Every finding on record at St William's Care Center

Based on observation, interview, record review, and policy review, the provider failed to implement pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) prevention interventions for one of one sampled resident (3) who was identified at risk for developing a pressure ulcer and developed an unstageable (wound bed not visible due to covering, such as debris, dead tissue, scabbing, or a non-removable dressing) pressure ulcer to her left heel while under their care. Findings include:1. Observation on 2/10/26 at 10:57 a.m. of resident 3 in the dining room revealed that she was sitting upright in her wheelchair. She was not wearing heel boots (a cushioned boot used to reduce pressure from a person's heel. 2. Observation on 2/10/26 at 2:21 p.m. of resident 3 in her room revealed she was still sitting in her wheelchair without heel boots on. That had been over approximately three hours she remained in the same position. 3. Review of resident 3's care plan (personalized plan that addresses a resident's care needs, goals, and interventions) revealed a focus area documented on 12/9/25 that indicated I have a skin injury and chronic fragile skin because I can't move around on my own. I have multiple sclerosis (MS) [a chronic autoimmune disease of the central nervous system where the immune system attacks the nerves in the brain, leading to communication issues between the brain and body], and I am confined to a bed or chair (non-ambulatory), I show this by having an existing skin injury (unstageable, pressure injury to left heel), my Braden's [a tool used to assess the risk of developing pressure ulcers] indicate a risk. I need my aides to help me reposition at least every one hour when I'm in a chair and every two hours during the night while I am in bed. Use pressure-reducing devices: air mattress in bed and cushion in wheelchair and recliner, heel boots to the left foot as needed. There was a 2/10/26 physician's order to cleanse left heel open area with normal saline (NS) and soap then apply therapeutic moisturizing fragrance free creme (due to dryness) twice a day. Another 8/2/22 physician's order indicated the heel boots should be placed on the resident's feet every morning, afternoon, and during the night shifts. Review of resident 3's electronic medical record (EMR) revealed that her Braden assessment scores ranged from 16 to 17, which indicated she had a mild risk for developing pressure ulcers. Her 12/11/25 Brief Interview for Mental Status (BIMS) score was 11 which indicated her cognition was moderately impaired. Review of resident 3's EMR revealed on 7/8/25 there was documentation for a new or sudden onset of left lower leg edema and blister to her left heel. The wound developed into an unstageable pressure ulcer. On 12/22/25 wound measurements revealed 4.0 centimeters (cm) long by 3.0 cm wide. On 2/16/26, the wound measurements were 2.0 cm long by 2.8 cm wide, and 0.1 cm deep. 4. Interview on 2/10/26 at 3:25 p.m. with resident 3 revealed that she did not have any complaints about her cares and she did not have any complaints of pain when the staff were completing her wound care. 5. Interview on 2/10/26 at 4:50 p.m. with licensed practical nurse (LPN) G revealed that resident 3 had an open skin wound on the back of her left heel. She explained that the wound nurse, LPN D, instructed the staff to leave the area open to air (a treatment method where wounds are left uncovered, without bandages or dressings, after initial cleaning) and to use a heel boot for cushioning to prevent it from getting bumped. 6. Observation on 2/11/26 at 8:41 a.m. of resident 3 in her room revealed she was asleep in her wheelchair with no heel boot on her left foot. She was wearing nonskid socks and no shoes. 7. Observation on 2/11/26 at 12:18 p.m. of resident 3 in her room revealed she was sitting in her wheelchair with no heel boot on her left foot. She was wearing nonskid socks and no shoes. 8. Observation on 2/11/26 at 4:37 p.m. of resident 3 in her room revealed that she was sleeping in a recliner. She was wearing a heel boot on her left foot. Director of nursing (DON) B and LPN D entered the resident's room to perform wound care. During the wound care treatment, resident 3 reported no pain in the area. LPN D stated they were leaving the wound open to air due to dry, sloughing skin (dead skin tissue in a wound that slows healing) around the wound. After the wound care was completed, DON B and LPN D did not reapply the left heel boot. Interview at that time with DON B and LPN D revealed that resident 3's pressure ulcer started out as a blister in July 2025 when they were using ACE wraps to try to control the edema (swelling caused by too much fluid trapped in tissues) in her legs. The clinic wound care nurse advised them that the ACE wraps would have to be removed and reapplied about eight times per day to treat the edema. Staff could not keep up with removing and reapplying the ACE wraps that many times per day, which resulted in the blister forming and opening. LPN D stated that wound care was completed once daily and wound assessment with measurements were completed weekly. 9. Observation on 2/12/26 at 8:45 a.m. in resident 3's room revealed that resident 3 did not have a heel boot on her left heel. She was sitting in her wheelchair and was leaning to the left side with her heel resting on the wheelchair footplate. 10. Interview on 2/12/26 at 9:29 a.m. with medication aide (MA) S revealed she was expected to reposition her assigned residents every two hours. She stated that the CNA Sheets have the information about each resident and their care needs. 11. Observation on 02/18/2026 at 2:03 p.m. of resident 3 in her room revealed she was lying on her back in bed without heel boots or pillows to offload pressure from her heels off the mattress. 12. Observation on 2/18/26 at 4:35 p.m. of resident 3 in her room revealed she was in the same position as the above observation. She had been lying in that same position for approximately 2 hours and 30 minutes. 13. Interview on 2/19/26 at 9:49 a.m. with certified nursing assistant (CNA) DD revealed that she used the CNA sheet (a document that identifies residents' care needs and interventions) to know how often to reposition the residents. She said that for resident 3, she usually laid her down after meals. CNA DD explained that she helped resident 3 put the heel boots on only when the resident was in her wheelchair, but not when the resident was in bed. She said she did not understand why resident 3 would need the heel boots on in the bed or the recliner, so she did not apply the heel boots in those situations. 14. Interview on 2/19/26 at 9:57 a.m. with CNA H revealed that she was not aware of resident 3's specific care needs, but she would refer to the CNA sheets for specific resident care needs such as turning and repositioning and use of pressure relieving devices. 15. Interview on 2/19/26 at 10:05 a.m. with CNA collaborator W revealed that she would refer to the CNA sheets for specific resident care needs. If the travel staff were not aware of how to care for a resident she would locate a nurse on duty. 16. Review of the CNA sheet revealed that it did not include information regarding resident 3's pressure ulcer interventions to her left heel, including when to reposition her or to use her heel boots. It indicated the staff should monitor her skin for breakdown, lay her down after her meals, use an air mattress on her bed, and place a cushion in her chair. 17. Interview on 2/19/26 at 1:34 p.m. with DON B revealed that she confirmed that resident 3's pressure ulcer on her left heel developed because of the use of ACE wraps for edema. She reported that the wound assessments were completed weekly on resident 3 and the Braden assessments were completed quarterly. She said that residents should ideally be repositioned every two hours unless resident 3 requested otherwise. When asked about resident 3's care plan, which directed the staff to reposition her every one hour, DON B responded, well that is not happening with anyone. She agreed that the care plan should reflect the most current care that a resident needed to achieve the highest level of health and safety.

