheelchair independently for moving around the facility.*She had no history of exit-seeking or elopement. *She occasionally required supervision.*Her current care plan dated 4/24/25 was reviewed and revised on 6/2/25 for risk of wandering and eloping. 4. Observation on 7/8/25 at 9:45 a.m. of the facility entrance doors revealed:*A sign was posted on the front entrance door to alert visitors to check with staff before assisting a resident outside. Visitors and staff were to look around for residents in the area before exiting the door.*The other exit doors throughout the facility had key code access panels for staff to enter codes to unlock those doors. 5. Interview on 7/8/25 at 11:30 a.m. with administrator A regarding resident 2's elopement revealed:*Letters were generated on 6/5/25 by receptionist M to send or distribute to families regarding education on resident safety.-The letters were sent to the residents' power of attorneys (POA's) listed as number one on file.-Visitors/family members were to be aware of their surroundings with residents with dementia (a decline in mental ability, such as memory) or Alzheimer's diseases(a progressive disease that destroys memory and other mental functions). -Visitors/family members were to check with staff before assisting a resident outside. 6. Observations on 7/8/25 between 1:30 p.m. and 2:10 p.m. in hall 100 and the common area between the 100 and 200 halls of resident 2 revealed: *Resident 2 was sitting in her wheelchair and slowly propelled herself down the hall.*She was pleasantly confused and answered simple questions appropriately.*She entered the common area and sat and watched the birds in the display.*She appeared content and happy bird watching.*She had no observed aimless wandering or exit seeking behaviors.*The Wander Guard bracelet was on her left ankle. 7. Interview on 7/8/25 at 1:59 p.m. with registered nurse (RN) K regarding resident 2 revealed:*Resident 2 wandered in her wheelchair daily throughout the halls.-She usually stayed in hall 100 near the nurse's station when she was awake and in her wheelchair.-She was content in the common area (bird room) watching the birds or television.*RN K was not aware of any attempts made by resident 2 to elope prior to the 6/1/25 incident.*She indicated that resident 2 had not attempted to exit seek or elope while RN K had been on duty during previous shifts. 8. Interview on 7/8/25 at 2:04 p.m. with certified medication aide (CMA) L regarding resident 2's elopement revealed: *Resident 2 would only wander in the hallways in her wheelchair.*CMA L felt that the incident was an isolated incident.*Resident 2 did not exit seek and had never eloped from the building before.*Resident 2 seemed content to sit out by the nurse's station near the common area. 9. Interview on 7/8/25 at 2:09 p.m. with administrator A and director of nursing (DON) B regarding resident elopement revealed:*The front entrance doors were the only doors visitors could enter and exit the facility.-A sign was posted on that door to alert visitors and asking staff before assisting residents outside.*Education was provided to new hires and at least annually on resident wandering, elopement, reporting, and the door alarm system. *Elopement education and facility reporting education was completed with all facility staff on 6/2/25.*Residents were assessed upon admission, quarterly with MDS and as needed with resident monitoring activity for wandering and elopement risks.*Elopements, facility reported, and non-facility reported incidents were tracked and discussed in the monthly quality assurance and process improvement (QAPI) meetings regarding trends and audit findings. 10. On 7/8/25 between 3:30 p.m. and 3:46 p.m. random residents' POA's were contacted to confirm they had received the 6/5/25 letter. *Two of four resident POA's confirmed the 6/5/25 letter was received. 11. Interview on 7/8/25 at 3:54 p.m. with resident 3's spouse in hall 200 revealed:*She received verbal education from a staff member on the day of the incident.-The staff member told her that resident 2 needed staff supervision if she was outside and that she should ask staff to assist the resident outside. -She indicated that she also wrote a statement about the incident that had occurred and signed it for the facility.-She verified receiving the letter in the mail from the facility about resident safety and understood to ask staff to assist residents outside. Review of the provider's Quarter 3, 2018 Elopements policy revealed:*The provider followed their policy and procedure related to a missing resident.*The elopement was reported timely, and it was determined that resident 2 was not authorized to be outside without staff knowledge or staff supervision. Review of the provider's revised 6/10/25 Resident Alarms policy revealed:*Policy Explanation and Compliance Guidelines:-Wander/elopement alarms- includes devices such as bracelets, pins/buttons worn on the resident's clothing, sensors in shoes, or building/unit exit sensors worn/attached to the resident that alert the staff when the resident nears or exits an area or building. This includes devices that are attached to the resident's assistive device (e.g., walker, wheelchair, cane) or other belongings.*Identification of risk:-Each resident shall be assessed for fall and elopement risk upon admission and periodically thereafter as part of the comprehensive assessment process.*Implementation of interventions.-Alarms shall be initiated only to address a specific medical symptom or unique risk, when the benefit of the alarm outweighs the risk associated with its use.*Monitoring and modification:-Supervision shall be provided to the resident in accordance with the resident's plan of care.-When alarms are utilized, additional monitoring shall be provided, including but not limited to:--1. Verifying alarms are used in accordance with the resident's care plan.--2. Verifying alarms are working properly, at least once per shift, per facility protocol. The provider's implemented actions to ensure the deficient practice does not recur was confirmed onsite on 7/9/25 after observations, interviews, and record reviews revealed the facility had followed their quality assurance process and action plan for tracking and trending incidents and:*Resident 2 had a Wander Guard bracelet placed on 6/1/25 after the incident. *A wandering risk assessment was completed for resident 2 on 6/1/25, which determined she needed a Wander Guard bracelet after she exited the front entrance door of the facility.*Education on resident safety and supervision was provided to resident 3's spouse on 6/1/25.*There was a plan to include the following in the provider's SD DOH FRI final report:-Nursing staff were checking the functioning and placement of the Wander Guard bracelet on resident 2 twice a day. -Resident 2's physician orders were verified and her care plan was reviewed and revised.-Resident 2 had a wandering risk assessment and an elopement risk assessment completed upon her admission, quarterly with her MDS and as needed with her monitoring activity. -New resident admissions will have wandering and elopement risk assessments completed upon admission, quarterly with their MDS, and as needed with their monitoring activities. -The facilities policies and procedures regarding elopement and wandering residents were reviewed. -Re-education about resident wandering, elopement, safety and reporting was provided to all facility staff on 6/2/25. -New hire education about wandering, elopement, resident safety, and reporting will continue as a part of the facilities orientation process. -Letters educating families on resident safety and supervision were sent to the POA's on 6/5/25.-Resident 3's spouse confirmed verbal and written education was received on 6/1/25 and on 6/9/25. -Interviews with staff confirmed they knew the requirements for elopement and were aware of the procedures to address a resident who had eloped. -Signage was posted on the front entrance door for visitors not to assist residents out of the building without checking with staff. Based on the above information, non-compliance at F684 occurred on 6/1/25, and based on the provider's implemented corrective actions on 6/9/25 and additional corrective action plans, for the deficient practice confirmed on 7/9/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure one of one resident's (1) repositioning and incontinence care needs were being provided according to her plan of care. Failure to follow the plan of care for her repositioning and incontinence needs potentially placed resident 1 at a higher risk for discomfort, infection, and skin breakdown. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 6/10/24 SD DOH FRI and resident 1's electronic medical record revealed: *At the time of the incident, resident 1 was on comfort care with a pending hospice referral. -She was incontinent of urine and unable to reposition herself without the staff's assistance. -She had a urinary tract infection (UTI) with a pending urinalysis lab culture and sensitivity results and anticipated orders for antibiotic treatment. *On 6/8/24 at 5:30 a.m., bath aide D found resident 1 lying in her bed with a urine-saturated incontinence brief and linens. *Certified nursing assistant (CNA) C was responsible for her care and admitted during the investigation that he had not provided repositioning or incontinence care to resident 1 during his night shift which started on 6/7/24 at 10:00 p.m. Interview on 6/19/24 at 11:00 a.m. with director of nursing (DON) B revealed an investigation was immediately initiated, no other similar incidents were identified, and education was provided to all care staff regarding repositioning and incontinence care. The provider implemented systemic changes to ensure the deficient practice does not recur was confirmed after: record review revealed the provider had followed their quality assurance process; staff training and education of repositioning and incontinence care needs had been provided; verifying ongoing staff education was being provided to ensure residents' repositioning and incontinence care needs were being met; care plan review verified each resident's care plan contained individualized repositioning and incontinence care interventions; verifying the CNA's resident care sheets accurately reflected each resident's repositioning and incontinence care needs as directed in their plans of care; observations and interviews revealed staff had been educated and understood when to provide resident repositioning and incontinence care; interviews with residents and family members confirmed they felt resident care was being provided in a timely manner; confirming ongoing staff audits of resident incontinence care and repositioning needs were being conducted; and review of the provider's policies confirmed a clear definition of resident care expectations. Based on the above information, non-compliance at F684 occurred on 6/8/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 6/19/24, the non-compliance is considered past non-compliance.

Based on review of provider's 4/24/24 South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, observation, interview, and policy review, the provider failed to ensure a thorough investigation was completed for one of one resident (1) who had a burn from hot coffee. 1. Review of provider's SD DOH FRI revealed the following: *On 4/24/24 resident 1 had a coffee burn from spilling her hot coffee on her lap at breakfast. *A certified nursing assistant (CNA) [D] alerted licensed practical nurse (LPN) C of the spill. *LPN C assessed the skin and noted redness and two small blisters to the right upper, inner thigh. CNA [D] stated that resident was in dining room for breakfast and resident spilled coffee in own lap. Review of resident 1's electronic medical record revealed the following: *Her Brief Interview of Mental Status score was a five, which meant her cognition was impaired. *A 3/28/24 hot liquid safety evaluation revealed she was not at risk for spilling hot liquids. *A 4/24/24 hot liquid safety evaluation revealed she had cognitive impairment, tremors or abnormal muscle movements of her hands, and altered range of motion or contractures of her fingers. -This evaluation included an intervention that she was to be provided a cup with a lid and to drink hot liquids at a table only. Observation at on 5/1/24 at 12:02 p.m. of resident 1 in the dining room revealed she had a two-handled cup with a lid for her coffee. Interview on 5/1/24 at 3:10 p.m. with director of nursing B regarding resident 1's burn revealed: *Resident 1 was cognitively impaired and was not able to say what happened. *An unknown CNA [D] observed resident 1 spill her coffee at approximately 8:30 a.m. on 4/24/24. *That CNA [D] took resident 1 to her room and called for a nurse [LPN C], to assist, over the walkie-talkie. *There were no statements from individuals who may have had knowledge of the event. Interview on 5/1/24 at 3:43 p.m. with LPN C regarding resident 1's coffee burn revealed: *She thought CNA D was the CNA who notified of her of the event but was not sure. *She went to resident 1's room to assess the resident for the coffee burn. -Resident 1's right abdomen was red and her right inner thigh was red and had a blister on it. -She contacted the resident's physician and received an order for Silvadene for partial thickness burn. Interview on 5/2/24 at 9:22 a.m. with CNA D regarding resident 1's coffee burn revealed: *An unknown therapist had notified her resident 1 had spilled her coffee on herself in the dining room. -She was not able to recall who that therapist was. *After she was notified, she took resident 1 to her room and called for a nurse [LPN C] over the walkie-talkie to assess resident 1. -LPN C had responded to that call. Review of the provider's 3/2018 Abuse and Neglect-Clinical Protocol policy revealed: *The staff, with the physician's input as needed, will investigate alleged abuse and neglect to clarify what happened and identify possible causes. *The physician will provide adequate documentation regarding significant negative outcomes that have resulted from a resident's underlying medical illnesses or conditions, despite appropriate care. Review of the provider's 7/2017 Accidents and Incidents - Investigating and Reporting policy revealed: *All accidents or incidents involving residents, employees, visitors, vendors, etc., occurring on our premises shall be investigated and reported to the Administrator. *The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. *The following data, as applicable, shall be included on the Report of Incident/Accident form. -The circumstances surrounding the accident or incident. -The name(s) of witnesses and their accounts of the accident or incident; -The signature and title of the person completing the report.

Based on interview, and policy review, the provider failed to ensure mail delivery was available on Saturdays for all 67 residents residing in the facility. Findings include: 1. Interview on 2/6/24 at 9:00 a.m. with resident 19 revealed: *The facility's business office staff delivered resident mail Monday through Friday. -Resident mail was not delivered on Saturdays because there were no business office staff available to deliver it on that day. *There was no delivery of Saturday mail for as long as I can remember. Interview on 2/6/24 at 9:05 a.m. with assistant business office manager (BOM) J regarding Saturday resident mail delivery revealed: *She, BOM I, and receptionist M were responsible for delivering mail to the residents on weekdays. *Resident mail delivered on Saturdays was held over (not given to residents) until the next Monday when she, BOM I, and receptionist M returned to work. -There was no designated staff person assigned to deliver resident mail on Saturdays. Interview on 2/7/24 at 8:30 a.m. with administrator A and director of nursing B revealed: *They were not aware resident mail delivery was not occurring on Saturdays. *The activities department was responsible for ensuring resident mail was delivered on Saturdays. -An activities department staff person was scheduled to work seven days a week. Review of the revised May 2017 Mail and Electronic Communication policy revealed 4. Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box [including Saturday deliveries.]