Based on observations, interview, and record review, the provider failed to ensure two of two dietary staff (cook L and dietary aide P) followed the menu serving sizes for each diet offered for two of two observed meals. This had the potential to affect all residents who requested the main menu items. Findings Include:1. Observation on 2/10/26 at 11:25 a.m. in the kitchen revealed that cook L was preparing to set up the hot-serving table for the lunchtime meal service. Interview at that time with cook L revealed that most residents requested smaller portions, but she provided about four ounces of the meat option and two ounces of vegetables or two ounces of the side dish to the residents. She did not reference the dietitian approved menu at that time to verify the correct serving sizes for each prescribed resident diet.2. Observation on 2/10/26 from 11:50 a.m. to 12:19 p.m. in the dining room during lunch revealed that cook L was placing serving utensils in the food items. She used a four-ounce scoop for the peas, and two-ounce scoops for the pureed peas, stewed tomatoes, and mashed potatoes. When serving the stewed tomatoes, mashed potatoes, and pureed peas, cook L only used one scoop, meaning that only two ounces were served. [NAME] L served smaller portions of the baked chicken legs to the female residents, and she served the larger bone-in chicken breasts to the male residents. Additionally, cook L was serving residents one scoop (about two ounces) of mashed potatoes, and one scoop (about two ounces) of the pureed peas to residents. The menu indicated four ounces of mashed potatoes, and four ounces of peas should have been served.Cook L served resident 26 one scoop of peas (about four ounces), one scoop of mashed potatoes (about two ounces), one scoop of gravy (about two ounces), one slice of bread, and one small chicken leg. The laminated diet card did not indicate any requests for small-portioned meals.3. Review of the dietary extension menus revealed the menu for 2/10/26 included three ounces of protein (either the baked chicken or the cube steak), a half-cup of mashed potatoes (four ounces), and choice of a half-cup of stewed tomatoes or a half cup of peas. Residents on the pureed diet were supposed to have received a half-cup of the pureed peas. There was no small portions diet.4. Review of the resident diet orders report revealed that seven residents requested small portions, and two residents were on a pureed diet.5. Interview on 2/18/26 at 9:58 a.m. with dietary manager K revealed she expected staff to use the menu book that outlined the appropriate serving sizes for each menu item. There was a binder labeled Cold Orders in the kitchen for staff to access that contained all the menus and serving sizes for each diet. She expected all dietary staff to know where to find the diet menu spreadsheets and how to use them.6. Observation and interview on 2/18/26 at 11:51 a.m. with dietary aide P in the dining room revealed that she was using a two-ounce scoop for the mashed potatoes and ground beef. She said that cook L helped her set up the hot-holding table because she just started her job about four days ago. She used only one scoop of mashed potatoes and one scoop of the ground beef to serve the resident's their lunch.7. Review of the provider's menu for lunch on 2/18/26 revealed that the menu included a half-cup of mashed potatoes (about four ounces) and three ounces of roast beef (three ounces of ground beef for those on the mechanical soft diet).

Based on observation, interview, record review, and policy review, the provider failed to:*Minimize cross-contamination via glove use during two of three meals observed by cook L and during food preparation by dietary aide T.*Properly store and sanitize food thermometers prior to use by cook L.*Maintain one of one kitchen in a clean and sanitary manner as evidenced by dusty ceiling vents throughout the kitchen, dusty ventilation fans in one of one walk-in cooler, rusty shelves in one of one walk-in cooler, and food scum buildup inside one of one commercial dishwashing machine.*Monitor and document the temperatures for one of one commercial dishwashing machine according to the provider's policy to ensure it reached the minimum rinse cycle temperature of 180 degrees for sanitization of dishes and equipment used to prepare and serve residents' meals.*Ensure safe food storage practices were maintained as evidenced by storing potentially hazardous foods at room temperature for an extended period of time by one of one cook (L) and storing raw bacon above ready-to-eat (RTE) mashed potatoes in one of one walk-in cooler.*Discard visibly spoiled and expired foods on or before the manufacturer's date.Findings Include:1. Observation on 2/10/26 at 8:40 a.m. in the dining room revealed cook L was serving breakfast. She had on a pair of disposable gloves. She wore the same gloves throughout the observation. She touched several surfaces with those gloves, including the serving utensils, the laminated diet tickets, the serving table, her apron, and the handle of the serving cart. With those potentially contaminated gloves, she touched the food-contact surface of the plates and the slices of toast. She then used her gloved hand to scoop loose brown sugar into two-ounce plastic containers to serve with the hot cereal. She did not use a serving utensil for the toast or the brown sugar.Observation on 2/10/26 at 8:48 p.m. in the kitchen of dietary aide T revealed she was preparing cold deli sandwiches with disposable gloves on her hands. She touched several surfaces with those gloves including the loaf of bread, the sandwich meat, the plastic cling wrap, and the permanent marker to mark the date on the cling wrap. She then exited the kitchen to place the deli sandwiches in the refrigerator in the cafeteria. She came back to her prep area and continued making sandwiches without changing gloves or performing hand hygiene.Interview on 2/10/26 at 8:52 a.m. with dietary aide T about the above observation revealed she prepared those deli sandwiches for both staff and residents. She wrapped the sandwiches in cling wrap and wrote the preparation date on the cling wrap using the permanent marker.Observation on 2/10/26 at 11:55 a.m. during lunch service in the dining room revealed cook L wore a pair of disposable gloves. She touched the serving utensils, the serving table, and the laminated diet cards. With those potentially contaminated gloves, she touched the food-contact surface of the plates and slices of bread.Continued observation on 2/10/26 at 11:58 a.m. during lunch service in the dining room revealed dietary aide M wore a pair of disposable gloves. He touched the serving table and the laminated diet cards. With those potentially contaminated gloves, he touched the drinking surface of the cups.Review of the provider's 2023 Hand Washing policy revealed that staff should wash their hands when switching between working with raw food and working with ready to eat food.Review of the provider's 2023 Bare Hand Contact with Food and Use of Plastic Gloves policy revealed that staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling food. Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only one task such as working with ready-to-eat (RTE) food or with raw animal food, used for no other purpose and discarded when damaged or soiled, or when interruptions occur in the operation. Additionally, hands are to be washed when entering the kitchen and before putting on the single use gloves (before beginning to work with food) and after removing single use gloves.2. Observation on 2/10/26 at 8:58 a.m. in the kitchen revealed that two thermometer probes were kept in a cup with an unidentified clear liquid. The container had food debris floating around the liquid.Interview on 2/10/26 at 9:02 a.m. with cook L revealed that the above unidentified clear liquid was a sanitizer solution. She said it was changed daily, but she had not changed it yet from the previous day. Testing of the sanitizer solution concentration revealed that it was within acceptable range for proper sanitation. There were food particles floating within the sanitation solution. The sanitization solution was then changed.Observation on 2/10/26 at 11:30 a.m. in the kitchen revealed cook L was preparing to measure the temperature of the chicken that was to be served for lunch that day. She used one of the above-mentioned thermometer probes. She wiped the probe on a cloth that had been sitting on top of a container of papers near the microwave. She did not use an alcohol wipe to sanitize the probe before inserting it into the chicken. There were alcohol wipes available on a neighboring food prep table.Interview on 2/18/26 at 9:58 a.m. with dietary manager K revealed that the sanitizer solution used to store the thermometer probes should have been changed every shift. She expected staff to clean the thermometer probes with an alcohol wipe before inserting the probe into the food. She explained it was not acceptable to use a potentially soiled cloth found in the kitchen to wipe the thermometer probe prior to use. She also expected staff to refrain from touching food with potentially contaminated gloves. If each food item had a serving utensil, then the staff would not need to wear gloves.Review of the provider's 2023 Resource: Taking Accurate Temperatures policy revealed to take temperatures, a clean, rinsed, sanitized and air-dried thermometer that is the metal stem type, numerically scaled and accurate to plus or minus 2 degrees Fahrenheit is needed.3. Observation on 2/10/26 at 8:53 a.m. in the kitchen revealed that the two ceiling vents above the walk-in cooler and freezer were caked with a thick layer of dust.Observation and interview on 2/10/26 at 9:21 a.m. in the dish room with dietary aide N revealed that the inside of the dishwasher doors had a thick layer of food scum and limescale buildup. That buildup was also present to the left of the dishwasher, underneath the seam of the dishwasher track where it connected with the dirty dish table. Dietary aide N stated that the dishwasher was delimed once per week, but they did not use any cleaning tools, such as a cloth wipe or dish brush, to scrub areas where the food scum accumulated.Observation on 2/18/26 at 9:41 a.m. in the walk-in cooler revealed there were four fans used to circulate refrigerated air throughout the cooler. All four fans and the grates covering them had a collection of dust. There were streaks of dust buildup on the ceiling. There was more dust buildup on the light fixtures.Continued observation on 2/18/26 at 9:51 a.m. in the walk-in cooler revealed several of the storage shelves were rusty and the chrome or paint coating was chipping away. Several RTE food items were below the rusty parts of the shelves, such as fresh vegetables and fruit.Interview on 2/18/26 at 9:58 a.m. with dietary manager K revealed there was not a designated person in the facility to clean the ceiling vents or the fans in the walk-in cooler. She also indicated the rusty shelves might have to be replaced due to the potential for physical contamination of rust falling on the RTE vegetables on the shelf below.Review of the provider's dishwasher deliming schedule for 2025 revealed from July to December 2025, 26 of 31 scheduled cleanings were completed. In December 2025, deliming was completed only once.Review of provider's 2023 Food Storage policy revealed Racks and other storage surfaces should be clean and protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.)4. Review of provider's dishwashing temperature logs (August 2025 to February 18, 2026) revealed several missed opportunities for temperature documentation. Each monthly log had spaces to record the dishwasher temperature after each meal. There was a total of three temperatures required per day according to the log. In August 2025, there were 10 missing temperature documentations out of 93 opportunities. In September 2025, there were 36 missing out of 90 opportunities. In October 2025, there were 38 missing out of 93 opportunities. In November 2025, there were 32 missing out of 90 opportunities. In December 2025, there were 52 missing out of 93 opportunities. In January 2026, there were 61 missing out of 93 opportunities. From 2/1/26 to 2/18/26, there were 32 missing temperature documentations out of 54 opportunities.Interview on 2/18/26 at 9:58 a.m. with dietary manager K revealed that she expected staff to complete the temperature logs for the commercial dishwashing machine after each meal service when the dishes were cleaned.Interview on 2/18/26 at 11:50 a.m. with dietary aide O revealed that he was assigned to the dishwashing duties that shift. He stated that he did not check the temperature of the dishwashing machine and added, but I probably should. He further stated that he did not remember the last time he checked the dishwashing temperatures.Review of provider's 2023 Cleaning Dishes/Dish Machine policy revealed that staff will monitor dish machine temperatures through the dishwashing process. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. Staff will be trained to report any problems with the dish machine to the director of food and nutrition services as soon as they occur. The director of food and nutrition services will promptly assess any dish machine problems and take action immediately to ensure proper sanitization of dishes.5. Observation on 2/10/26 at 8:55 a.m. in the kitchen revealed there were several different covered containers of food, and an uncovered sheet pan of cooked beef patties sitting on the counter. Testing of the food temperatures revealed that the covered container of beef tips in gravy was at 56.1 degrees Fahrenheit, and the beef patties were at 68.9 degrees Fahrenheit.Interview on 2/10/26 at 9:28 a.m. with cook L revealed that the containers of food were designated for lunch that day. They usually prepare the lunch food before breakfast was served, panned it into containers, and placed the containers back in the cooler before they went to serve breakfast. She confirmed the food had been sitting out at room temperature since before she went out to serve breakfast, which she started serving at 7:30 a.m. She stated that it was not normal practice for the lunch food to sit on the counters during breakfast service. She usually put the food back into the cooler, but she had not done so that morning. She planned on using that food for lunch, and her goal final cooking temperature was at least 160 degrees [Fahrenheit].Observation on 2/10/26 at 11:22 a.m. revealed that the final cooking temperatures for the above-mentioned lunch foods were all above the minimum 165 degrees Fahrenheit temperature for reheated food.Observation on 2/18/26 at 9:49 a.m. in the walk-in cooler revealed raw bacon was stored in a cardboard box above a box of RTE mashed potatoes. This potentially exposed the mashed potatoes to cross-contamination from raw meat juices.Observation on 2/18/26 at 9:53 a.m. in the walk-in freezer revealed a box of frozen beef patties that was uncovered and left open to air on the bottom shelf of the storage rack. This potentially exposes the beef patties to physical, chemical, or biological contamination in addition to quality concerns with freezer burn.Interview on 2/18/26 at 9:58 a.m. with dietary manager K confirmed that raw foods should not have been stored above RTE foods. She was not aware of the box of frozen beef patties that was left open to air in the freezer. She further explained that if food was left out on the counter and entered the temperature danger zone [41 to 135 degrees Fahrenheit], it should have been discarded because they did not know how long that food had been sitting out. Dietary manager K explained that food that had been sitting out for over an hour could cause residents to become ill with a foodborne illness. She had not heard of any gastrointestinal illnesses amongst the residents lately.Review of the provider's 2023 Use of Leftovers policy revealed, Leftovers should be covered, labeled, and dated; then stored appropriately (refrigerated or frozen if necessary) immediately after the end of the meal service. Leftovers that have not been properly stored will be discarded. (When in doubt, throw it out.)6. Observation on 2/10/26 at 9:10 a.m. in the kitchen revealed there was a shelving unit with various baking ingredients like food coloring, flavor extracts, and coffee syrups. Several items were past the manufacturer's Best By or expiry dates, including: [NAME] branded butter extract with an expiry date of 3/3/25, [NAME] branded lemon extract with an expiry date of 3/18/25, egg shade yellow food coloring that had a delivery receipt of 1/6/11, Torani branded sugar-free caramel coffee syrup with Best If Used By 11/24/22, Torani branded coconut coffee syrup with Best If Used By 12/28/25, another bottle of egg shade food coloring with a delivery date of 10/22/13, a bottle of dried cilantro with Best By 2/27/2025, and a bottle of Creme de Menthe coffee syrup with an expiry date of 1/17/21.Observation on 2/18/26 at 9:45 a.m. in the walk-in cooler revealed there was a gallon jug of sweet pickle relish and a gallon jug of thousand island dressing. The cover on the pickle relish was not fully secured and had an unidentified white substance on the inside surface of the lid. The jug of thousand island dressing had what appeared to be mold growing on the outside of the container, on the inside of the lid. and on the handle. There was no opened date written on that container.Interview on 2/18/26 at 9:58 a.m. with dietary manager K revealed that they did not use the food coloring, flavor extracts, or coffee syrups often in their baked goods. She was not aware that those items were past the best by dates. She was also not aware of the potentially moldy jug of dressing in the cooler. She guessed the white substance on the inside of the pickle lid could have been something like mayonnaise, but she was not sure.Review of the provider's 2023 Food Storage policy revealed that All stock must be rotated with each new order received. Rotating stock is essential to assure the freshness and highest quality of all foods. Food should be dated as it is placed on the shelves if required by the state regulation. Date marking should be visible on all high-risk food to indicate the date by which a ready-to-eat TCS [time and temperature control for safety] food should be consumed, sold or discarded.All containers or storage bags must be legible and accurately labeled and dated. All foods should be covered, labeled and dated and routinely monitored to assure the foods (including leftovers) will be consumed by their use by dates, or frozen (where applicable) or discarded. All foods should be covered, labeled and dated.

Based on interview, document review, and policy review, the provider failed to ensure a water management program was in place to mitigate the growth and spread of Legionella (a type of bacterium commonly found in natural water sources). This had the potential to affect all residents, staff, and visitors within the facility. Findings include:1. Interview on 2/18/26 at 12:45 p.m. with maintenance director U revealed:*He checked the in-line water heater temperature every morning, and the temperature range was to be no more than 125 Fahrenheit (F), so he kept it at 117-118 degrees F.*They did not add any chemicals to their water for the prevention of Legionella.*The building's water was not tested for chlorine levels.*He or housekeeping sometimes ran the water and flushed the toilets in the empty rooms, but he did not have a formal plan or documentation for running stagnant water. 2. Review of the November 2025 through February 2026 water heater temperatures revealed that the water heater temperatures were always at 117 degrees F. The water temperature was required to be 122 degrees F to 125 degrees F for control of Legionella. 3. Interview on 2/19/26 at 9:00 a.m. with city water employee HH revealed he did chlorine testing at the nearby upstream facility daily, but not at this nursing home. 4. Interview on 2/19/26 at 12:55 p.m. with director of nursing/infection preventionist B revealed she expected maintenance to follow the federal guidelines for the prevention of Legionella. 5. Interview with administrator A on 2/19/26 at 1:30 p.m. revealed:*She expected maintenance to follow the guidelines to prevent Legionella.*There was a changeover in staff, and no one was monitoring that it was being done.*They did not have a formal process for running stagnant water or making sure the water was the correct temperature to kill Legionella.*She was responsible for ensuring the water management process was followed. 6. The 10/2025 Infection Prevention and Control Policy did not contain information regarding Legionella management and prevention.