Based on observation, interview and policy review the provider failed to ensure: *One of one hallway (400) was maintained in a home-like environment. *One of one hallway (400) refrigerator was clean. *One of one carpet in the sunroom was maintained and clean. *One of one loveseat cushions in the sunroom was maintained and clean. *The faucet heads on the sinks in 34 out of 34 residents' rooms, on the green unit were maintained and clean. Findings include: 1. Observation on 2/6/24 at 11:32 a.m. of hallway 400 and the sunroom revealed: *There were multiple unused screw holes in the walls. *The refrigerator had dark brown stains on the bottom of the refrigerator and the top shelf on the door. *The carpet in the sunroom had multiple dark stains on it. *The cushions on the loveseat in the sunroom had stains on them. *The faucet heads on the sinks in residents' rooms had white, hard and thick buildup on them. Interview on 2/7/24 at 8:50 a.m. with plant maintenance assistant Z revealed: *He had not noticed the multiple unused screw holes in the walls. -The holes in the walls should have been filled and painted over. *Maintenance was not responsible for the cleaning of the refrigerator. *He confirmed the carpet in the sunroom had multiple stains but was unsure who was responsible for it. *Cleaning of the cushions on the loveseat in the sunroom was completed by housekeeping staff. *He confirmed that maintenance was responsible for the upkeep of the faucet heads in residents' room. -He confirmed the faucet heads were unappealing and needed to be addressed. Interview on 2/7/24 at 10:15 a.m. with administrator A and director of nursing (DON) B revealed: *DON B was not aware of the unused screw holes in the 400 hallway. -The unused screw holes should have been filled and painted over. *Confirmed that the refrigerator in the 400 hallway was unclean and all staff was resposible for cleaning it. *They confirmed that the sunroom carpet had multiple stains on it. -The carpet cleaners were to have been there the next week to clean the carpet. *They were unaware of the stains on the cushions of the loveseat that was in the sunroom. -They confirmed that the cushions on the loveseat in the sunroom were not cleanable. *DON B was not aware of the buildup of white, hard, and thick buildup on the head of the faucet heads in the resident's rooms on the green unit. -She agreed that the buildup on the faucet heads was unappealing and needed to be addressed. Review of providers revised 2023 Cleaning and Disinfection of Environmental Surfaces policy reveals: *3. Devices that are used by staff but not in direct contact with residents shall be cleaned and disinfected regularly by the environmental services staff and as needed by the nursing staff. *10. Environmental surfaces will be disinfected on a regular basis and when surfaces are visibly soiled. Review of providers revised December 2009 Cleaning/Repairing Carpeting and Cloth Furnishings policy revealed: *2. Carpets shall be deep cleaned periodically or more often as needed. *6. Stained or soiled upholstered furniture shall be cleaned in a manner consistent with the type of fabric and stain.

Based on observation, interview, and policy review, the provider failed to ensure infection prevention and control practices were implemented to ensure the following: *One of two bath aides (O) had demonstrated effective cleaning of the whirlpool (WP) tub, air jets, and bath seat, in one of two sampled multi-use resident WP bathrooms. *Urine collection bags for three of six sampled residents (13, 25, and 54) were kept off of the floor and covered with a protection bag (dignity bag used to hold and protect urine collection bags). Findings include: 1. Observation and interview on 2/07/24 at 11:45 a.m. with bath aide O in the [NAME] hallway multi-resident use WP bathroom revealed: *She had already cleaned the WP tub but was willing to demonstrate her cleaning methods. *She would spray down the tub, including the chair, with an unlabeled spray bottle that was hanging off a linen cart in the main resident bath area. -Stated the bottle contained a sanitizing solution but could not recall the name of the solution. *After spraying the inside surfaces of the WP tub, she let those areas soak in the spray solution for about 10 minutes. -She was unable to recall exactly how long the sanitizing spray should soak before wiping it off. -She would then wipe down the inner sides of the tub and the surface of the chair seat with a clean cloth. -She would then rinse the tub with clean water. -She would flush the WP air jets with a sanitizer solution after every second resident's bath. *She would scrub and sanitize the underside of the WP seat about two times in every five days of her giving baths. -Stated, Probably not as often as I should. -Sometimes she would use a brush to scrub the tub surfaces, but not always. *She could not recall the provider's protocol for cleaning and disinfecting of the WP bathtub and bathroom. -She had been shown several different ways of cleaning the WP room with several different bath aides. -Stated she felt she was being very thorough in how she cleaned the WP tub. *She had not identified the cleaning of any other WP room surfaces other than the inside surfaces of the WP bathtub. *She agreed infectious materials like bacteria, viruses, and fungi, could remain in the tub, on the seat, and in the WP jets if they were not thoroughly cleaned, scrubbed, and sanitized between each resident. Interview on 2/07/24 at 3:29 p.m. with director of nursing (DON) B and administrator A regarding the cleaning and sanitizing of the WP bathtub and bathroom revealed it was their expectation for the WP tub, jets, seat, and surrounding surfaces to be thoroughly cleaned, scrubbed, and sanitized between each resident use and according to their policy. Review of the provider's February 2023 'Bath, Shower/Tub' policy revealed: *Steps in the Procedure. -9. Be sure the tub or shower is clean. -35. Clean the bath tub with a disinfectant solution. *There were no instructions or policy provided on how to clean and sanitize the WP bathtub or bathroom surfaces. Review of the provider's 2023 'Infection Prevention and Control Program' policy revealed: *11. Prevention of Infection. a. (3) educating staff and ensuring that they adhere to proper techniques and procedures; 2. Observation on 2/05/24 at 3:50 p.m. of resident 54 while in her room revealed her urinary catheter drainage bag was attached to the side of a small garbage can with the lower half of the urine collection bag lying on the floor unprotected. Further observations on 2/06/24 at 8:35 a.m. and at 2:00 p.m. of resident 54, while sitting in her wheelchair and while lying in her bed, revealed the lower half of the urine collection bag lying on the floor unprotected. Observation and interview on 2/06/24 at 2:05 PM with CNA S, while emptying resident 54's urine collection bag revealed: *Following the emptying of the collection bag, CNA S placed the urine collection bag into a dignity protection bag and hung it so the bag was not touching the floor. *She thought the therapist had placed the resident in bed following therapy and had left the bag uncovered and touching the floor. -She stated that sometimes people would get into a hurry and would not put the urinary collection bag into the dignity protector bag. *Stated the urine collection bags should be protected with a dignity bag at all times to prevent contamination of the collection bag. Interview on 2/06/24 at 2:18 p.m. with therapist T revealed: *She was a traveling occupational therapist and had been at this facility since September of 2023. *She had assisted resident 54 into bed following her therapy after lunch. *The facility orientation that was provided to her had consisted of computer navigation and the layout of the facility. -She was trained by her travel company on infection control practices. *Stated the dignity protector bags were usually kept on the wheelchairs for when the resident was in a wheelchair. *Confirmed the unprotected urinary collection bag probably should not have been touching the floor and agreed it posed a potential infection control risk. 40788 3. Observation on 2/5/24 at 2:38 p.m. of resident 13 revealed: *She was asleep in a recliner chair in her room. -Her uncovered urine collection bag lay on the floor beside her chair. 4. Observation and interview on 2/05/24 at 3:00 p.m. with activities director H and CNA N in resident 25's room revealed: *Staff prepared to transfer the resident from his wheelchair to his bed using a Hoyer mechanical lift. *CNA N: -Laid the resident's uncovered urine collection bag onto the floor after removing it from his wheelchair frame. -Assisted activities director H to secure the mechanical lift sling that was beneath the resident's body to the Hoyer lift. -Picked the uncovered urine collection bag up from off the floor and attached it to the resident's bed frame. -Completed the Hoyer transfer of resident 25 with activities director H. *Activities director H and CNA N agreed the resident's uncovered urine collection bag should not have been laid on the uncleaned floor. -Resident 25's urine collection bag was expected to have been inside of a dignity protection bag. Interview on 2/7/24 at 8:45 a.m. with administrator A and director of nursing B regarding the uncovered urine collection bags referred to above revealed: *Urine collection bags were expected to be kept inside of dignity protection bags and off of the floor. -Uncovered urine collection bags laid onto or that touched the floor were an infection control risk. Review of the revised August 2022 Urinary Catheter Care policy revealed Infection Control 2. Be sure the catheter tubing and drainage bag are kept off the floor.

Based on observation, interview, and policy review, the provider failed to ensure the following: *Four of four Resident Council members' (22, 28, 32, and 47) preference to have menu information posted was accommodated. *One of one sampled resident (33) had not received his requested food choice at meals. Findings include: 1. Group interview on 2/6/24 between 11:00 a.m. and noon with Resident Council members 22, 28, 32, and 47 regarding the facility's food service program revealed: *Resident menus were not posted. *The Resident Council members referred to above made food choices each day from a paper menu provided that listed the following days meal option information. -Families of some residents who were unable to make their own food choices were provided multiple days worth of menus to complete for their family member. *Menu information was supposed to have been posted on the white erasable board at the entrance of the dining room or on a mounted television screen inside the main dining room. *Knowing in advance of upcoming menu information was important to the Resident Council members. -That sometimes dictated whether one of the Resident Council members chose to eat somewhere other than the facility. -Other Resident Council members were unable to remember what they selected for the next days meal after they completed their daily menu. Interviews on 2/6/24 at 3:45 p.m. and again on 2/7/24 at 11:15 a.m. with dietary supervisor E revealed: *He was rehired as the dietary supervisor two days ago after having been the facility's administrator for a year and a half. -Before that time, he was the facility's dietary supervisor. *He confirmed there was no posted menu information for residents to know what was scheduled to be served to them beyond the next days menu. *A television screen in the dining room was designated to display facility-specific information including the weekly menu information. -The computer flash drive that contained the current menu cycle was not available to the kitchen staff to upload on that television so it was turned off. *The erasable whiteboard was used to communicate menu changes. *He was aware of the significance of residents knowing what their food choices were beyond the next day's menu options. Review of the revised October 2017 Menus policy: 11. Copies of menus are posted in at least two (2) resident areas, in positions and in print large enough for residents to read them. 47780 2. Interview and observation on 2/5/24 at 5:35 p.m. in the main dining room revealed: *Resident 33's daughter stated she had been noticing her father had not been getting the food that they requested on his meal tickets. *Resident 33's supper meal had been served accordingly to what the family requested on his meal ticket. Observation on 2/6/24 at 12:47 p.m. of resident 33 revealed he: *Had been served pureed peas instead of the requested pureed capri vegetable mix. *Had been served chocolate pudding instead of the requested pureed peaches. Interview on 2/6/24 at 4:35 p.m. with dietary supervisor E regarding the above observation revealed: *There were pureed peaches in the kitchen. *He was unsure why the staff had not served resident 33 the pureed peaches. *They did not have any capri vegetable mix to puree. Observation on 2/6/24 at 5:33 p.m. of resident 33 revealed he was served pureed peas instead of the requested pureed green beans. Interview on 2/7/24 at 11:13 a.m. with dietary supervisor E regarding the above observation revealed he: *Had told his staff they needed to be watching what was on the tickets and what was served to the residents more closely. *Had told the staff if they do not see the food that was requested, they need to ask him and he would assist them in finding the requested food. *Agreed that staff should have been asking the resident or family if a substitute was fine before serving the substitute to them. 3. Review of provider's March 2021 revised Accommodation of Needs policy: 2. The resident's individual needs and preferences are accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered.