A. Based on observation and interview the provider failed to ensure one of one sampled resident (32) had anything to eat or drink or had blood glucose monitoring within thirty minutes of receiving Novolog (a fast-acting insulin used to lower blood sugar) administered by licensed practical nurse (LPN) D. Findings include:1. Observation and interview on 2/12/26 at 7:51 a.m. of LPN D revealed: *She woke up resident 32 to administer her insulin. The resident had not eaten breakfast yet but was going to get a room tray. *Resident 32's blood sugar was 264 (normal blood sugars are 70-130), and LPN D administered 5 units of Novolog and 42 units of Toujeo SoloStar (a long-acting insulin). 2. Observation on 2/12/26 at 8:53 a.m. revealed resident 32 was sleeping, her room tray was delivered and left on her bedside table by CNA GG. 3. Interview on 2/12/26 at 9:17 a.m. with resident 32 revealed that the staff did not wake her up when they delivered her room tray, and she did not eat anything yet that day. 4. Observation on 2/12/26 at 9:22 a.m. revealed resident 32 was sleeping, and her breakfast tray sat on her bedside table untouched. 5. Interview on 2/12/26 at 9:24 a.m. with LPN D revealed: *After Novolog was administered, the resident should have something to eat or drink within 20 to 30 minutes because it was a fast-acting insulin. *The staff were to wake resident 32 up to eat and set up her room tray. *She went into resident 32's room, woke her up, set her tray up, and encouraged her to eat her food. 6. Interview on 2/12/26 at 9:35 a.m. with certified nursing assistant (CNA) GG revealed: *She had delivered the room tray to resident 32. *She was to wake the residents up when she dropped their room trays off, set the room tray up if they needed her to, and feed the residents if they could not feed themselves. *Resident 32 was able to feed herself but needed her room tray set up. 7. Interview on 2/12/26 at 10:07 a.m. with pharmacist Q revealed that after administering Novolog to a resident, the resident should have something to eat or have blood glucose monitoring completed within 30 minutes. 8. Interview on 2/19/26 at 12:55 p.m. with director of nursing (DON) B revealed that after Novolog was administered to a resident, the resident should eat within 20 to 30 minutes. The provider did not have an insulin administration policy. B. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (42) had a physician's order for compression stockings in her electronic medical record (EMR) and on her treatment administration record (TAR). 1. Observation and interview on 2/10/26 at 4:23 p.m. with resident 42 in her room revealed she had bilateral compression stockings on each of her lower legs. She indicated the staff would put them on her every morning when they put her clothes on. She stated the stockings helped with the swelling in her lower legs, but was unsure what caused it. Interview on 2/12/26 at 11:07 a.m. with CNA H revealed that resident 42 was to wear her bilateral compression stockings when out of bed to assist with the edema in both lower legs. Interview on 2/18/26 at 1:30 p.m. with resident 42 revealed she did not have bilateral compression stockings on her lower legs. She indicated that the compression stockings were in the bathroom, and the staff did not put them on her when they dressed her that morning. Interview on 2/18/26 at 12:25 p.m. with LPN F verified that resident 42 did not have an active physician's order for the bilateral compression stockings, and she should have. Interview on 2/19/26 at 3:09 p.m. with the director of nursing, A revealed that resident 42 should have had a physician's order for the compression stockings in EMR. She should have had a treatment listed on her TAR for the compression stockings to be applied by the staff in the a.m. and taken off in the p.m. Observation of the Team 1 CNA B pocket care plan revealed that resident 42 was to have Ace wraps on/am and off/HS (bedtime). 2. Review of resident 42's electronic medical record (EMR) revealed her 2/11/25 Brief Interview for Mental Status (BIMS) was 15, which indicated she was cognitively intact. She had a diagnosis of atherosclerotic heart disease of native coronary artery (plaque buildup in the heart's natural arteries), and a cerebral infarction due to an embolism of the left anterior cerebral artery (uncommon ischemic stroke). She had a 11/22/21 physician's order to apply TED (Thrombo-Embolism-Deterrent hose that prevents blood clots) hose (knee high) to both lower extremities in the a.m. and off in the p.m. She had a 6/7/22, physician's order for an Ace elastic bandage to both lower extremities daily, on in the a.m. and off in the p.m. On 8/22/23, the Ace elastic bandages were discontinued. She had a 10/21/25 physician's order to hold the compression stockings and measure both ankles daily in the a.m. starting on 10/22/25 through 10/25/25. She had a 10/27/25 physician's order to discontinue the compression stockings due to no changes in the ankle measurements. Her primary care provider assessed her on 12/15/25, and the progress note indicated Her weight remained unchanged. She lasted one day right after my last visit without her compression stockings on her lower extremities. There was no physician order initiated on 12/15/25 that indicated resident 42 is to wear bilateral compression stockings. The facility did not have a policy regarding physician orders being transcribed and communicated to the designated staff to be implemented for the residents.

Based on observation, interview, and policy review, the provider failed to ensure medications were securely stored and labeled for safe use according to professional standards to ensure:*One of one medication room was free from expired medical supplies.*Insulin pens for three of six sampled residents (7,12, and 32) were dated when removed from the refrigerator.*Five of five sampled residents (7,9,35,46, and 48) inhalers were dated when opened.*Two of two glucose test strip bottles were dated when opened.*Two of two medication carts were locked when unattended by two of two nurses (B and R). Findings include:1. Observation and interview on [DATE] at 10:20 a.m. in the medication room with licensed practical nurse (LPN)/director of nursing (DON) in training E revealed: *There was a sign that hung on the refrigerator that stored insulin to indicate how long different types of insulins were good for once opened. *There were thirteen swabs that tested for respiratory infections that expired on [DATE]. *There was one wound culture that expired on [DATE]. *There were two urinary catheter drainage bags that expired on [DATE] and [DATE] *There were three 14 french (fr) self cath (flexible tubing placed in the bladder to drain urine and then removed) kits that expired on [DATE] and [DATE]. *There were sixteen 14 fr female straight catheters that expired on [DATE]. *The code (medical emergency) box contained one suction yanker (suction instrument) that expired on [DATE], four nasopharyngeal airways (emergency airway) that expired [DATE], [DATE], and [DATE], two endotracheal tube (ETT) (emergency airway) that expired on [DATE] and [DATE], one non-rebreather mask (for oxygen administration) that expired on [DATE], and one nasal cannula tubing (for oxygen administration) that expired on [DATE]. *They used the code box yesterday on a resident. *The overnight nurses were to check the outdates in the medication room on their downtime, and medication aide (MA) S checked the outdates weekly. *LPN/DON in training E verified that the expired items should have been removed, and if expired items were used, they could not ensure that the item would function appropriately and could not guarantee sterility. 2. Observation and interview on [DATE] at 4:25 p.m. with LPN/DON in training E of the [NAME]/Humming Bird medication cart revealed: *Resident 35 had fluticasone and albuterol inhalers that were opened, used, and not dated. *Resident 7 had a used Amelog Solos Star insulin pen that expired on [DATE], a used Lantus insulin pen that was not dated, and an albuterol inhaler that was opened, used, and not dated. *There was one bottle of glucose test strips that was open and not dated to indicate when it had been opened. 3. Observation and interview on [DATE] at 4:30 p.m. with LPN/DON in training E of the Farmer/Woodland medication cart revealed: *Resident 48 had an Alvesco inhaler that was opened, used, and not dated. *Resident 12 had a Lantus pen that was not dated once removed from the refrigerator. *Resident 32 had a Toujeo Solostar insulin pen that was opened, used, and not dated. *Resident 9 had a Trelegy Ellipta inhaler that was opened, used, and not dated. *Resident 46 had an albuterol inhaler that was opened, used, and not dated. *There was one bottle of glucose test strips that was opened and not dated to indicate when it had been opened. *LPN/DON in training E expected the insulin pens not to be used past the expiration date as it might not be as effective, and the insulin pens and inhalers to be dated once opened. The medication carts were to be checked for outdated items weekly by MA S and by the night nurses during their downtime. 4. Observation on [DATE] at 7:54 p.m. revealed a medication cart was in the hallway by resident rooms, it was not locked, and there were no staff present near it. Registered nurse (RN) R verified it was unlocked, and she thought it was okay to leave it unlocked since she was in a resident room that was across the hall from it. 5. Observation on [DATE] at 7:56 p.m. revealed one of the medication carts was left unlocked and unattended near a resident room with a resident sitting in front of the cart. DON B was then observed walking down the hallways towards the medication cart to continue passing medications. 6. Interview on [DATE] at 8:04 p.m. with DON B revealed she did not think the insulin pens needed to be dated until they were used, and not when they were taken out of the fridge. 7. Interview on [DATE] at 10:07 a.m. with Pharmacist Q revealed that insulin was to be dated once it was removed from the fridge. 8. Interview on [DATE] at 12:55 p.m. with DON B revealed that it was best practice to date insulin once it was removed from the fridge, inhalers were to be dated once opened, and the medication carts were to be locked when out of the nurse's vision. Regarding medication and supplies, they only had the Administration of Medication policy. 9. According to the provider's [DATE] Administration of Medication policy revealed: *It is best practice to lock cart prior to walking away from it, but at least visual control of the cart must be maintained to assure hat [that] no one else is able to access it. *The medication cart is to remain locked at all times when a nurse is not in close proximity.

Based on interview, record review, and policy review, the provider failed to ensure medical director EE attended and meaningfully participated in the provider's Quality Assurance and Assessment (QAA) meetings at least quarterly. Findings include:1. Interview on 2/19/26 at 11:25 a.m. with administrator A revealed that the QAA committee meets monthly. She texted medical director EE monthly to remind him of when the meetings were, and he usually texted topics he wished the committee to discuss. He sometimes would attend via telephone. He did not have a nurse practitioner or physician's assistant to attend in his absence. She confirmed she was aware that the medical director was required to attend at least quarterly. 2. Review of the provider's QAA committee binder at that time with administrator A revealed that medical director EE attended the QAA committee meeting via telephone on 1/29/26 (their most recent QAA committee meeting), and he attended in person on 8/13/25. All other months throughout 2025 he either did not attend or only sent a text to administrator A with topics he wanted them to discuss. 3. Review of the provider's July 2025 QAPI (Quality Assurance and Performance Improvement) policy revealed that the medical director was on the QAA committee, and the committee would meet at least quarterly.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (1) had a physician's order for supplemental oxygen when she was readmitted to the facility, and was provided continuous oxygen using a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) by the staff. Findings include:Based on observation, interview, record review, and policy review, the provider failed to ensure one of one resident (1) had a physician's order for supplemental oxygen when she was readmitted to the facility and was provided continuous oxygen using a nasal cannula (flexible tubing with prongs that delivers oxygen through the nose) by the staff.Findings include: 1. Observation and interview on 2/11/26 at 10:41 a.m. with resident 1 in her room revealed there was an oxygen concentrator (a device that filters room air into purified oxygen). Attached to the concentrator was an NC tube and a plastic bottle that contained water (a bubbler), which was used to humidify the oxygen inside it. There was no date on the bubbler or the NC tubing to indicate when they were provided or cleaned. There was no sign outside of the resident's room to indicate that oxygen was in use. Resident 1 indicated she propelled herself to her room after she had breakfast in the dining room, and she did not start the oxygen concentrator or put on the NC tubing when she returned. She stated she knew that she was to receive the oxygen and wear the NC tubing per her doctor's order. Resident 1 attached the NC tubing around her ears, placed the nasal prongs on the tubing in her nose, and turned on the oxygen concentrator. Observation and interview on 2/11/26 at 11:00 a.m. in resident 1's room revealed that resident 1 did not have the NC tubing on, and the oxygen concentrator was not on. Still, shortly after I had entered her room, she stated, I better put this on like I am supposed to (NC tubing) and applied the NC tubing. She then turned on the oxygen concentrator, which revealed the settings were set to 1.3 L/min. The resident was short of breath during our interview and stated, I am short of breath because I just brought myself back to my room from the dining room. Licensed practical nurse (LPN) G entered resident 1's room and checked her oxygen saturation level with a pulse oximeter (a finger-clipped device that measures blood oxygen saturation and pulse). The amount of oxygen resident 1 was to receive using the NC was contingent upon her oxygen saturation level, which was 98 percent, and she did not remove the NC tubing or shut off the concentrator. 2. Observation of the certified nurse assistant (CNA) B pocket care plan (a document that identifies residents' care needs and interventions) revealed that resident 1 was to have Oxygen at all times. 3. Interview on 2/18/26 at 9:34 a.m. with ward secretary (WS) V revealed that resident 1 did not have a physician's order for oxygen using an NC at 1 percent L/min if her oxygen saturation level was less than 90 percent, to change the oxygen tubing, or to have the bubbler cleaned. 4. Interview on 2/18/26 at 9:52 a.m. with LPN D revealed that the CNAs will ask the nurse what the resident's oxygen concentrator should be set to when they turn the concentrator on and apply the NC tubing for residents. 5. Interview and record review on 2/18/26 at 12:25 p.m. with LPN F revealed that resident 1 was admitted to the hospital on [DATE], and was discharged from the hospital and readmitted to the facility on [DATE]. When she was readmitted to the facility, there was no physician's order written for oxygen to be administered using a NC if the resident's oxygen saturation level was less than 90 percent. 6. Interview on 2/18/26 at 9:39 a.m. with CNA GG revealed she was not aware of resident 1's physician's order for oxygen, and it was not on the CNA pocket care plan on how to care for the residents. She indicated that she only knew resident 1 was to have her NC on. 7. Interview on 2/18/26 at 3:09 p.m. with director of nursing (DON)/infection preventionist B revealed that resident 1 should have had a physician order in her electronic medical record (EMR) for oxygen to be applied using a NC at 1 L/min if her oxygen saturation level was less than 90 percent. Resident 1 should have treatments to be completed by the staff listed on her treatment administration record (TAR) for the bubbler to be cleaned weekly, for the NC tubing to be changed twice per month, and for a sign to be placed outside of her room to indicate oxygen was in use. 8. Review of resident 1's EMR revealed her 1/13/26 Brief Interview for Mental Status (BIMS) was 15, which indicated she was cognitively intact. She had a diagnosis of heart failure. There was a respiratory treatment order in resident 1's TAR to check her oxygen saturation level three times a day, morning, evening, and at night. The order indicated that if her oxygen saturation level was greater than 90 percent, she did not need supplemental oxygen. There was no physician order for oxygen to be supplied using a NC at one percent L/min if her oxygen level was less than 90 percent. There was no order to change the NC tubing or clean the bubbler. 9. Review of the provider's revised 10/19/26 Oxygen Therapy policy revealed, Place sign OXYGEN IN USE outside the room of the resident. Cleanse humidifier/bubbler on a weekly basis. Reservoirs must be kept dry when not in use.