Based on observation, interview, record review, and policy review, the provider failed to ensure the following: *One of one sampled resident (116) was provided timely incontinence care by one of one certified nurse aide (CNA) (P). *Physical therapy recommendations regarding bed mobility for one of one sampled resident (25) were followed by one of one activities director (H) and one of one CNA (N). Findings include: 1. Observation and interview on 2/5/24 at 1:30 p.m. with CNA O assisting resident 116 in the bathroom revealed: *CNA O was a float CNA [assisted other CNAs in different resident living units provide resident care] that day. -That was her first encounter with resident 116 on that day. *CNA O commented the resident was wearing two pairs of incontinent briefs underneath his pants. -He had a bowel movement in the first pair of briefs and the second pair of briefs was dry. *The resident was unable to verbalize why he was wearing two pairs of briefs. -He was unable to independently have placed those briefs on himself. Interview on 2/5/24 at 2:24 p.m. with director of nursing (DON) B revealed CNA O had discussed with her the observation referred to above regarding resident 116. Interview on 2/5/24 at 2:26 p.m. with CNA P revealed he: *Overheard the conversation between the surveyor and DON B referred to above. *Had forgotten about resident 116 and not provided him incontinence care since arriving for work at around 6:00 a.m. that day. -The resident had moved to a different room on that unit last Friday and this was CNA P's first day back to work since that move occurred. Interview on 2/5/24 at 3:30 p.m. with unit director/licensed practical nurse C regarding the process for shift-to-shift communication regarding resident care revealed: *Off-going staff and on-coming staff were expected to complete daily walking rounds. -That included walking from room to room with the off-going staff providing the on-coming staff a verbal report regarding each resident residing on that unit. Interviews on 2/6/24 at 12:15 p.m. and again on 2/7/24 at 3:30 p.m. with DON B and administrator A regarding resident 116 revealed: *DON B interviewed the overnight staff person responsible for resident 116's care on the evening of 2/4/24 through the morning of 2/5/24. That staff person reported: -CNA P was given a verbal hand-off report on 2/5/24 around 6:00 a.m. that included resident 116. -No walking rounds occurred. -Resident 116's incontinence brief was dry when it was last checked before leaving the overnight shift around 6:00 a.m. *DON B confirmed CNA P had not checked resident 116's incontinency brief between 6:00 a.m. and 1:30 p.m. on 2/5/24. -CNA P's failure to have provided resident 116 personal care during that time was careless. *There was no explanation or reason why resident 116 was wearing two incontinent briefs when he was checked and changed at 1:30 p.m. on 2/5/24. 2. Observation and interview on 2/5/24 at 3:08 p.m. with activities director H and CNA N transferring resident 25 from his wheelchair to his bed with a Hoyer mechanical lift revealed: *One side of his bed was pushed against the south wall. -On that wall directly above the center of the bed was a sign that read: Pillow between knees when rolling. *After lowering the resident to his bed using the lift, activities director H and CNA N rolled the resident without using a pillow between his knees on his right then his left side to remove the Hoyer lift sling from underneath his body. -The resident cried out in pain each time he was rolled onto his side. *CNA N thought the resident had a left leg fracture but was not aware of any specific precautions that were expected to be followed when he was physically moved. -She was hired about a week ago and had only cared for the resident one other time. *Activities director H (also a CNA) referred her to the resident's Kardex (a resource that provided an overview of an individual resident's care needs) for resident-specific care information. *Activities director H and CNA N confirmed seeing the sign on the wall referred to above regarding the resident's care needs but it just didn't register [to have followed those instructions]. Review of resident 25's electronic medical record revealed he: *Was admitted to the facility on [DATE] after he was hospitalized with a left intertrochanteric femur fracture (a specific type of hip fracture). -Elected not to have surgery on that fracture while he was hospitalized but after his admission to the facility decided he wanted to have surgery. -Was waiting on medical clearance from a pulmonologist and orthopedic surgery before that surgery was able to be scheduled. *Had no physician orders related to his weight bearing status or specific care instructions for staff to have followed related to his fracture. Review of his care plan revised on 2/5/24 revealed: *The resident had declined the use of a knee immobilizer to his left lower extremity but used a pillow between his knees when rolling in bed for all care. -There was no mention of his current weight bearing status or how the resident was expected to have been transferred in and out of bed. Interview on 2/5/24 at 3:17 p.m. with unit director/licensed practical nurse D regarding resident 25 revealed: *He admitted to the facility with comfort care orders but had since decided to proceed with rehabilitation and surgical treatment of the hip fracture. *Staff were expected to use a pillow between his legs to prevent him from crossing his legs. Interview on 2/6/24 at 8:40 a.m. with physical therapist L regarding resident 25 revealed: *She placed the sign above his bed regarding the use of a pillow between his legs when he was rolled in bed during care. -It was purposely hung where the activity [bed mobility] occurs to ensure staff had read and followed her instructions. *The purpose of using a pillow was for the resident's comfort and to keep his left hip in a neutral position to prevent undue stress. Interview on 2/7/24 at 8:45 a.m. and review of resident 25's care plan with administrator A and DON B revealed: *It was last week when the resident started transferring out of his bed and into a wheelchair. *Director of rehabilitation K and the resident's medical provider discussed the physical restrictions related to his hip fracture. -The therapy department was responsible for but had not updated the resident's care plan to reflect his weight-bearing status or how the resident was expected to have been transferred in and out of his bed. *Care plan content was linked to the resident's individualized Kardex for staff to have know-how to care for resident 25's hip fracture. *Activities director H and CNA N failed to follow physical therapist L's instructions regarding how to safely and comfortably remove the lift sling from beneath resident 25 causing him undue stress and discomfort. Interview and review of the 2/2/24 Requested Change in Care Plan on 2/7/24 at 9:45 a.m. with director of rehabilitation K regarding resident 25 revealed: *Orders from the resident's medical provider: Staff to assist out of bed with Hoyer lift, at least daily. NWB [non-weight bearing] L LE [left lower extremity]. -A copy of that communication was to be routed to the following facility staff: the Minimum Data Set Coordinator, director of nursing, the nurses' station and placed in a staff communication book, and charge nurse sheets. *Director of rehabilitation K was out sick and the process referred to above had not occurred. Review of the September 2022 Identifying Neglect policy revealed: *5. Neglect includes cases where the facility's indifference to or disregard for resident care, comfort or safety results in (or could have resulted in) physical harm, pain, mental anguish or emotional distress. *9. Examples of failures to provide care and services to the resident that result in neglect include: f. Failure of staff to implement resident interventions, even when residents are assessed and interventions are identified in the care plan;

Based on observation, interview, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) (X) had removed and cleaned the nebulizer mask and the medicine reservoir when the treatment was completed for one of one sampled resident (33). Findings include: 1. Observation and Interview on 2/5/24 at 4:40 p.m. in resident 33's room revealed: *LPN X was administering the resident's nebulizer treatment. *After the setup of the nebulizer, LPN X had asked the resident's daughter if she would prefer the LPN to have come back and remove the nebulizer mask or if the daughter would remove the nebulizer mask and the daughter stated she would remove the nebulizer mask. *The daughter stated she had visited her father in the evenings and his nebulizer mask was still on and the liquid in the medication reservoir was gone. *She understood the medicine was gone when the machine had made a different sound and the smoke in the nebulizer mask was gone. -The nebulizer treatment would have taken about 10 minutes. -She would have cleaned the nebulizer mask and the medicine reservoir. -She had not had any formal training or any discussion that covered knowing when the treatment was completed or how to clean the nebulizer mask or medicine reservoir. Observation on 2/6/24 at 4:00 p.m. in resident 33's room revealed: *LPN X was administering the resident's nebulizer treatment. *After the setup of the nebulizer, LPN X had asked the resident's daughter if she would prefer the LPN to have come back and remove the nebulizer mask or if the daughter would remove the nebulizer mask and the daughter asked the nurse to come back and remove the nebulizer mask. Interview on 2/6/24 at 4:07 with LPN X regarding the above observation revealed she: *Had been allowing the family to remove the mask after the nebulizer treatment was done. *Had taught the family to listen for a different sound when the nebulizer treatment was done and the smoke inside the nebulizer mask would have been gone, and it would have taken between 8 to 12 minutes to complete the treatment. *Had been going back to the resident's room after the family had removed the nebulizer mask and cleaned the nebulizer mask and the medicine reservoir. *Had discussed with her unit manager that she had been working with the resident's family. Interview on 2/7/24 at 1:16 p.m. with unit manager D regarding the above observation revealed she: *Felt resident 33's family had been particular with some of their requests for their father and that had included the nebulizer treatments. *Had verbally taught the daughter and son when the nebulizer treatments were finished and how to remove the nebulizer mask. *Had not put any documentation in the resident's chart of any formal training with the family. *Had not put a cleaning schedule into the treatment administration record (TAR) for staff to follow regarding the nebulizer mask or the medicine reservoir. Interview on 2/7/24 at 1:55 p.m. with director of nursing (DON) B revealed she: *Expected LPN X to have removed and cleaned the nebulizer mask and the nebulizer medication reservoir. *Had not expected the resident's family to have removed and cleaned the nebulizer mask and the reservoir cup. Review of provider's revised October 2010 Administering Mediations through a Small Volume (Handheld) Nebulizer Policy revealed: 24. When treatment is complete, turn off nebulizer and disconnect T-piece, mouth piece and medicine cup. 27. Rinse and disinfect the nebulizer equipment according to facility protocol.

Based on interview, resident council minutes review, and policy review, the provider failed to ensure resident expressed concerns were thoroughly investigated including follow-up with complainants, and resolved as much as possible to everyone's satisfaction for six of six sampled residents. Findings include: 1. Interview on 2/1/23 from 11:15 to 11:45 a.m. with six residents (14, 16, 26, 32, 36 and 42) who attended resident council revealed: *They met every month. *They were able to voice their concerns. *The activity coordinator D was always present and kept notes of the meeting. *The emergency permit holder (EPH)/administrator A had started on 9/1/22 and attended the December 2022 meeting. *The residents complained about wandering residents coming into their rooms, laying in their beds, using their bathrooms, and taking their belongings. *Resident council stated management had verbally responded with, put up with it, or use Velcro banner across their room door, a stop sign or close their room door. *The residents felt their concerns had not been resolved. Review of the November-December 2022 and January 2023 resident council minutes revealed: *New business for the November 2022 meeting included: -Shared concern about those residents who previously resided in the memory care unit because they wander excessively. -They felt the environment of the facility was not suited for some of the residents that would excessively wander. -They discussed how these residents wander in and out of other residents' rooms, would sleep in their beds, or get into their personal belongings. *Old business for December 2022 and January 2023 meeting included no mention of any follow up regarding the residents wandering into their rooms, sleeping in their beds and getting into their personal belongings. Interview on 2/1/23 at 4:18 p.m. with activities director D regarding the follow-up of concerns brought up in resident council revealed: *She facilitated the meetings, and minutes were kept of each meeting. *Residents were given an opportunity to voice concerns. *She made a determination during the meeting if it was a discussion or concern. *Concerns were brought up in the interdisciplinary meeting and then referred to the specific department. *She agreed she should have completed a grievance form from the November 2022 Resident Council meeting referring to the concern of residents wandering. *She agreed there was no documentation in December 2022 or January 2023 Resident Council minutes that discussed a resolution. Interview on 2/2/23 at 11:00 a.m. with director of nursing (DON) B regarding concerns brought up by residents in Resident Council revealed she: *Started her position on 1/4/23. *Had known about the concerns of the wandering residents during her walk-through interview with residents. *Encouraged residents to complete a grievance form. *Was aware education was provided to staff for redirecting the wandering residents to activities. *Stated that locks were given to the residents to lock up their personal property in their rooms. *Was aware there were no new interventions put in place. Interview on 2/2/23 at 11:23 a.m. with EPH/administrator A revealed he: *Transitioned from his previous position in the facility to his current position on 9/1/22. *Was the grievance officer. *Was aware of the November 2022 resident council concerns about the wandering residents. *Met with resident 16, who was the council president, in November to discuss interventions that would have been put in place for the residents who had wandered. *Discussed in December 2022 resident council meeting the interventions that the facility had taken. -Agreed there was no documentation in the resident council minutes for December 2022 of his discussion regarding interventions for those residents that wandered. Review of the undated Grievance/Complaints Filing policy revealed: *1. Any resident, family member, or appointed resident representative may file a grievance or complaint concerning care, treatment, behavior of other residents, staff members, theft of property, or any other concerns regarding his or her stay at the facility. *3. All grievances, complaints or recommendations stemming from residents or family groups concerning issues of resident care in the facility will be considered. Actions on such issues will be responded to in writing, including a rationale for the response. *8. Upon receipt of a grievance and/or complaint, the Grievance Officer will review and investigate the allegations and submit a written report of such findings to the Administrator within five (5) working days of receiving the grievance and/or complaint.

Based on observation, interview, and policy review, the provider failed to ensure: *One of one certified nurse assistant (I) had not reused disposable razors on more than one resident. *One of one licensed practical nurse (F) had performed proper hand hygiene procedures during one of two observed wound care treatments. Findings include: 1. Observation and interview on 1/31/23 at 9:30 a.m. with certified nurse assistant (CNA) I in one of the bathing rooms revealed: *She was finishing up cleaning and sanitizing the whirlpool tub. *There were two disposable razors and a nail clipper sitting on top of the tub. *When asked if she used the disposable razors on one resident or reused them for multiple residents, she said: -To be honest, yes. -I will swish the razor around in the sanitizer water that I'm cleaning the bathtub with to sanitize the razors and nail clippers. *She placed the two razors in the sharps container after she was done cleaning the tub. Interview on 2/1/23 at 4:43 p.m. with director of nursing (DON) B and registered nurse consultant (RNC) N about the reuse of nail clippers and disposable razors revealed: *Each resident should have had their own nail clippers. *They provided the disposable razors if a resident did not have their own. -It was not their policy or practice to reuse nails clippers and razors on more than one resident. Review of the provider's 2018 Cleaning and Disinfection of Resident-Care Items and Equipment policy revealed: *d. Reusable items are cleaned and disinfected or sterilized between residents (e.g., stethoscopes, durable medical equipment). -3. Single resident-use items are cleaned/disinfected between uses by a single resident and disposed of afterwards (e.g., bedpans, urinals). *e. Single-use items are disposed of after a single use (e.g., thermometer probe covers). *5. Only equipment that is designated reusable shall be used by more than one resident. *6. Single use items will be discarded after a single use. 2. Observation and interview on 1/31/23 at 11:00 a.m. of licensed practical nurse (LPN) F during resident 63's wound dressing change revealed: *She gathered supplies from the wound care cart. *She took a pair of scissors from her pocket and placed it on the bedside table with the wound care supplies. -There was no barrier placed underneath the wound care supplies. *She placed a paper towel on top of the supplies. *Without performing hand hygiene or putting gloves on, she removed the resident's shoe and sock. *She placed another paper towel on the floor beneath the resident's foot. *She put on a pair of clean gloves without performing hand hygiene. *She removed the gauze and inspected the wound, touching it with her gloved hand. *With the same gloves on, she: -Retrieved the normal saline and poured some into a cup. -Grabbed a clean gauze pad, dipped it into the normal saline, and cleansed the wound. -Grabbed the foam dressing and scissors, and cut the dressing. --Placed the scissors in her shirt pocket after she was done cutting the dressing without sanitizing the scissors. -Placed the foam dressing over the resident's wound. *She removed her gloves, threw away the unused supplies and the soiled gloves, then washed her hands. Interview on 1/31/23 at 11:20 a.m. with LPN F about the above wound care procedure revealed she should have: *Placed a barrier on the bedside table before putting the wound care supplies down. *Performed hand hygiene before putting on the gloves. *Changed her gloves and performed hand hygiene after handling the resident's wound and soiled dressing. *Not have placed the scissors in her pocket. Interview on 2/1/23 at 4:43 p.m. with DON B and RNC N about the above observation revealed: *They were aware of the above wound observation. *It was their expectation that staff should perform hand hygiene before putting gloves on, after taking gloves off, and in-between glove changes. Review of the provider's 2022 Handwashing/Hand Hygiene policy revealed: *Policy Statement: This facility considers hands hygiene the primary means to prevent the spread of infections. *Policy Interpretation and Implementation: -2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: --b. Before and after direct contact with residents. --f. Before donning [putting on] sterile gloves. --g. Before handling clean or soiled dressings, gauze pads, etc. --i. After contact with a resident's intact skin. --j. After contact with blood or bodily fluids. --k. After handling used dressings, contaminated equipment, etc. --m. After removing gloves. -8. Hand hygiene is the final step after removing and disposing of personal protective equipment. *Procedure: Applying and Removing Gloves. -1. Perform hand hygiene before applying non-sterile gloves. -5. Perform hand hygiene [after removing gloves]. Review of the provider's 2018 Wound Care policy revealed: *Steps in the Procedure: -2. Wash and dry your hands thoroughly. -4. Put on exam glove. Loosen tape and remove dressing. -5. Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly. -6. Put on gloves. -8. Pour liquid solutions directly on gauze sponges on their papers. -19. Use clean field saturated with alcohol to wipe overbed table. -21. Wipe reusable supplies with alcohol as indicated (i.e., outsides of containers that were touched by unclean hands, scissor blades, etc.). Return reusable supplies to resident's drawer in treatment cart. -23. Wash and dry your hands thoroughly.