Based on record review, interview, and policy review, the provider failed to incorporate one of one sampled resident's (9) Level II (2) Preadmission Screening and Resident Review (PASRR) into the Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment.Findings Include:1. Review of resident 9's electronic medical record (EMR) revealed she had a diagnosis of post-traumatic stress disorder (PTSD) and she was admitted to the facility on [DATE]. Her 11/11/25 MDS comprehensive assessment and 1/28/26 MDS quarterly assessment indicated that a PASRR Level II was not completed.2. Interview on 2/18/26 at 2:30 p.m. with social worker (SW) J revealed that the facility did not have a process to update the staff on if a PASRR Level II was completed for a resident. She completed the PASRR forms and kept them in her office. She did not share the completed PASRR documentation with the interdisciplinary team or registered nurse (RN)/MDS coordinator C. SW J stated, It would never occur to me that I would have to tell [RN/MDS coordinator C] if the resident was a PASRR Level I or II. I would let the nursing team know what the recommendations were, if any, from the PASRR. I don't have permissions other than Section S [state defined items] on the MDS to update anything.3. Review of resident 9's PASRR Level II obtained from SW J revealed she was reviewed by the South Dakota's contracted PASRR service on 10/27/25 and was approved for a 180 day stay at the facility with an end date of 4/25/26.4. Interview on 2/18/26 at 3:25 p.m. with RN/MDS coordinator C revealed there was no process to determine whether a PASRR Level II was completed for a resident and that Section S of the MDS assessment does not trigger Section A (the section for the resident's identifying information). RN/MDS coordinator C was not aware that SW J completed a PASRR Level II for the residents.5. Review of the provider's July 2025 admission Process - Criteria policy revealed The resident must meet the following medical/psychosocial and financial criteria to be eligible for admission: Must have PASRR pre-admission screening and approval for appropriate level of care prior to admission.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the facility failed to ensure the safety for one of one sampled resident (48) who was identified at risk for elopement (leaving the facility without staff knowledge) and left the building unsupervised on 9/19/25. Findings include:1. Review of the 9/19/25 FRI report submitted to the SD DOH revealed: *On 9/18/25 at 8:47 p.m., resident 48 exited out of the facility's back door. *Another resident's family member heard the alarm and called a staff member who was not on duty and notified her that the alarm was sounding. That staff member called the facility and told the nurse on duty, and she went out and assisted resident 48 back inside. *The wander guard alarm sounded at the door, at the alarm panel, and an alert was sent to the radio staff wore. *Staff did not hear the alarm going off at the panel because no staff was in that area at that time. Not all staff heard the alert on their radio. -Two certified nursing assistants (CNA) heard the alert on their radio but they were assisting other residents and were not able to immediately respond. -One CNA was on break and had the radio turned down and was unable to hear it. -One CNA had her radio in her pants pocket and the volume had accidentally been turned down. -One nurse did not have a radio, and the other nurse on duty left her radio on the medication cart and was not near it. 2. Interview on 2/18/26 at 12:45 p.m. with maintenance director U revealed: *He checked that the wander guard door alarm functioned appropriately monthly by bringing a wander guard near it to see if it alarmed. *If the wander guard alarm sounded, a code needed to be entered on the wander guard panel to turn the alarm off. *There was a keypad next to the front door. If a code was not entered prior to leaving the front door, the door would alarm. The alarm would turn off when the door closed, without staff needing to enter a code. 3. Observation and interview on 2/19/26 at 8:54 a.m. with ward secretary V revealed: *An alarm on the panel by the CNA station alarmed, she reviewed the cameras, did not see anyone or an open door, so turned the alarm off. *She did not need to go check the door. 4. Observation on 2/19/26 at 9:45 a.m. of resident 48 in her room revealed she was sitting in her recliner reading a book, and both of her walkers had a wander guard on them. 5. Observation and interview on 2/19/26 at 9:49 a.m. with CNA DD revealed: *She was a travel CNA, and it had been six months since she had worked at the facility. *She did not receive any education after coming back to the facility. *The alarm on the panel by the CNA station sounded. She stated, I don't know what this is for, walked over to the panel, pushed a button that silenced the alarm, and did not look into why the alarm was sounding. 6. Interview on 2/19/26 at 10:15 a.m. with CNA collaborator W revealed: *She worked at the facility for about a year. *When the door panel by the CNA station alarmed, they were to look at the camera to see if they saw anything suspicious on it, and then turn the alarm off if they didn't. *If they did not see anything on camera then they did not need to go check the door. *If she heard the wander guard alert over the radio, or the alarm on the wander guard panel sound, she would go and check that door. *The wander guard alert did not alarm at the CNA station, and it sounded at the door and needed a code to turn it off. *She recalled talking about elopements at a CNA meeting, she completed a video training, but she did not recall receiving training since September 2025. *She sometimes carried a radio, if one was available. *There was a sign that hung at the CNA station that reminded staff how to alert others of a missing resident by overhead page. They were to look for the resident in resident rooms, and to check the sign-out book. 7. Interview on 2/19/26 at10:26 a.m. with CNA H revealed: *She had worked at the facility for about five months. *If the door panel alarmed, she was to review the cameras to see if someone was there or if the door was open. *She was supposed to go check the door to see if anyone had gotten out. *An alert went to the staff's radios that said wander guard and the location. *All staff were to carry a radio. *The CNA sheets (a document that identifies residents' care needs and interventions) identified residents who wore wander guards. *There was a list of residents who wore wander guards that were in a binder in the report room. *She recalled having education regarding elopements for her new hire education, and they had monthly CNA meetings. 8. Interview on 2/19/26 at 11:52 a.m. with licensed practical nurse (LPN) G revealed: *She had worked at the facility for a year and a half. *Wander guards were to be checked every shift to ensure they were functioning by bringing the resident who wore the wander guard by the exit to see if the alarm went off. *She was not sure who was responsible for testing the wander guards, and it was not documented on the medication or treatment record. *The wander guard alarm sounded at the panel by the exit door, and it sounded at the control panel by the CNA station. *She took the radio out of her pocket, looked at it, and stated that it was on the incorrect channel, channel 4, and it needed to be on channel 1. *The wander guard did not send an alert to radios, but they used the radios to ask staff to locate residents. *After resident 48 eloped, she recalled receiving education regarding elopements and having the doors to the unit closed in the evenings. *There was a list of residents who wore wander guards in a binder in the report room. 9. Interview and document review on 2/19/26 at 12:09 p.m. and 1:54 p.m. with director of nursing (DON) B revealed: *Resident 48 had an elopement assessment completed last on 10/25/24 that indicated she was at risk for elopement, had eloped once before, and was to wear a safety exit alarm (wander guard), and was to be checked on frequently. *Elopement risk assessments were to be completed upon admission by LPN F, every three months, and as needed by registered nurse (RN) FF. *If a resident was found to be at risk for elopement and was ambulatory, they would wear a wander guard. *A list of residents who wore wander guards were kept in a binder in the report area. *All departments but housekeeping and maintenance were made aware verbally who was at risk for eloping, and it was discussed at regular resident review meetings. *Ward secretary V was responsible for adding who wore wander guards on the CNA sheets. *The nurse or medication aide was to check that the resident was wearing the wander guard twice a day, and to document it on the medication or treatment record. They had issues with getting that added to the medication or treatment record. *Resident 48's wander guard checks were on the treatment record, it was entered on 11/9/25, and it was only being done at bedtime because it did not pull correctly into the treatment record. *At the time resident 48 eloped on 9/18/25, the provider was lax because their main wanderers were no longer there. *After resident 48 eloped on 9/18/25, they started to close the doors to the unit in the evenings to deter her from wandering in that direction. *Resident 48 had worn the wander guard for quite some time. *When the door alarm panel alarmed she expected staff to check the camera to see who was near the door and to silence the alarm unless there was suspicion to go check the door. *Staff did not need to go check the doors unless the wander guard alarm was going off. *The wander guard alarm sounded by the exit door where it was triggered, and an alert went to the staff's radios to alert them. *All nursing staff on duty were expected to carry a radio and have the volume turned up far enough so they could hear and respond to the alert. *The ward secretary had extra radios at the desk, but did not always listen to them. *The radio needed to be on channel one to receive the alerts and radio communications. *Maintenance checked the wander guard panels at the exit doors monthly. *They did not have a device to check whether the wander guard functioned; they just checked for placement. *After resident 48 eloped, staff were educated to keep the unit door closed in the evenings, to carry their radios, and to have the volume turned up. *She was unsure who was all educated, but stated the dietary staff were because they were the ones to close the doors to the unit in the evenings. *They completed audits that the doors were being closed, brought those to QAPI, and determined they did not need to be continued. 10. Interview and document review on 2/19/26 at 1:45 p.m. with administrator A revealed: *She did in-service regarding the elopement policy on 9/22/25. *Every department provided the education to their areas, and staff who were at the meeting read the elopement policy. *Staff who did not attend that meeting were to read the elopement policy and sign that they had read it. *Review of the education sign-off sheets revealed thirty-four staff, including nine managers, signed that they received the elopement education. She verified that not all the staff received that education, and they should have. 11. Review of resident 48's electronic medical record (EMR) revealed: *Her 12/11/25 Brief Interview for Mental Status (BIMS) assessment score was 9, which indicated she had moderate cognitive impairment. *She had an order entered on 11/9/25 for her wander guard sensor to be checked on both of her walkers three times a day, in the morning, at night, and at bedtime. *Her 12/9/25 care plan indicated she: -Was admitted on [DATE]. -Had Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and bodily functions) -Had a BIMS score that indicated moderate cognitive impairment. -Wandered and got lost looking for her room. -Had a wander guard on her merry walker (type of walker). -Was unaware of her own safety, and the staff were to monitor her wander guard and respond if she set that alarm off. 12. Review of the CNA sheets revealed that resident 48 had a wander guard. 13. Review of resident 48's September 2025 through February 2026 treatment record revealed: *September 2025 and October 2025 did not indicate that the wander guard was checked. *On 11/9/25 the wander guard was added to check it three times a day. *11/9/25 through 2/17/26 was signed off as checked once a day at bedtime. 14. Review the provider's 9/19/25 Elopement/Missing Resident policy revealed: *Each resident at [facility] will be provided a safe environment in which to reside. *Wandering is a behavior that is characteristically associated with dementia, therefore residents with this diagnosis are observed upon admission. *[Facility] does not have a secure or locked unit, therefore the facility has installed a WanderGuard system which consists of sensors (worn by identified residents displaying wandering behaviors) and sensor detector strips that are at or near exit doors. *These residents are routinely monitor4ed [monitored] to assure they do not purposefully cut the strap and/or that the sensor is activating when it is supposed to do so. Another safeguard [facility] has implemented is installing auxiliary audible local alarms on interior doors of the facility. These alarms are activated when the interior door is opened which enables staff to reach the resident prior to exiting the building. These alarms sound until staff physically reset them. *The doors from the resident hallway (Farmer's Fairway) to the dining room will be closed following the evening meal and/or around evening snack. The door at the end of Farmer's Fairway will also be closed as added security.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI] report, interview, record review and policy review the provider failed to prevent staff to resident sexual abuse from occurring for one of one resident (29). Findings include: 1. Review of the SD DOH FRI report for resident 29 revealed: *On 9/21/24 at 11:35 p.m. certified nursing assistants [CNAs] reported to licensed practical nurse (LPN) H that resident 29 was complaining of CNA M being rough after she had used the bathroom and was being cleaned up. *LPN H assessed resident 29 in her room. *Administrator A and director of nursing (DON) B were notified. *Resident 29's power of attorney (POA) was notified. *Resident 29's primary physician was notified. *Administrator A contacted CNA M to suspend her pending investigation results. *Medical director C was contacted and he arranged for her transfer to the local emergency room for further assessment. *CNA M was terminated from the facility on 9/25/24. 2. Interview on 9/30/24 at 4:42 p.m. with resident 29 revealed: *She had a urinary tract infection (UTI) and was on antibiotics. *She stated she would get UTIs from her catheter. -I am on the strongest antibiotic you can be on for a UTI and I take my last pill tonight. *She stated staff treated her with respect and dignity and she had no problems with any staff. 3. Review of resident 29's electronic medical record revealed: *Her recent Brief Interview for Mental Status (BIMS) score was 15 indicating she was cognitively intact. *An order on 9/26/24 5:41 p.m. for, LevoFloxacin [antibiotic] 500 mg [milligrams] tablet dose ordered (1/2 tablet /500 mg) by mouth daily x 5 days Supper through: 9/30/24 for: urinary tract infections. *Her care plan dated 8/22/24 indicated she had a indwelling catheter, and history of UTIs. 4. Interview on 10/01/24 at 3:03 p.m. with resident 29 regarding the incident on 9/19/24 with CNA M revealed: *CNA M had been cleaning her up after she had used the bathroom. -She stated, I didn't think she should be cleaning me in that area. She clarified she was referring to her vagina. -The way CNA M cleaned her hurt her and she stated, I'm not sure she realized where she was going and was digging into my vagina from behind after I went to the bathroom and had a bowel movement. *She had no problems with any other staff. *She stated, I believe she did it intentionally because she told me I was dirty and she wanted to get me clean so I wouldn't get any infections, that was different from when my catheter gets pulled on. *She stated, She didn't tell me she needed to clean my vagina just that she needed to clean me. *She felt bad for reporting CNA M and stated, But what if she did that to someone else. *She went to the emergency room and had a video conference evaluation. They gave her a choice of a more thorough exam and she agreed to have the additional exam. -She stated they did not draw blood but did a swab of her vagina and she was told she did not have any open areas. -She did not know if she would get any results back from the exam but had not gotten any as of today (10/1/24). *She stated she thought the staff handled the incident well. *She was not aware of any new or different interventions or cares for her since this incident. 5. Interview on 10/01/24 at 4:01 p.m. with CNA K regarding providing peri cares for resident 29 revealed: *She would put on a gown and gloves and explain what cares she would be providing to resident 29. *She and another staff would use the mechanical lift to position her to clean the peri area. *She stated one staff would stand in front of resident 29 to keep her steady while the other staff would stand behind her to clean her. -She stated she cleaned her from front to back with wet wipes then with a washcloth and soap and water. She held the catheter to one side and cleaned the opposite side. *She was not aware of any new interventions for resident 29. *She was not aware of any abuse to residents. *She was not aware of any abuse education or training provided in the last month. 6. Interview on 10/01/24 at 4:27 p.m. with CNA N revealed: *He was not aware of any staff being rough with resident cares. *He thought he had abuse and neglect education in August. 7. Interview on 10/2/24 at 8:32 a.m. with certified medication assistant (CMA) J regarding abuse revealed: *She stated there had been staff to resident abuse in July or August a staff member had slapped a resident. -CNA M was no involved in this incident. -She was not aware of any allegations of staff to resident sexual abuse. *She had not had any sexual abuse education in the last couple of weeks. 8. Interview on 10/2/24 at 8:39 a.m. with social service designee E regarding the above incident involving resident 29 and CNA M revealed: *She stated she didn't know much but she knew that resident 29 had been in the mechanical lift. -Resident 29 had said 'ouch to the CNA when a nurse was putting in a catheter. -She stated she thought resident 29 had said ouch to the catheter being put in. *She said CNA M no longer worked there. *She was in the room when administrator A confronted CNA M about the incident. *She was not aware of any type of abuse education that had been provided since this incident. *She did not completed interviews or take part in the investigation regarding the incident, but administrator A did. *She did not put a social services note in resident 29's record regarding the incident on 9/19/24. 9. Interview and on 10/02/24 at 8:51 a.m. with DON B regarding resident 29's hospital report dated 9/22/24 revealed: *She agreed the provided hospital report did not have the sexual assault nurse examiner (SANE) dictation or results. -She called the medical director C while this surveyor was in the room. -She placed the phone on speaker mode and informed him this surveyor was in the room and asked about resident 29's SANE report results that had been done via telehealth conference. -The medical director stated he would have to talk to the nurses and call back. *DON B said medical director was called during resident 29's emergency room visit. -Medical director C did not call back regarding resident 29's SANE report or results before the end of the survey. *She stated she would get this surveyor CNA M's employee file to review. -CNA M's file was not provided before the end of the survey. 10. Interview on 10/2/24 at 10:19 a.m. with CMA I regarding abuse revealed: *She was aware of a staff to resident physical abuse that involved a staff member who slapped a resident, but she was not aware of any sexual abuse allegations. *She had attended abuse education in August or September, and everyone in the building had to attend and sign in for the training. -She was not aware of any other training or education regarding sexual abuse. 11. Interview on 10/02/24 at 11:06 a.m. with LPN G regarding resident 29 revealed: *She had been informed by DON B about resident 29's sexual abuse allegation Monday because it was reported over the weekend. *She stated, It was kept hush hush, but staff were whispering about it. *The incident happened Thursday evening 9/19/24. -Resident 29 did not report what happened until Saturday 9/21/24 and she reported to the nurse aides who then reported to LPN H. -LPN G stated LPN H had contacted administrator A and DON B about resident 29's allegation. -LPN H had been told to file an incident report by DON B. -Resident 29 was sent to the ER for a rape kit to be done on Sunday 9/22/24 for vaginal swabbing. -Staff were told to monitor resident 29 for vaginal bleeding which there was none reported. *They had a safety meeting on Monday 9/23/24 with administrator A, DON B and human resource manager (HRM) F. -LPN G stated she had walked in during the discussion about resident 29 because she was late. -She stated she had asked DON B why there were no nurse's notes made regarding the incident and DON B told her LPN H would be coming back to make a nurse's notes. -LPN G stated DON B reassured her LPN H would make a late entry because she was a new nurse and was unsure how to chart the incident. *LPN G showed this surveyor the abuse audits she had done which were given at a nurses meeting on 9/19/24. -She stated abuse had been talked about along with incident reporting to the state, and both nurses and aides were in the meeting. -Nurse managers were to complete the abuse audits weekly and the audits would be given to administrator A. -She stated the audit was from the plan of correction from the previous abuse where staff slapped a resident. *LPN G stated CNA M had been terminated on 9/24/24 at 10:30 p.m. *LPN G said she had worked there for seven years and worked with resident 29 a lot. She stated, She has a BIMS of 15 and knows what is going on. -She did not think that resident 29's current UTI was from the alleged sexual abuse incident. -Resident 29 had a history of UTIs and had refused peri cares and did not want to be cleaned up because the nurse would ask her about moving her skin folds when she was being cleaned, and she would not let them. -Resident 29 had requested often that her catheter be advanced. 12. Interview on 10/2/24 at 11:50 a.m. with administrator A about abuse education and investigation revealed: -She had provided staff abuse education and was completing audits for abuse from the previous physical abuse incident. -She agreed she was using the same audits for the facility-reported incident regarding the alleged sexual abuse. -There was no education regarding sexual abuse provided after the incident with resident 29 and CNA M. -She stated, Abuse is abuse. *They terminated CNA M and had reported the incident to her employment agency which she thought would go on her record. -She stated she would print off CNA M's personnel information for this surveyor to review. -CNA M's information was not provided by the end of the survey. 13. Review of the provider's 8/19/24 abuse, neglect and misappropriation of resident property policy revealed, Residents will be treated with dignity and respect. There is a zero tolerance for abuse. each staff member is a mandatory reporter for the state of SD.