Based on observation, interview, record review, and policy review, the provider failed to ensure reasonable care for the protection of personal property from loss or theft by confused wandering residents for one of one sampled resident (62) who had created his own space. Findings include: 1. Observation and interview on 1/31/23 at 10:23 a.m. with resident 62 revealed he: *Had a Velcro banner with stop do not enter on it, across his open doorway. *Was in bed watching television. *Had complained that several confused residents entered and dismantled his room frequently and he was not able to get up on his own and stop them. *Had tried shutting his door but they still came into his room and there were times when he returned to his room that he could tell his items had been moved or were missing. *Had told confused residents to leave and they had become aggressive, swore at him, once one of them slammed his door and then returned with a butter knife, and another instance one took off her clothes and attempted to climb into his bed at 1:00 a.m. *Had many personal items in his room that he collected or were gifts and he stated they were valuable, sentimental and irreplaceable. -A walrus tooth carved figurine he received from his ex-wife had been missing from his room and the facility replaced it with a similar item he found on the Internet that cost $400 but, it was not the same and not from his ex-wife. *Had his own personal food and snack items in his room. -He was not able to enjoy his snacks after another resident touched and rifled through them touching his Pringles in the can and other food items. *Was in the process of packing up his [NAME] tooth tiger skull, mounted on a handmade tiger wood platform and was sending it to his mothers home. -Felt the item was far too valuable and irreplaceable and would be broken or go missing from his room. *Had complained to the staff repeatedly about the confused residents in his room and felt nothing had been done. *Filed a grievance with the administrator and the administrator responded but there had been no improvement with the confused residents wandering into his room. Review of the resident's record revealed he: *Was admitted to the facility on [DATE]. *Had a Brief Interview for Mental Status (BIMS) score of 15 indicating he had no cognitive deficit. *Was a younger resident with identified care needs that he had determined the facility was the best place for him to live. *Had filed five grievances beginning in 2022 through January 2023. -On 7/30/22, the facility had replaced a walrus tusk figure. Review of resident council meeting minutes revealed: *In November residents had complained about confused residents wandering into their rooms. *There was no documentation of follow up in the December or January resident council meeting minutes. Interview on 2/1/23 at 11:15 a.m. of the resident's at the resident council meeting held with surveyors present revealed; *Resident's reported wandering residents in the facility was a big problem since the memory unit had closed, they came into others rooms, got in their beds, used their bathrooms, got aggressive, got into altercations, and took and broke personal items belonging to other residents. Interview on 2/1/23 at 2:03 p.m. with activities director D who attends the resident council meetings revealed: *Confused residents wandering into other residents rooms was an issue brought up at the resident council meeting in November. *No formal grievance was created and no follow up was done regarding the wandering residents concern brought up at the resident council meeting. *Options she discussed at the meeting were Velcro sign and redirection. Interview on 2/2/23 at 9:53 a.m. certified nursing assistant (CNA) H regarding the resident revealed: *She had worked at the facility for seventeen years. *Felt she got the equipment and training needed to do her job. *The new director of nursing asked staff what could she do to help staff and the registered nurses were helpful. *They used a staff communication book, but she did not feel it was always effective and communication of events had gotten missed. *The computer/kiosk/Kardex told staff how to care for residents and it was updated well. *Felt staffing had gotten better and they had a good team. *Was aware of issues with confused residents wandering into other resident's room. *They used stop banners to deter confused residents and they were working 50 percent of the time. *They attempted to redirect confused residents as best they could, and no other interventions were used. *There are two to three residents that come over here and enter other residents rooms. *Resident 62 is unable to get up independently and other residents would eat his food, go through his personal belongings, and dismantle his room. *It had gotten better in the last month or so, they are still a challenge, the residents with sundowners [NAME] to the med cart and it is disruptive and difficult to pass meds. *We have been told it is their right to wander. *There have been safety concerns, staff have had to intervene where there could have been a possible physical altercation between the residents. One lady takes silverware from the dining room and carries it with her. Another one at night gets violent and frustrated. *There is one confused resident that will shove his walker at people and get physically aggressive. *Management was aware of those issues. *Management had not shared a plan with staff. *The staff are instructed to do the best they can and keep an eye on those wandering residents. Interview on 2/2/23 at 9:26 a.m. with social services coordinator E revealed: *She had worked in the facility since May 2021. *She had a licensed social worker that provided oversight and collaboration. *They corresponded via email, the licensed social worker reviewed the grievances, provided feedback on needed changes, and told her what needed to be done. *Agreed five grievances were on her report from this resident. *We replaced a figurine and could not get the exact same one. -He picked out one online, she was aware it had been a gift and was irreplaceable, so they offered him a lock box. *She agreed residents had the right to have a room with personal items, and it was unfair he felt he had to send his valuable items to his mother's home. *Our primary intervention for managing confused residents wandering into other residents' rooms was signage, educating staff on redirecting, offering different activities, and making sure needs were met, snacks, toileted etc *She agreed it would be frustrating for the resident to watch confused residents come into his room, go through his personal belongings, and not to have been able to do anything about it. *She agree it would be frustrating for the resident to not be able to have personal items in his room and feel they are safe. Interview on 2/2/23 at 9:58 a.m. with EPH/administrator A regarding Quality Assurance and Improvement(QAPI) revealed: *He is the emergency administrator since September 2022. *QAPI met monthly. *The medical director comes more often than quarterly. *The consultant pharmacist attends quarterly and sends a monthly summary too. *Direct care staff are invited when they are oriented, they are reminded that they can attend QAPI meetings annually too. *They had a direct care staff come in September. *Usually direct care staff bring their concerns to administration and they are shared at QAPI. *QAPI and the governing board were aware of the issue with confused residents wandering into other residents rooms. *They do not currently have a performance improvement plan for this. *He was aware of the situation with the confused resident with the knife. -She took the silverware from the dining room after the meal. -Staff were now more vigilant during the meals to make sure she is not taking the silverware. -He told staff to always pick up the silverware to make sure she does not have access to the silverware after meals. Review of the facility's undated Personal Property policy revealed: *2. Each resident is encouraged to maintain his/her room in a home-like environment by bringing personal items (i.e., photographs, knickknacks, etc.) to place on nightstands, televisions, etc. Review of the facility's 2018 Resident Rights policy revealed: *1. Federal and State laws guarantee certain basic rights to all residents of this facility,. These rights include the resident's right to: ee. retain and use personal possessions to the maximum extent that space and safety permit

Based on observation, interview, closed record review, record review, manufacturer's review, and policy review, the provider failed to ensure professional standards were followed for: *Appropriate care and treatment, assessments were completed and documented, interventions implemented, and followed-up for one of one sampled resident (132) who had a major change in condition. *Neurological (neuro) checks were completed and documented for one of one sampled resident (132) conducted by two of two licensed practical nurses (LPN) (R and C). *Complete and fully documented fall scene investigations had been conducted for one of one resident (132) who had falls on [DATE] and again on [DATE]. *Evaluation, assessment, and documentation of care needs for one of one sampled resident (21) who had unique needs. *Blood glucose testing completed by one registered nurse (RN) (G) and licensed practical nurse (LPN) (F) for four of four sampled residents (23, 24, 181, and 382). Findings include: 1. Review of resident 132's closed medical record revealed: *She had been admitted on [DATE]. *She had a Brief Interview for Mental Status assessment score of nine indicating she was moderately, cognitively impaired. *Her [DIAGNOSES REDACTED].>-Acute posthemorrhagic [MEDICAL CONDITION]. -Unspecified dementia without behavioral disturbance. -Hypertension. -Fracture of femur, closed with routine healing. Review of resident 132's undated care plan revealed she was independent with bed mobility, transfers, toileting, and ambulation. Review of resident 132's [DATE] quarterly Minimum Data Set assessment tool revealed: *Toilet use: -Self performance: Supervision-Oversight, encouragement or cueing. -Support: One person physical assist. a. Review of the [DATE] at 10:20 a.m. nursing progress note regarding resident 132 revealed: *Event Type: Fall. *Date of Event: [DATE]. *Time of Event: 10:10 a.m. *Detailed description: Staff reported to this nurse that resident was on the floor. This nurse and an aid went to the residents room where she was sitting upright against her bedside table. Resident stated that she does not have any pain and upon assessment there were no signs of swelling, bruising or lacerations. Patients (resident) description of event: Resident states she was walking to her bathroom from her bed when she slipped and fell on her bottom. Review of the [DATE] Neurological Observation sheet for resident 132 started by LPN C revealed: *Instructions on the sheet stated: -Neuro (neurological) checks and vital signs (vs) should be observed and recorded as follows: --Every 15 minutes x (times) 4; every 30 minutes x 4; hourly x 4; every 4 hours x 24 hours. *Beginning on [DATE] at 10:15 a.m. through [DATE] at 6:30 a.m. they had completed four out of the sixteen required neuro checks and vs. *The neuro check and vs record had not followed the above requirements. Review of the provider's [DATE] at 10:15 a.m. Fall Scene Investigation (FSI) Report regarding resident 132 revealed: *The following portions of the FSI had been left blank: -Medications given in last eight hours prior to fall (Check all that apply). -Re-creation of last three hours before fall. -Root cause of this fall. -Nurse completing form. -Fall team meeting notes. Record review of the [DATE] at 9:39 a.m. interdisciplinary team fall review note regarding resident 132 revealed a fall intervention of Staff will remind resident to use walker. b. Review of the [DATE] at 12:01 a.m. nursing progress note regarding resident 132 revealed: *Event Type: Fall-Unwitnessed. *Date of Event: [DATE]. *Time of Event: 9:05 p.m. *Detailed description: CNA (certified nurse assistant) called nurse to resident's room via walkie-talkie. Upon arrival resident was laying on her back across from the sink. Resident did not appear to be in distress at this time. Resident was wearing shoes during incident. Resident was questioned about the incident, and assessed for injuries, none found at this time. Resident denied any pain r/t (related to) the fall during assessment. Resident was then assisted back into her bed, neuro's were started, and vs were obtained. *Patients description of event: Resident stated that she was coming back from the bathroom and had tripped over her roommate's walker. She also stated that she had not hit her head when she fell . Review of the [DATE] Neurological Observation sheet for resident 132 started and completed by LPN R revealed: *The same instructions as the neuro sheet used for the [DATE] fall. *Eleven of the eighteen neuro checks had not been completed. *A handwritten note dated [DATE] at the bottom of the sheet by DNP (Doctor of Nursing Practice) (name) revealed: *Above assessment data offers little to draw off of. Based on above, appears neurologically intact. Review of the [DATE] at 9:22 a.m. interdisciplinary team fall review note regarding resident 132 revealed a fall intervention of: Remove recliner in room to declutter and lack of use. Review of the provider's Huddle Topic sheet dated [DATE] in regards to resident 132 revealed: *Fall charting-nurses must do an in depth progress note separate from the Risk Assessment that includes an intervention to prevent falls, who was contacted, neuro's, etc. -Must put neuro sheet on alert charting clipboard for others to complete. Must be completed per protocol. -Remember to chart. -Help keep (resident's name) room decluttered. *There was an area at the bottom of the page for employees to print their name after reading. -Some of the employees had signed their names, but they were unreadable. *That huddle sheet had been given to LPN I to disseminate the signatures. -She was unable to distinguish one signature. *LPN P's signature was not on that document as having been read by her. Review of the nursing progress notes dated [DATE] from 1:35 a.m. through 4:35 a.m. by LPN P regarding resident 132 revealed: *At 1:35 a.m. During MA (medication aide)/CNA rounds it was noted that the pt. (patient) was vomiting. MA/CNA asked if she needed help and pt. responded Get the hell out of here. This nurse was notified. Upon entering the room noted she has used a few napkins to wipe her mouth, vomit noted on napkins. Pt. was asked about how long she hasn't been feeling well, if she was in any pain, and if she needed something for her stomach. Pt. stated I am feeling better now, go away. *At 1:49 a.m. eMar (electronic medical record) medication administration note for [MEDICATION NAME] tablet 650 mg (milligram). -Give two tablets every six fours as needed for general discomfort. -PRN (as needed) administration was: Effective. -Follow up pain scale was: 0. *At 4:35 a.m. a nursing note was documented and stated: -At 0430 (4:30 a.m.) CNA/MA entered her room for a round and noticed pt. was not breathing. This nurse was notified and upon entering the room pt. was found laying supine in her bed. Resident was pale in color and skin was slightly warm to the touch. No lung sounds auscultated and no chest wall movement noted. No radial pulse was found. Resident pupils were fixed and dilated, and resident did not respond to verbal stimuli or sternal rub . *At 4:35 a.m. a Death note without CPR (Cardiopulmonary resuscitation) had been documented. Review of resident 132's medical record revealed there had not been nursing notes, assessments, or documentation pertaining to her vomiting after 1:35 a.m. and before her death at 4:30 a.m. on [DATE]. c. Interview on [DATE] at 11:30 a.m. with director of nursing (DON) A and LPN I concerning resident 132 revealed: *A FSI report had been completed for the fall on [DATE] but not on [DATE]. *Both agreed a FSI should have been completed for the fall on [DATE]. *Both agreed all FSI needed to be filled out completely. Phone interview on [DATE] at 2:14 p.m. with LPN P concerning resident 132 the morning of [DATE] revealed: *She had helped clean up resident 132 after she vomited. *She stated she had tried to get vital signs on the resident, but the resident had refused. *She had not documented any interventions or assessments on [DATE] between 1:35 a.m. and her death note at 4:30 a.m. Phone interview on [DATE] at 3:20 p.m. with certified medication aide S concerning resident 132 revealed he: *Had been working the night shift on [DATE]. *Had answered the call light of resident 132's roommate. -Noticed resident 132 was vomiting. *Stated the resident had been upset and would not let him help her. -Had been told to Get the hell out of here by her. *Had informed LPN P the resident was vomiting and what she had said to him. -Told LPN P he would check back later referring to resident 132. -Stated he had other residents and call lights to check on. *Stated during his last round of his shift resident 132's roommate's call light was again on. -When he walked into the room to check on the call light, he checked on resident 132. -She was deceased . *Did not recall seeing LPN P checking on resident 132. -I was busy doing my work and checking on other residents. Continued interview on [DATE] at 11:30 a.m. with DON A and LPN I concerning LPN P revealed: *She had not completed vital signs or reevaluated resident 132 after she vomited. *Both agreed resident 132 should have been rechecked and assessed after vomiting. Interview on [DATE] at 8:25 a.m. with LPN I concerning the neuro check sheets revealed: *Employees were to have filled it out completely following the timeline on the form. *It was to be filled out completely if a fall was unwitnessed or a witnessed fall, and they had hit their head. Interview on [DATE] at 9:25 a.m. with administrator O concerning resident 132 revealed she would have expected: *All Neuro check sheets to be filled out completely unless the resident was out of the building. *Documentation, assessments, and notification to the provider to be completed with a change in a resident's condition. Review of the provider's Qtr 3, (YEAR) Falls-Clinical Protocol revealed: *2. In addition, the nurse shall assess and document/report the following: a. Vital signs. d. Change in cognition or level of consciousness. e. Neurological status. 5. The staff will evaluate and document falls that occur while the individual is in the facility; for example when and where they happen, any observations of the events, etc. *Monitoring and Follow-Up. -1. The staff, with the physicians/designee's guidance, will follow up on any fall with associated injury until the resident is stable and delayed complications such as late fracture or subdural hematoma have been ruled out or resolved. -a. Delayed complications such as late fractures and major bruising may occur hours or days after a fall, while signs of subdural hematomas or other intracranial bleeding could occur up to several weeks after a fall. Review of the provider's Qtr 3, (YEAR) Abuse and Neglect-Clinical Protocol revealed: *Definitions: -2. Neglect .The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional distress. *Assessment and Recognition: -1. The nurse will assess the individual and document related findings. Assessment data will include: --a. Injury assessment. --b. Pain assessment. --c. Current behavior. --g. Vital signs. --h. Behavior over last 24 hours. Review of the provider's Qtr 3, (YEAR) Change in a Resident's Condition or Status Policy revealed: *Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status . -1. The nurse will notify the resident's attending physician or physician on call when there has been a(an): d. Significant change in the resident's physical/emotional/mental condition. -3. Prior to notifying the physician or healthcare provider, the nurse will make detailed observations and gather relevant and pertinent information for the provider, including (for example) information prompted by the Interact SBAR (situation, background, assessment and recommendation) Communication Form. 2. Observation and interview on [DATE] at 3:44 p.m. with resident 21 revealed: *She had been a resident of the facility for three years. *A shunt was placed on the right side of her head above and behind her ear to drain fluid from her brain. -It was visible as the resident had sparse hair that did not cover the shunt area. *She stated she had a history of [REDACTED]. *She used an electric wheelchair to get around the facility. Review of resident 21's medical record revealed: *Her [DATE] quarterly Minimum Data Set (MDS) assessment revealed: -A Brief Interview for Mental Status score of fifteen indicating she was cognitively intact. *[DIAGNOSES REDACTED]. *The shunt or the condition that caused it to be placed was not listed under the current [DIAGNOSES REDACTED]. Interview on [DATE] at 9:03 a.m. with MDS assistant/registered nurse assessment coordinator (RNAC) K regarding resident 21 revealed: *She was familiar with the resident and had known her for several years. *The resident had been admitted on [DATE]. *A shunt had been surgically placed to drain fluid from the resident's brain prior to her admission. *She had seen a neurologist on a regular basis and most recently in (MONTH) 2020. -She was admitted to the hospital for testing of the shunt function. *She was unsure why the shunt had not been listed in her diagnoses, but it should have been. *The care plans were usually developed by the MDS coordinator, but revisions that were needed could be added by anyone on the team. *She agreed it should have been listed on the MAR, in the current diagnoses, and on the care plan for signs and symptoms to watch for if there had been problems. Interview on [DATE] at 12:36 p.m. with director of nursing (DON) A and RN/director of education J regarding resident 21 revealed: *They were unaware the resident did not have her shunt listed under her [DIAGNOSES REDACTED]. *They were unaware the care plan did not address the shunt, how to care for it, or signs and symptoms for staff to watch for. -They stated the staff should follow the standards of practice for all residents. -They also stated the resident had been able to alert staff of pain and other symptoms in the past and would expect their staff to let nursing know of changes. 3a. Observation on [DATE] at 11:17 a.m. of LPN F while she completed blood glucose testing for resident 181 revealed she: *Used an Assure Platinum glucose monitoring device. *Wiped the resident's finger with alcohol. *Immediately tested the resident's blood glucose. -Did not waste the first drop of blood but applied it on the blood glucose test strip. b. Observation on [DATE] at 11:22 a.m. of LPN F while she completed blood glucose testing for resident 382 revealed she: *Used an Assure Platinum glucose monitoring device. *Wiped the resident's finger with alcohol. *Immediately tested the resident's blood glucose. -Did not waste the first drop of blood but applied it on the blood glucose test strip. c. Observation on [DATE] at 4:30 p.m. of RN G while she completed blood glucose testing for resident 23 revealed she: *Used an Assure Platinum glucose monitoring device. *Wiped the resident's finger with alcohol. *Immediately tested the resident's blood glucose. -Did not waste the first drop of blood but applied it on the blood glucose test strip. d. Observation on [DATE] at 4:40 p.m. of RN G while she completed blood glucose testing for resident 24 revealed she: *Used an Assure Platinum glucose monitoring device. *Wiped the resident's finger with alcohol. *Immediately tested the resident's blood glucose. -Did not waste the first drop of blood but applied it on the blood glucose test strip. e. Interview on [DATE] at 11:52 a.m. with DON A and LPN I revealed they had been unaware: *LPN F had not been wasting the first drop of blood when doing a blood glucose test. *RN G had not been wasting the first drop of blood when doing a blood glucose test. *Agreed the first drop of blood should have been wasted when doing a blood glucose test. Review of the provider's Qtr. 3, (YEAR) Obtaining a Fingerstick Glucose Level policy revealed: *Obtain a blood sample by using a sterile lancet. *Discard the first drop of blood if alcohol is used to clean the fingertips because alcohol may alter the results. Review of the undated Assure Platinum manufacturer's guidelines revealed no mention of preparation for or technique to use to have obtained a blood sample. The guidelines only said, Obtain a blood sample. [NAME] [NAME] Potter et al., Fundamentals of Nursing, 9th Ed., Elsevier, St. Louis, Mo., (YEAR), p. 1096, revealed: Wipe away first drop of blood with cotton ball. First drop of blood may contain more serous fluid than blood cells.

Based on observation, interview, record review, policy review, and job description review, the provider failed to ensure the appropriate care and services had been delivered to 3 of 3 sampled residents (59, 286, and 287) who had been dependent on staff in the following areas: *Appropriate Hospice services for end-of-life (final stage of a person's life) support for 2 of 5 sampled residents (286 and 287). *Consistent repositioning for 3 of 3 sampled residents (59, 286, and 287) who had been at high risk for skin breakdown. *Timely pain management for 2 of 2 sampled residents (286 and 287) who required end-of-life care and either exhibited or voiced complaints of pain. *Activities of daily living (ADL) including personal hygiene, toileting, repositioning and nutrition to promote physical and psychosocial well-being for 3 of 3 sampled residents (59, 286, and 287). Findings include: 1. Observation on 2/4/19 at 5:01 p.m. of resident 287 revealed: *He appeared very thin, weak, and frail with his bones easily identified through the skin. *He had been laying on his bed resting and was positioned on his back on an air flow mattress. *His heels were resting directly on the mattress. *The head-of-bed was elevated at approximately a thirty-five degree angle with pillows underneath his head causing his chin to rest on his chest. *He was unresponsive, and he was making wet/gurgling type sounds with each breath. *One of his healthcare representatives was there visiting him. Interview on 2/4/19 at 5:05 p.m. with resident 287's healthcare representative revealed: *She had been a friend and a past student of the resident. *She and another male friend were his healthcare representatives. *Confirmed he had been receiving end-of-life care with Hospice services support since 1/29/19. *Had been concerned about his admission, stay at the facility, and wanted the opportunity to visit with the surveyor tomorrow. *Stated: -He is a dad type figure to me. -I have known him for thirty years, he was my teacher. -This is the first day he has not responded, but he is finally comfortable. -He is getting pain meds (medication) every four hours now, so I think they are ahead of his pain. -It has been a rough week. Interview on 2/5/19 at 9:47 a.m. with resident 287's healthcare representative revealed: *He had passed away last night, but she came back today to visit with the surveyor. *She: -Confirmed he was admitted on [DATE] at approximately 1:30 p.m. -Had arrived at 4:30 p.m. after he had been admitted . *He had been: -In his room sitting in a wheelchair (w/c). -Very upset, crying, and wanted her to take him home. -Very confused, restless, and kept trying to get out of the w/c. *All of his belongings had remained in their bags and were sitting on the floor by his feet. *She had asked the administrator if he could have medication to help calm him down. -The administrator told her they had no medications for him and were waiting on Hospice. *She had: -Contacted Hospice and was told the doctor had ordered him medications upon his discharge from the hospital, and he had some here. No staff had administered any pain medication. -Stayed with him until 7:30 p.m. *From 1:30 p.m. through 7:30 p.m. on 1/28/19: -He remained in his w/c with his belongings on the floor by his feet. -He continued to be restless and confused. -No staff had stopped in his room to check on him, attempted to move him, offered him any supper, take him to the bathroom, or put him to bed. -No nursing staff had attempted to give him any medications. *Prior to leaving she had: -Asked the staff for some ice cream and attempted to feed it to him. -Assisted him to the bathroom, got him ready for bed, and laid him down to rest. *She came back at 9:00 a.m. the next morning, and the staff informed her he had a restless night. *She had asked if he received any medication and they were unsure and would have to check. -No staff had ever gotten back to her with that information. -To her knowledge he never received anything for restlessness and pain. *His belongings remained in bags and on the floor. -She unpacked his belongings and put them away. *She spent most of her days with him. *During her visits he: -Continued to be very restless, agitated, and uncomfortable. -Was confused and unable to voice his concerns or what was wrong. -Would attempt to undress himself and get up on his own. -Was so agitated one day that he completely undressed himself. -Was assisted by the staff very little when she was at the facility. -Typically she had to ask for assistance for him. *He fell on ce last week and when they voiced concerns about more falls they moved him closer to the nurses' station. *Finally they voiced some of their concerns with Hospice, and Hospice re-educated the staff on his goals for end-of-life care. *She stated: -We are careful what we complain about or ask of them. -We don't want them to stop taking care of him either. -Finally then yesterday was a better day for him. --That had been eight days after he had been admitted . -He didn't respond much, but at least he was comfortable. -I didn't feel I could leave him alone much. -He was so restless and upset all last week. -I just wanted him to have good care, and I felt I needed to be here for that to happen. -It was disheartening. Review of resident 287's medical record revealed: *An admission date of [DATE]. *His [DIAGNOSES REDACTED]. *His life expectancy was limited, and he had been receiving end-of-life care from Hospice. *He was dependent upon the staff to assist him with all activities of daily living (ADL). -That had included bed mobility, transfers, personal hygiene, toileting, and management of his pain medications. *At times he had increased confusion and could not always voice his needs thus depending on staff to anticipate his needs. -During those times he had been dependent upon the staff to anticipate his needs. *Upon admission on 1/18/19 he could have had: -[MEDICATION NAME] 0.5 milligram (mg) to 1.0 mg every six hours as needed (prn) for anxiety. -[MEDICATION NAME] sulfate (MS) solution 0.3 ml to 0.4 ml every two hours prn pain. -[MEDICATION NAME] solution 1 milliliter (ml) to 2 ml every six hours prn for anxiety and nausea. --On 2/2/19 the physician had ordered that medication to have been administered at 0.25 ml three times a day. That had been five days after his admission for end-of-life care. Review of resident 287's 1/28/19 through 1/31/19 Medication Administration Record [REDACTED] *His pain level was to have been monitored and documented every shift. -His pain level had ranged from a zero to a nine. --On a pain scale ranging from one to ten with ten being the worst pain. -Two out of the ten shifts had no documentation on what his pain level had been. *In those four days and in a ninety-six hour period he had only received: -MS four times for pain with one of those doses documented as unknown for helping with his pain. --He did not receive that first dose of MS until eleven hours after his admission to the facility. -[MEDICATION NAME] once for anxiety with the effectiveness documented as unknown. -[MEDICATION NAME] two times for anxiety, and it was helpful. --He did not receive that first dose of [MEDICATION NAME] until eight and half hours after his admission to the facility. Review of resident 287's 2/1/19 through 2/4/19 MAR indicated [REDACTED] *They continued to monitor his pain level every shift. -His pain level had ranged from zero to a seven. *On 2/2/19 the physician had ordered: -The [MEDICATION NAME] to be given twice a day. -The MS to be given every four hours for pain. --That was five days after his admission for end-of-life care. Review of resident 287's interdisciplinary (IDT) progress notes from 1/28/19 through 2/4/19 revealed: *On 1/28/19 at 2:34 p.m. an admission note had been completed. -The resident had been alert and denied any pain. -There was no documentation to support: --His mood and behavior as described above by one of his healthcare representatives. --If he had required any medication to help with anxiety and comfort. *On 1/29/19: -No documentation to support an assessment of the resident had been completed by the night shift nursing staff. -At 7:09 a.m. Patient (resident) got combative with staff during care. Later he was found at his doorway urinating on the floor. Staff redirected him to bathroom and later assisted him to his recliner. Will continue to monitor. -At 3:14 p.m. Resident found in hallway heading toward his room. Resident proceeded to pull down his pants and urinate on floor in room. Assisted him to recliner and noted food spill all over room. Called for assistance with CNA (certified nursing assistant). -No documentation to support his mood, comfort level, and behaviors from 1/29/19 at 3:14 p.m. to 1:37 p.m. on 1/30/19. *On 1/30/19: -At 1:37 p.m. the resident had been found on the floor in his room with no injury noted. -No further documentation and assessments completed for that day by the nursing staff. *On 1/31/19: -No documentation that the resident had been assessed for end-of-life care and comfort for the entire day. -No follow-up documentation from his fall on 1/30/19. *On 2/1/19 at 6:06 p.m. he had been given a dose of the [MEDICATION NAME]. -No documentation to support: --The reason that medication (med) had been administered and the effectiveness of the med. --He had been assessed and provided end-of-life care prior to 6:06 p.m. by the nursing staff. *On 2/2/19 at 5:46 a.m. Resident up and down all night. Unable to get comfortable. Continuously attempted to get up unassisted. -No documentation to support if he had been provided any medication or nursing interventions to help with his mood and behaviors. *On 2/3/19 there was no documentation to support the nursing staff had assessed and provided end-of-life care. *No further documentation by the nursing staff until 2/4/19 at 8:00 p.m. when they had found him without a pulse, no respirations, and no blood pressure. -At 9:00 p.m. the Hospice nurse supported the above assessment to further confirm the death of the resident. Review of resident 287's 1/28/19 comprehensive care plan revealed: *He had been admitted for palliative care under Hospice services. *His goal was to have been kept as comfortable and pain free as possible. *He required assistance with bathing, dressing, grooming, and mobility. -That had included transfers, bed mobility, and ambulation. *He wanted to remain as continent of urine and bowel as possible with staff support. -He was to have been toileted often during the night time. --No documentation to support a toileting program had been established and initiated. *He was at risk for falls. -There were no interventions put in place for the prevention of falls. *He wanted to be as independent as possible with his eating. -The interventions supported he required extensive assistance from the staff with eating. *He was at risk for skin breakdown and required cueing and assistance from the staff for repositioning. -No documentation to support a repositioning program had been established and initiated. Continued medical record review for resident 287 revealed there was no documentation to support: *How much assistance he had required for ADLs from the certified nursing assistants (CNA). *Assessments had been completed by the nursing staff and direct care givers. *End-of-life and comfort care had been provided in the absence of the Hospice staff. *His initial forty-eight hour care plan had been followed and implemented by the nursing staff. 2. Review of resident 286's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She had been alert with some confusion but capable of making her needs known. *Her life expectancy was limited, and she had been receiving end-of-life care from Hospice. *She was dependent upon others to assist her with all ADLs. -That had included eating, bed mobility, transfers, personal hygiene, toileting, and management of her pain medications. *Upon admission the physician had ordered: -Tylenol suppository 650 mg every six hours prn pain. -[MEDICATION NAME] 12 microgram (mg) apply every seventy-two hours. -[MEDICATION NAME] 1 mg every three hours prn for [MEDICAL CONDITION] activity. -MS 0.25 ml to 0.5 ml every two hours prn pain. Observation on 2/4/19 at 4:57 p.m. of resident 286 revealed: *She appeared: -Very thin, weak, frail, and pale in color. -To be able to move her arms without difficulty, but no spontaneous movement of her legs was observed. *She had been dressed in street clothes. *She had been laying on her bed resting, positioned partially on her back and left side, and on top of an air flow mattress. *Her heels had been resting directly on the mattress without any devices used to prevent pressure from occurring. *Her head had shifted off the pillow and was positioned next to the side rail. *Her facial expression was flat, and she moved her head yes or no to any questions asked of her. *She denied any pain at that time. *Three family members were there visiting her. Random observations of resident 286 on 2/5/19 from 7:40 a.m. through 11:30 a.m. revealed she: *Had the same appearance as observed above. *Wore the same clothes she had on the day before. *Continued to lay in her bed partially on her back, and left side. *Continued to answer yes or no questions by nodding her head. *Had one of her daughters staying there with her. *At 10:30 a.m. an unidentified staff member had been observed taking a breakfast tray in for the resident. -They left her room immediately after leaving the breakfast. On 2/5/19 at 7:30 a.m. the surveyor requested to observe the staff assist the resident with any and all types of care. At 11:30 a.m. the staff still had not contacted the surveyor to observe them with the resident. Interview on 2/5/19 at 11:30 a.m. with resident 286's daughter revealed: *Her mother [MEDICAL CONDITION] and was receiving end-of-life care through Hospice services. *She had spent the night with her mother. *Her mother was: -Weak and the family had to assist her with the call light. *To her knowledge no staff had been in to check on her mother throughout the night. *The staff would not have come in to check on her unless they put the call light on. *She was currently complaining of pain and had requested something for it earlier that morning. -The nursing staff had not been in to give her any pain medication. *She did not like to be repositioned often as it was painful. Interview on 2/5/19 at 11:50 a.m. with registered nurse (RN) M regarding resident 286 revealed: *She had been aware of the request from the resident for pain medication. *Review of the resident's MAR indicated [REDACTED]. *She stated: -Her daughter had asked for her. -When I ask her (resident) she says no. -But she doesn't know me very well either. -She doesn't appear to be in pain at this time. -She appears to be resting comfortably. -She is not grimacing or anything like she is in pain. -I just changed her pain patch yesterday, and she seems more comfortable since then. *The Hospice nurse had: -Been in to assess the resident that morning. -Reviewed with the nurse her goals for pain management and was going to have the MS put on a schedule. *The surveyor requested the staff to contact her when they provided care for the resident, and the nurse assured the surveyor the staff would contact her. Interview on 2/5/19 at 2:30 p.m. with resident 286's daughters revealed: *The family had been staying with her around the clock to ensure she was cared for. *The staff would not have assisted her with personal care, positioning, and toileting unless the family had requested it. -They confirmed she would have laid in the same position for hours at a time. -They agreed she was at risk for skin breakdown. *A couple of times the staff had left her in the bathroom unattended. -During those times the staff expected the resident to pull the call cord when she was finished. *The meals were brought to her room and left there for her to feed herself. -The family assisted her with those meals. *They confirmed she had been in the same clothes for two days. -The daughter had just changed her shirt, because it was soiled. *She had a bed bath on Mondays and Thursdays. -She had received two out of two bed baths since her admission on 1/28/19. -Her hair was not washed during either of those times. *They stated several times We just want her comfortable and taken care of that is why we stay here. *The Hospice nurse had been in to assess the resident that morning. -Pain control had been discussed. -The Hospice nurse was going to get the MS on schedule to ensure the resident would have been receiving it to ensure pain control. *The charge nurse had given the resident some MS at 1:15 p.m., but she continued to complain of a headache. -They were not aware she could have received Tylenol to help with the headache. *They had not been a part of any initial care plan review and were unsure of the goals for their mother. *They stated: -I don't know who is supposed to feed her or move her. -We have been, because they don't offer or do it. -They did come in and get her up to the bathroom over lunch. Observation and interview on 2/5/19 at 3:00 p.m. with resident 286 revealed she had been resting in bed as observed above. She had been holding her head with her left hand. She nodded her head yes when asked if her head continued to hurt. -Her daughter confirmed she had not received any other pain medication since 1:15 p.m. Review of resident 286's 1/28/19 through 1/31/19 MAR indicated [REDACTED] *Her pain level was to have been monitored and documented on every shift. -Her pain level had ranged from zero to three. -Two out of the ten shifts had no documentation on her pain level. *In those four days and ninety-six hour period: -She had received MS once for pain control, and it was effective. -Her [MEDICATION NAME] was not changed on 1/29/19 as directed by the physician's orders [REDACTED]. --There was no documentation to support other pain medications had been given. Review of resident 286's 2/1/19 through 2/6/19 MAR indicated [REDACTED] *They continued to monitor her pain level every shift. -Her pain level ranged from zero to a five. -All of her complaints of pain had occurred from 6:00 a.m. to 2:00 p.m. *In those six days she had: -Received Tylenol once on 2/4/19. -Her [MEDICATION NAME] had applied on 2/2/19. --That had been six days after her admission. -Received MS once per day on 2/2/19, 2/3/19, 2/4/19, and 2/5/19 and was effective. Review of resident 286's IDT progress notes from 1/28/19 through 2/4/19 revealed: *On 1/28/19 at 3:37 p.m. an admission note had been completed. -She had been alert with some confusion. -She had denied pain, and her condition was stable. *On 1/29/19 at 3:53 p.m.: As a practical matter, (resident's name) was admitted to skilled nursing facility for malignant neoplasm of upper lobe, left bronchus of lung on 1/28/19. *On 2/6/19 at 7:34 a.m.: Staff and family notes (resident) has been needing more assistance w/meals. Blowing bubbles in beverages w(with)/straw. Discussed w/ST (speech therapy) who recommends offering nectar liq (liquid) when (name) needs to be fed liquids. Family aware, offering both nectar and thin liq beverages at all meals. *No further documentation to review on her. Continued medical record review for resident 286 revealed there was no documentation to support: -How much assistance she had required for ADLs from the CNAs. -Assessments had been completed by the nursing staff and direct care givers. -End-of-life and comfort care had been provided in the absence of the Hospice staff. Review of resident 286's 1/29/19 comprehensive care plan revealed: *She had been admitted for palliative care under Hospice services. *Her goal was to have been kept as comfortable and pain free as possible. *She had required staff assistance with all ADLs except eating. -The staff were to have monitored her for any difficulties with eating. *She was at risk for falls with no interventions identified for that focus area. 3. Interview on 2/5/19 at 3:40 p.m. with RN M revealed: *She had been aware residents 286 and 287 were on palliative care and required staff assistance with ADLs. *She would have expected: -The CNAs to assist the residents with changing of their clothes and personal hygiene between baths. -The resident's hair was to have been washed during the bath. -The residents to have been repositioned at a minimum of every two hours. -The CNAs should have assisted the residents with any and all ADLs unless the families requested something different. -The CNAs to have documented the ADLs they had assisted the residents with in their charts. *She had: -No specific policy to follow for pain management. -Not identified that resident 286 had increased pain. *She stated: -She seems comfortable to me. -She's not grimacing or anything. -But family does say she is hurting terribly. -But I am still new to her, so maybe she's more comfortable telling them then me. -I did give her some MS for a headache, and it seemed to help. -We do our own assessments/documentation and Hospice does theirs. -I am not aware of any delay in getting the residents their medications. *She had not been aware: -Of all the concerns identified above with pain management, repositioning, personal hygiene, assisting the residents with their ADLs, lack of assessments, and documentation. -The staff had not contacted the surveyor to watch them assist resident 286. *She: -Confirmed they had been short staffed, and today was one of those days. -Stated We do the best we can, we get people up, and take care of them. On 2/5/19 at 4:00 p.m. the surveyor had been contacted to watch the staff assist resident 286 with personal care and repositioning. The resident had been laying in her bed and in the same position as observed above at 3:00 p.m. The staff assisted her with incontinence care and repositioning to her other side. At no time did she refuse their assistance for care. 4. Random observations on 2/5/19 from 9:06 a.m. through 2:10 p.m. of resident 59 revealed she: *Had been laying on her bed resting, was positioned on her back, and on top of an air flow mattress. *Had been dressed in street clothes. *Her heels had been resting directly on the mattress without any devices used to prevent pressure from occurring. *She appeared to: -Move her arms without difficulty. -Not be able to move her legs spontaneously. *At 9:30 a.m. her daughter: -Arrived to spend the day with her. -Requested an interview with the surveyor in the afternoon. Interview on 2/5/19 at 3:10 p.m. with resident 59's daughter revealed she: *Had been concerned that her mother had been in bed most of the day. -The staff had assisted her with incontinence care at 9:30 a.m. and again at 1:30 p.m. *Confirmed she had: -Required staff assistance for all ADLs. -Remained in the same position as observed above all morning until 2:30 p.m. --At 2:30 p.m. the staff had assisted her with getting out of her bed and into the w/c. *Stated: -Typically she is up by 7:00 a.m. and out for breakfast. -I come frequently, and when I get here she has had breakfast and usually is out sitting with the birds. -When I got here today she had no teeth in or hearing aides. -She got her breakfast late and it was cold. -She got it so late that when they came in to see if she wanted to go for lunch she said no. -They didn't come and get her up until 2:30 p.m. today. -I think there has been staffing problems, but I am not sure. 5. Interview on 2/5/19 at 4:45 p.m. with the director of nursing (DON) revealed she: *She had been: -Working as the DON since the end of October. -Aware of some of the concerns identified above. *Confirmed: -They had been working short staffed. -There had been budget cuts, and that had caused a problem with staffing. *Had recently worked as a CNA twice and a charge nurse once. *Was not aware that due to (d/t) the size of their facility she should not have been working those positions. *Stated: -We work short almost everyday. -Yes, it has affected the care the residents are receiving.-I have proven that our increased falls is d/t staffing issues. -When we are staffed appropriately we do not have the number of falls. -I know the grooming is poor, and they are not getting their nails cut, shaving done, repositioning, or baths. -The tub on 100 wing has not been working since I was hired. -We have one tub and one shower to use for bathing, and it's not enough. -We have been working short almost every day since I was hired. -Because of budget cuts we had to let the [MEDICATION NAME] go. -The staff are tired, and I'm having problems getting them to come in and help on their days off. -And I don't blame them. -Today was a good day. *She was not aware: -The residents identified above had received such a lack of care. -The residents and their families had not been included in their plan of care meetings. -Of the pain management and documentation concerns by the nursing staff. *Stated: -I have been so busy putting out fires out that I have not had time to notice all of those things. -I didn't even see it, and I am a Hospice nurse. *Would have expected the staff to follow the residents' care plans to ensure they received the appropriate care and services they had required. Interview on 2/6/19 at 12:03 p.m. with RN O, RN P, and the medical director revealed: *They had not been aware of all the concerns identified above. *They were aware: -Of the break down of communication between Hospice and the facility nursing department to promote consistency with care. -Of the pain management concerns and the delivery of those medications to promote comfort. *They had concerns with the poor hygiene practices by the staff for the residents. -Those practices had allowed for one resident to sit in bowel movement so long it had stuck to their bottom. *Hospice had twenty-four hours to assess a resident and ensure they were appropriate for their services and care. *The physician would have ordered medications for those residents to ensure pain management had occurred in a timely manner upon their admission to the facility. -Concerns had been identified with the delivery of those pain medications in a timely manner d/t the process involved with the current pharmacy to access them. *The Hospice department provided a medication pack for the staff to use once the resident was admitted under their care and services. -There had been concerns of the staff accessing and using that pack in a timely manner. *They should have been a part of the care conference meetings to support any concerns. -The time frame for the notification of those meetings had not allowed for them to attend. *The medical director confirmed she was aware of several of the concerns identified throughout the survey including: -End-of-life care, pain management, wounds, infection control, and over-all quality of care delivered by the staff. -The lack of communication between Hospice services and the nursing staff. -The concern with staff knowledge and the need for pain management education to ensure adequate pain control had occurred for the residents. -There was a staffing concern, and she had mentioned it several times in their quality assurance performance improvement meetings (QAPI). -There were concerns with the continual admittance of residents and the lack of staff to provide the appropriate care and services for them. -Staffing had been discussed in the QAPI. --Those discussions had only involved the case mix of the facility and money versus staffing. --No discussion had involved the lack of staffing in the facility on a regular basis to ensure quality of care had been delivered. Interview on 2/6/19 at 2:50 p.m. with the DON and administrator regarding all of the concerns above revealed: *The DON: -Confirmed those observations, medical record reviews, Hospice concerns, and staffing concerns. -Would have expected the nursing staff to assess and document on the residents themselves. -Not rely on the Hospice nurses' assessments. *The administrator repeatedly stated: -I get it. -I am very open, my door is always open. -I talked to (resident's name) family and this is very unsettling. *The administrator: -Confirmed the DON worked the floor and should not have. -Would not comment on the staffing concerns and stated I said no last summer to admits. Interview on 2/6/19 at 5:40 p.m. with RN Q revealed: *She had not been sure if there was a policy on pain management and documentation for them to follow. *She stated Hospice is here daily, they do the assessing, and documenting on those residents. -She would not have assessed those Hospice residents or documented on them when the Hospice staff were in the building. Interview on 2/6/19 at 5:50 p.m. with LPN I regarding the above documentation concerns revealed: *She had been the unit manager for the transitional care area. *She was new to the facility and had not been sure of their documentation requirements from the nursing staff. *She would have expected the nursing staff to have documented and assessed the residents on her units to ensure: -The appropriate care and services had been delivered. -The consistency of care with Hospice services had occurred. Surveyor: 7. Review of the provider's (MONTH) (YEAR) Terminal/Dying Resident, Caring for policy: *Purpose The purpose of this procedure is to provide guidelines for the personal care needs of a dying resident. *The resident's family: -Family participation in end-of-life care is encouraged. This can sometimes require you to work around the family. -Inso far as permitted by facility policy or the resident's advance directives, honor the family, and resident's requests. *The resident's personal care needs: -Continue to provide the resident with routine personal care (i.e., bathing, mouth care, etc.). -Provide routine skin care and repositioning to make the resident comfortable. -Keep the resident's body clean and dry at all times. -Provide food and liquids to the resident as instructed. Review of the provider's (MONTH) (YEAR) Hospice Program policy: *It is the responsibility of the facility to meet the resident's personal care and nursing needs in coordination with the Hospice representative, and ensure that the level of care provided is appropriately based on the individual resident's needs. -Communicating with the Hospice provider to ensure that the needs of the resident are addressed and met 24 hours per day. *Collaborating with Hospice representatives and coordinating facility staff participation in the Hospice care planning process for residents receiving these services. *The coordinated care plan will reflect the resident's

Surveyor: Based on observation, interview, record review, and policy review, the provider failed to have sufficient qualified nursing staff available at all times to provide nursing and related services to meet all the residents' needs safely and in a manner that promoted each resident's rights and physical, mental, and psychosocial well-being. Findings include: Surveyor: 1. Interview on 2/5/19 at 10:30 a.m. with the resident council revealed: *Their greatest concern was the lack of staff with weekends being the worse. *Residents had incidents of having to wait for extended periods of time to have their call lights answered. -Sometimes it was in excess of one-half hour. *They had to wait a long time for their meals in the dining room. *They had not always received weekly baths. -If the bath aide was not there on their scheduled bath day they might have to wait two weeks to get one. -The bath aides (BA) were frequently pulled to work on the floor which put them behind. *Those concerns had been brought to the management's attention through resident council. -Nothing seemed to change. *They no longer had any temporary staff which they thought was a good thing, because some of them were rude. Random review of the provider's Grievance file for the following revealed: *8/27/18: A resident was incontinent, because she did not get taken to the toilet in time. -A resident complained she did not get to activities of her choice in time. *9/10/18: A family called with concern about how long it had taken to get a call light answered. *9/25/18: Nature of Grievance: Resident Council are concerned about c.n.a. (certified nursing assistant) staffing (feel we are short) and think that the certified nursing assistants (CNA) need more training, specifically getting residents on/off toilet and changing. -Response/action taken: CNAs do get training during class and then are trained on he floor. *10/23/18: Residents still have concern about lack of CNA staffing. -Response: Reviewed with Resident Council group that Administrator is working on getting pool staffing. Explained to group all of the recruiting activities that are occurring to recruit staff. *11/26/18: Resident complained of having to wait to get served in the dining room. -Also voiced they either were brought to the dining room too early and had to wait, or had to wait to be brought back to their rooms after meals. -Residents voiced they had to wait for call lights to be answered. *1/22/19: Residents complained CNAs would tell residents they would be right back to help them, but they did not come back for an extended period of time. 2. Interview on 2/5/19 at 10:00 a.m. with resident 43 regarding staffing revealed: *It took a long time for staff to answer his call light. *They had told him it was a state regulation to answer call lights within five to seven minutes. *They had also told him They were working on the staffing issues. *He was continent of urine but had started to wear an incontinent brief at night, because staff were not able to answer his call light. He would end up being incontinent. *He usually had to wait anywhere from ten minutes to an hour for a staff member to answer his call light. Review of resident 43's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *The quarterly 12/14/18 Minimum Data Set assessment revealed: *A Brief Interview for Mental Status examination score of fifteen indicating he was cognitively intact. *He required: -Extensive assistance of one staff member for bed mobility, toileting, and personal hygiene. -Total assistance of two staff members for transfer using a total mechanical lift. *He was occasionally incontinent of bladder and bowel. Review of resident 43's 8/15/17 care plan revealed: *Focus: -I need assist with my ADL's (activities of daily living) due to MS. -I have only limited movement of my left hand, otherwise I am immobile. *Goal: -My needs will be met by staff through next review. 3. Interview on 2/5/19 at 2:36 p.m. with health unit coordinator (HUC) A regarding baths revealed: *A few months ago she took over the 100, 200, and 300 hallway wing bath monitoring. *HUC B took over the 400, 500, 600, and 700 hallway wing bath monitoring. *The administrator wanted the baths audited. *In order to keep track of the baths: -HUC's A and B were given the duty to audit baths. -If the baths had not been done they were to be completed the next day. *The bath aides had not been given any direction of who they were to give bath information to or report the baths too. *At that time they had three bath aides. *There was a lot of miscommunication between the bath aides. *The bath aides were to report to HUCs A and B now. -They were now using two staff members as designated bath aides. -CNA V was the designated BA for the 100, 200, and 300 hallway wings. -CNA F was the designated BA for the 400, 500, 600, and 700 hallway wings. *They had gone through the resident list to ensure all the residents were on the bath list. *Residents received one bath per week and two if they had requested it. *If the resident refused his/her bath on their bath day or the BA was not able to get the residents' bath completed the BA would to try the next day. *They did not have a BA for 2/5/19 to replace the BA who had called in absent. -They replaced the BA with another staff member who was to complete what she could, and the rest of the baths would be finished the next day. *Previously the director of nursing (DON) had completed bath audits with results of one resident had been missed. *They were told it was okay to alternate the bath schedule as long as the residents received their baths. Surveyor: Interview on 2/6/19 at 8:34 a.m. with BA F revealed: *There were two BAs who worked full time. *She was scheduled to work Monday through Friday. -The other BA worked Tuesday through Saturday. *Each bath took one-half to three-quarter of an hour. *They did about twelve baths per day. *They were both frequently pulled off the bath schedule to work as an aide on the floor for up to three and one half hours. -That put them behind in their bath schedule. -It was especially bad on Saturdays, because they had so many staff call in they were not coming into work. *There was not a back-up plan for days when one of them needed to take off. -No one replaced them. *They tried to get those residents who might have missed their bath the day before to get a bath as soon as possible. -But it was not uncommon for a resident to not get a bath until their next scheduled bath day. *A review of their schedule revealed that fourteen out of twenty-one days they were pulled to the floor and did not get all their baths completed. Surveyor: Interview and bath record review documentation on 2/5/19 at 3:40 p.m. with the director of nursing (DON) regarding baths from (MONTH) 5, 2019 through (MONTH) 5, 2019 revealed: *Resident 15 had received a bath on 1/18/19. *Resident 36 had not received any baths. *Resident 61 had received baths on 1/16/19 and 1/23/19. *The DON: -Felt the baths had been getting done. -Knew the baths had not been documented, because the BA had not had time to document them. -Knew BAs were pulled to other areas of the building when they were short staffed. *She agreed if the baths had not been documented that meant they had not been done. *She had wanted to have two bath aides work five days a week, but the BAs were pulled to other areas of the building when a staff member called in. 6. Interview on 2/5/19 at 9:47 a.m. with resident 287's healthcare representative revealed: *He had passed away last night, but she came back today to visit with the surveyor. *She: -Confirmed he was admitted on [DATE] at approximately 1:30 p.m. -Had arrived at 4:30 p.m. after he had been admitted . *He had been: -In his room sitting in a wheelchair (w/c). -Very upset, crying, and wanted her to take him home. -Very confused, restless, and kept trying to get out of the w/c. *All of his belongings had remained in their bags and were sitting on the floor by his feet. *She had stayed with him until 7:30 p.m. *During that time frame: -He remained in his w/c with his belongings on the floor by his feet. -He continued to be restless and confused. -No staff had checked on him, attempted to move him, offered him any supper, took him to the bathroom, or put him to bed. -No nursing staff had attempted to give him any medications to help calm him down. *Prior to leaving she had: -Asked the staff for some ice cream and attempted to feed it to him. -Assisted him to the bathroom, got him ready for bed, and laid him down to rest. *She came back at 9:00 a.m. the next morning, and the staff informed her that he had a restless night. *His belongings remained in bags and on the floor. -She unpacked his belongings and put them away. *During her visits he was assisted by the staff very little and typically she had to ask for assistance for *She stated: -I didn't feel I could leave him alone much. -I just wanted him to have good care, and I felt I needed to be here for that to happen. -It was disheartening. 5. Interview 2/5/19 at 11:30 a.m. with resident 286's daughter revealed: *Her mother [MEDICAL CONDITION] and was receiving end-of-life care through Hospice service. *She had spent the night with her mother. *Her mother was: -Weak and unable to push the call light when she needed assistance from the staff. --Family had to assist her with that. *To her knowledge no staff had been in to check on her mother throughout the night. *The staff would not have come in to check on her unless they put the call light on. *She was currently complaining of pain and had requested something for it earlier that morning. -The nursing staff had not been in to give her any pain medication. Interview on 2/5/19 at 2:30 p.m. with resident 286's daughters revealed: *They had been staying with her around the clock to ensure she was taken care of. *The staff would not have assisted her with personal care, positioning, and toileting unless they had requested it. -They confirmed she would have laid in the same position for hours at a time. -They agreed she was at risk for skin breakdown, and they did not want that to occur. *She was too weak to put the call light on herself, and the family had done that for her. *A couple of times the staff had left her in the bathroom alone. -During those times the staff had reminded the resident to pull the call cord when she was finished. *The meals were brought to her room and left there for her to feed herself. -The family assisted her with those meals. *They confirmed she had been in the same clothes for two days. -The daughter had just changed her shirt, because it was dirty. *She had a bed bath on Mondays and Thursdays. -She had received two out two baths since her admission on 1/28/19. -Her hair was not washed during either of those times. *They stated several times We just want her comfortable and taken care of that's why we stay here. *They stated: -I don't know who is supposed to feed her or move her. -We have been, because they don't offer or do it. -They did come in and get her up to the bathroom over lunch. 6. Interview on 2/5/19 at 3:10 p.m. with resident 59's daughter revealed she: *Had been concerned that her mother had been in bed most of the day. -The staff had assisted her with incontinence care at 9:30 a.m. and again at 1:30 p.m. *Confirmed she had: -Required staff assistance for all ADLs. -Remained in the same position as observed above all morning until 2:30 p.m. --At 2:30 p.m. the staff had assisted her with getting out of bed and into the w/c. *Stated: -Typically she is up by 7:00 a.m. and out for breakfast. -I come frequently, and when I get here she has had breakfast and usually is out sitting with the birds. -When I got here today she had no teeth in or her hearing aides. -She got her breakfast late and it was cold. -She got it so late that when they came in to see if she wanted to go for lunch she said no. -They didn't come and get her up until 2:30 p.m. today. -I think there has been staffing problems, but I'm not sure. 7. Interview on 2/5/19 at 4:45 p.m. with the DON regarding staffing concerns revealed: *She: -Had been working in the facility since 10/29/18. -Had confirmed they were working short staffed almost daily since she was hired. -Confirmed they were short staffed today. --A bath aide and a CNA had called in ill today. -Confirmed there were issues with baths not getting completed, as the bath aide would have been pulled to work the floor. -Could not confirm if the residents would have gone longer than a week without a bath. *The administrator had stopped contracting out and having traveling staff work in the facility because of financial concerns. *There were concerns in the dining room with the resident assistance (RA) helping residents with eating and had not been trained for that. *She was aware of the concerns in regards to grooming, nail clipping, shaving with the residents d/t the short staff. *They had a fall committee, and it was proven falls had increased at times sixty plus in one month when short staffed. -When properly staffed falls would have decreased to thirty-one on an average for a month. *It was getting harder to fill the short shifts because the staff are tired. *She had worked the floor as a CNA two to three times and worked an evening charge nurse shift for coverage d/t the difficulties of getting staff in to assist. *She had a night nurse who would be done working for them soon and was not sure what they were going to do. *The tub on 100 wing had not been working since she started working here. -As of now they had a shower and one tub to use for eighty-nine residents. *They were still taking admissions even with the staffing concerns and the capability of not delivering good care to all the residents. Interview on 2/6/10 at 12:03 p.m. with the medical director revealed and confirmed: *There was a staffing concern, and she had mentioned it several times to administration. *There were concerns with the continual admittance of residents and the lack of staff to provide the appropriate care and services for them. *Staffing had been discussed in the quality assurance performance improvement meetings. -Those discussions had only involved the case mix of the facility and money versus staffing. -No discussion had involved the lack of staffing in the facility on a regular basis to ensure quality of care had been delivered. *She stated: -We don't have the staff to take care of them. -Residents are here, because they cannot take care of themselves. Interview on 2/6/19 at 2:50 p.m. with the DON and administrator regarding all of the concerns above revealed: *The administrator repeatedly stated: -I get it. -Confirmed the DON had worked the floor and should not have. -Would not comment on the staffing concerns and stated I said no last summer to admits. Review of the provider's Qtr (quarter) 3, (YEAR) Bath, Shower/Tub policy revealed: *Purpose: -The purpose of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. *Documentation: -1. The date and time the shower/tub bath was performed. -2. The name and title of the individual(s) who assisted the resident with the shower/tub bath. -3. All assessment data obtained during the shower/tub bath. -4. How the resident tolerated the shower/tub bath. -5. If the resident refused the shower/tub bath, the reason(s) why and the intervention taken. -6. The signature and title of the person recording the data. *Reporting: -1. Notify the supervisor if the resident refuses the shower/tub bath. -2. Notify the physician of any skin areas that may need to be treated. -3. Report other information in accordance with facility policy and professional standards of practice. Surveyor: Review of the provider's (MONTH) 2014 Resident Council Meetings and Resident Concerns policy revealed: *Any concerns from meeting will be written up on the Resident Concern Form and forwarded to appropriate department director for follow-up. *Appropriate department director or appointed staff will follow up with individual resident voicing the concern. Concern resolution should be completed in accordance with the Concerns/Grievance Policy. Surveyor: Review of the provider's (MONTH) (YEAR) Staffing policy revealed: *Our facility provides sufficient numbers of staff with the skills and competency necessary to provide care and services for all residents in accordance with resident care plans and the facility assessment. *Licensed nurses and certified nursing assistants are available 24 hours a day to provide direct resident care services. *Staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care. *Inquiries or concerns relative to our facility's staffing should be directed to the Administrator or his/her designee. Refer to F636, F656, F658, F661, F684, F698, F727, F732, F761, F835, F838, F842, F867, F880, and F948.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being for all eighty-nine residents in the facility. Findings include: 1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administrator had not ensured the safe management and overall well-being of the residents. Interview on 2/6/10 at 12:03 p.m. with the medical director revealed she: *Visited the facility frequently and was highly involved with the residents under her care. *Was available in-between her scheduled visits by phone or fax and made additional visits if needed. *Was aware of several of the concerns identified throughout the survey including: -End-of-life care, pain management, wounds, infection control, and over-all quality of care delivered by the staff. -The lack of communication between Hospice services and the nursing staff. -The concern with staff knowledge and the need for pain management education to ensure adequate pain control had occurred for the residents. *Attended the quality assurance performance improvement (QAPI) meetings at least a minimum of every other month. *Confirmed: -There was a staffing concern, and she had mentioned it several times to the administrative staff. -There were concerns with the continual admittance of residents and the lack of staff to provide the appropriate care and services for them. -Staffing had been discussed in the quality assurance performance improvement meetings. --Those discussions had only involved the case mix of the facility and money versus staffing. --No discussion had involved the lack of staffing in the facility on a regular basis to ensure quality of care had been delivered. *Stated: -We don't have the staff to take care of them. -Residents are here, because they cannot take care of themselves. Interview on 2/6/19 at 2:50 p.m. with the director of nursing (DON) and administrator regarding all of the concerns above revealed: *The administrator repeatedly stated: -I get it. -Confirmed the DON worked the floor and should not have. -Would not comment on the staffing concerns and stated I said no last summer to admits. Surveyor: Review of the provider's (MONTH) 1, 2013 Administrator Job Descriptions revealed: *Would have been responsible for planning, organizing, staffing, directing, and coordinating the facility to ensure quality care for residents; to be knowledgeable of and implement federal, state, and local laws and regulations applicable to the facility and residents, personnel, and physical plant. *Establish, implement, review, and update facility policies and procedures pertaining to resident care, financial control, public relations, maintenance of physical plant, and procedure manuals. *Reviewed resident complaints and grievances and make a written report of action taken. *Have operated, managed, and maintained the facility in accordance with established policies and procedures. *Have acted as the liaison with the corporate office and professional and supervisory staff through meeting and reports. *Have prepared and forwarded to authorities reports as required by federal, state, and local agencies and management as well as corporate staff. *Have ensured adequate food, nursing, and housekeeping supplies and equipment were available, properly stored, and in working order. *Have attended meetings of the facility. The administrator or designee should have attended meetings including those concerned with utilization, resident care and safety, such as Quality Assurance (QA), Safety, Care Plans, and Medicare. *Have designated, in writing, who would be responsible for administrative function in her absence. *Have functioned in a problem-solving capacity with regards to the facility operations, resident, and staff issues. *Cooperated with the medical staff and with all those concerned with rendering professional service resulting in quality care to the residents. *Over-seen and to have been generally responsible for the overall day-to-day administrative management and operation of the affairs of the facility. *Help monitor and ensure compliance with applicable laws, rules, and regulations. *Schedule work hours and assignments and was responsible to see that each shift had been properly staffed. *Plan for quality assurance in all departments of the nursing home and would have developed quality improvement plans with committee members. *Have been in charge of the QA committee and ensured facility involvement and compliance with cooperate requirements. *Maintain a safe and hazard free environment in the facility. Refer to F636, F656, F658, F661, F684, F698, F725, F727, F732, F761, F838, F842, F867, F880, and F948.

Based on observation, interview, record review, and facility assessment tool review, the provider failed to ensure they had evaluated the facility's resident population and identified resources that were needed to effectively implement the necessary care and services the residents had required to ensure quality of care and quality of life. Findings include: 1. Review of the provider's 6/27/18 Facility Assessment Tool revealed: *The purpose of the assessment was: -To determine what resources were necessary to care for the residents competently during both day-to-day operations and emergencies. - To make decisions about direct care staff needs as well as capabilities to provide services to the residents. *Persons involved in completing that assessment were: -Administrator. -Director of nursing (DON). -Two Governing body representatives. -Director of finance. -Medical director. *That assessment had been reviewed with the Quality Assessment Performance Improvement (QAPI) committee on 7/25/18. Review of the guidelines for conducting that assessment included: *The facility must review and update that assessment annually. *The assessment was to have been modified or updated with any facility plan changes. Further review of the Facility Assessment Tool revealed: *Part 1: Our resident profile section indicated they could have accepted residents with, or may develop the following diseases, conditions, physical and cognitive disabilities, or combinations of conditions that require complex medical care and management. -Urinary incontinence. -Urinary tract infections -Impaired cognition. -Stroke. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Skin ulcers/injuries. *Part 2: Services and care we offer based on residents need section indicated they were able to provide: -Activities of daily living that included: -Bathing, dressing, eating, and grooming. -Mobility and fall with injury prevention that included: -Ambulation, restorative nursing, and contracture prevention. -Bowel and bladder that included: --Responding to requests for assistance to the bathroom promptly in order to maintain continence. --Promote resident dignity. --Care of urinary catheter. -Skin care that included: --Pressure injury prevention and wound care. -Person centered and/or directed care that included: --Getting to know the resident and engaging them in conversation. --Find out what the resident's preferences and routines were. --Incorporate information into the care planning process. --Make sure staff caring for the residents had information for care. --Support resident having familiar belongings. --Prevent abuse and neglect. --Identify hazards and risks for residents. --Offer and assist resident and family to be involved in person-centered care planning. --Provide family/representative support. -Management of medical conditions that included: --Assessment and early identification of problems and or deterioration. -Management of medical and psychiatric symptoms, conditions, and infections. -Medications that included: --Awareness of any limitations of administering medications. --Administration of medications the residents needed. -Therapy that included: --Proper positioning and alignment. -Other special care needs that included: --[MEDICAL TREATMENT]. --Hospice. --End of life care. --Wound care. -Pain management that included: --Assessment of pain. --Pharmacological and nonpharmacological pain management. -Infection prevention and control that included: --Identification. --Containment. --Prevention of infections. -Nutrition that included: --Assistive devices. --Fluid monitoring and restrictions. *Part 3 Facility resources needed to provide competent support and care for our resident population everyday and during emergencies included the staffing plan for the evaluation of overall number of facility staff needed to ensure a sufficient number of qualified staff were available to meet each resident's needs. *3.3 Individual staff assignments included: -Meet each morning, Monday thru Friday, at quality conference to discuss resident care and needs. --Adjusts staffing as appropriate. *3.5 Policies and procedures for provision of care included: -Our medical director participates in our QAPI meetings on a quarterly basis. -If issues arise with coverage, we address them with our medical director. -Discussions were held on our care delivery and corroboration with our providers at our facility QAPI meeting. *3.8 Physical environment and building plant needs included: -Emergency power. -Medical supplies included hand sanitizer, infection control products, and urinary catheter supplies. --Process was to assess the needs of our residents each day in quality conference. -Non-medical supplies included: --Soap. --Body cleansing products. --Incontinence supplies. --Bed and bath linens. --Office supplies. ---Process was to assess the needs of our residents each day in quality conference. Review of the Infection Prevention Risk Assessment Scoring Grid revealed: *It had been dated (YEAR). *It was unclear if this was actual data or a template. Refer to E004, E041, F636, F656, F658, F661, F684, F698, F725, F727, F732, F761, F835, F842, F867, F880, and F948.

Based on interview, record review, and policy review, the provider failed to ensure an effective quality assurance and performance improvement (QAPI) program had been implemented to identify and address concerns related to all residents' care within the facility. Findings include: 1. Interview on 2/6/19 at 5:15 p.m. with the administrator regarding QAPI revealed: *The committee met monthly and was attended by all department managers. *The medical director attended at least quarterly. *They discussed problems they saw in the facility such as falls, weight losses, infection control, and customer services responses. *They were aware that residents had concerns regarding staffing and how quickly call lights were answered, but they had only completed one audit of that. *While they tracked infections in the facility, they currently had no policies in place and had not put a process improvement plan (PIP) in place to reduce the number of infections. Surveyor: Interview on 2/6/10 at 12:03 p.m. with the medical director revealed she: *Was aware of several of the concerns identified throughout the survey to include the over-all quality of care delivered by the staff. *Attended the QAPI meetings at least a minimum of every other month. *Confirmed: -There was a staffing concern, and she had mentioned it several times to the administrative staff. -There were concerns with the continual admittance of residents and the lack of staff to provide the appropriate care and services for them. -Staffing had been discussed in the quality assurance performance improvement meetings. --Those discussions had only involved the case mix of the facility and money versus staffing. --No discussion had involved the lack of staffing in the facility on a regular basis to ensure quality of care had been delivered. *Stated: -We don't have the staff to take care of them. -Residents are here, because they cannot take care of themselves. Surveyor: Review of the provider's 2001 QAPI Committee policy revealed: *The primary goals of the QAPI Committee are to: -1. Establish, maintain and oversee facility systems and processes to support the deliver of quality of care and services; -2. Promote the consistent use of facility systems and processes during provision of care and services; -3. Help identify actual and potential negative outcomes relative to resident care and resolve them appropriately; -4. Support the use of root cause analysis to help identify where patterns of negative outcomes point to underlying systematic problems. -5. Help departments, consultants and ancillary services implement systems to correct potential and actual issues in quality of care; -6. Coordinate the development, implementation, monitoring, and evaluation of performance improvement projects to achieve specific goals, and -7. Coordinate and facilitate communication regarding the delivery of quality resident care within and among departments and services, and between facility staff, residents, and family members. *Committee Audit Process: -1. The QAPI Committee will scrutinize all department reports and summarize the findings in the committee minutes. -2. The QAPI Committee shall help various department/committees/disciplines/individuals develop and implement plans of correction and monitoring approaches. These plans and approaches should include specific time frames for implementation and follow-up. -3. The committee shall track the progress of any active plans of corrections. -4. The committee shall advise the administration of the need for policy or procedural changes and, as appropriate, monitor to ensure that such changes are implemented. The committee should have implemented appropriate plans of actions to correct identified high risk areas and quality deficiencies. Refer to F658, F661, F684, F698, F725, F761, F838, and F880.