Based on record review and interview the provider failed to ensure appropriate and timely Medicare notices had been provided for two of three sampled residents (47 and 250) who discharged from skilled services. Findings include: 1. Review of resident 47's Centers for Medicare and Medicaid Services (CMS) Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form provided by social services designee E revealed: *Her Medicare Part A Skilled Episode start date was 7/25/24. *Her last covered day of Part A Service was 8/20/24. *Her signed SNF Advance Beneficiary Notice of Non-coverage (ABN) form had been completed on 8/19/24. *She had not been given notice 48 hours prior to her services ending. *Her Notice of Medicare Non-Coverage (NOMNC) form was outdated and did not have the correct header. 2. Review of resident 250's CMS SNF Beneficiary Protection Notification Review form provided by social services designee E revealed: *He was discharged to his home on 6/4/24. *His Medicare Part A Skilled Episode start date was 5/17/24. *His last covered day of Part A Service was 6/4/24. *His SNF ABN form was completed and signed on 6/4/24. *He had not been given notice 48 hours prior to his services ending. *His NOMNC form was outdated and did not have the correct header. 3. Interview on 10/2/24 at 10:46 a.m. with social services designee E regarding Medicare non-coverage notices revealed: *She had been completing the Medicare beneficiary reviews since 2021. *She was aware that notices were to be given 48 hours prior to services ending. *She was unaware that the forms were old and needed updating.

Based on observation, interview, record review, and policy review the provider failed to follow physician orders for two of six residents (36 and 32) during medication administration that resulted in a medication error rate of 5.13%. Findings include: 1. Observation, record review, and interview on 10/1/24 at 5:53 p.m. with licensed practical nurse (LPN) O during resident 36's medication administration revealed: *She withdrew naproxen sodium (pain and fever medication) 220 milligram (mg) tablet from the medication cart. *The physician's order on the resident's medication administration record (MAR) was for naproxen sodium 250mg tablet. *She stated she would give the resident the medication because it was a lower dose. *She stated she would call the physician later to verify the correct dose. 2. Observation, record review, and interview on 10/2/24 at 7:25 a.m. with LPN O during resident 32's medication administration revealed: *She withdrew brimonidine tartrate 0.2% solution eye drops from the medication cart. *Prescription on the bottle said to instill one drop into each eye twice a day. *The physician's order on the resident's MAR directed to instill two drops into each eye twice a day. *She stated she would call the doctor to verify the correct dosing. *She instilled one drop in each of the resident's eyes. 3. Interview on 10/2/24 at 9:53 a.m. with director of nursing (DON) B revealed: *Nurses were to verify orders from the physicians with orders in residents' MARs. *She expected staff to verify the prescription on the medications with the physicians' orders before administering medications to residents. *If there was an error, she expected the staff to call the physician and pharmacy before administering medications to residents. 4. Review of provider's reviewed 7/19/24 Administration/Self-Administration of Medication policy revealed: *The correct medication(s) will be given to the correct resident, at the appropriate time, in the dose ordered by the physician or physician extender by the correct route and for a specific diagnosis. *There was no mention of what should be done when incorrect dosing/orders were found.

Based on interview, observation, and record review the provider failed to ensure room trays were served at a satisfactory temperature for three of thirteen sampled residents (30, 47, and 150) who chose to eat meals in their rooms due to the long wait time for meals to be served in the dining room. Findings include: 1. Interview on 9/30/24 at 1:54 p.m. with resident 30 revealed: *She had been living at the facility for almost two years. *She chose to eat her meals in her room as she felt it took too long to be served in the dining room. *She stated the food on her room tray was often cold when it should have been hot. -She had asked staff to reheat a food item once. -By the time her warmed up food item was returned to her, she was done eating the rest of her meal. *She felt she was the last resident to get her room tray delivered. 2. Interview on 9/30/24 at 4:10 p.m. with resident 47 revealed: *She was recently admitted on [DATE] and ate a regular diet. *After her admission she went to the dining room for meals but decided to eat meals in her room as she felt it took too long to get served in the dining room. *Regarding her room trays, she stated her food was often cold by the time she got her room tray delivered. -She stated her food was not warm at all and actually cold. -She had not mentioned it to any of the staff as she was new and had not wanted to make waves [cause trouble]. 3. Interview on 10/1/24 at 8:06 a.m. with resident 150 revealed he: *Was recently admitted on [DATE]. *Stated he had to wait a long time to be served in the dining room, so he decided to eat his meals in his room. *Had complaints regarding the food on his room tray being cold when it should have been hot. 4. Interview on 9/30/24 at 10:40 a.m. with director of nursing (DON) B regarding their dining room meal times revealed: *Breakfast was served at 7:30 a.m. *Lunch was served at 11:30 a.m. *Supper was served at 5:30 p.m. 5. Observation on 9/30/24 of the noon meal revealed: *At 11:38 a.m. cook P wheeled the cart containing the food items into the dining room and loaded the residents' food items into the steam table. *Ten minutes later, at 11:48 a.m., the first room tray was plated and loaded into the insulated food cart. *At 11:57 a.m., cook P announced over the walkie-talkie that the room trays were ready and prepared the first plate for the dining room. *At 12:23 p.m. the meal service was completed for the dining room. -The first resident to be served in the dining room waited 27 minutes after the stated meal service time. -The last resident served in the dining room waited 53 minutes from the stated meal service time. 6. Review of the 9/10/24 resident council meeting minutes revealed: *Eleven residents and one family member attended. *Resident 17 expressed a suggestion because there have been residents complaining that meal times are taking too long. *Social service designee E told her that she can talk to administration and the kitchen to see what their thoughts are but just not sure . *Resident 4 stated she likes her food hot and it is not always that way. 7. On 10/1/24 at 6:07 p.m. the requested supper test tray was delivered to the survey team in the conference room and revealed the following food temperatures: *Three mini corn dogs: -One was at 99.1 degrees Fahrenheit (F). -One was at 100.6 degrees F. -One was at 103.6 degrees F. *Baked beans that had a good flavor and was at 128 degrees F. *Cheesy Cauliflower Soup that tasted lukewarm and was at 132.0 degrees F. 8. On 10/2/24 at 9:10 a.m. the requested breakfast test tray was delivered to the survey team in the conference room with a note 10/2/24 test tray served at 8:50 a.m. revealed the following food temperatures: *Coffee in an insulated mug was at 141.8 degrees F. *Cream of Rice in an insulated bowl was at 138.7 degrees F. *Scrambled eggs were at 115.1 degrees F. *The sausage link was at 104.6 degrees F. *The waffle was at 93.4 degrees F. *The syrup was at 88.1 degrees F. Interview on 10/2/24 at 10:50 a.m. with dietary manager D revealed: *She was not aware of any food complaints from September's resident council meeting. *She stated it had been quite awhile since she had received any concern forms and stated either residents would bring her a concern form or social service designee E would forward her a concern form. Continued interview with dietary manager D regarding concerns with cold food on the room trays served revealed: *She was aware of complaints regarding food being cold on room trays served to the residents in their rooms. *She agreed that the Cheesy Cauliflower Soup served on the 10/1/24 supper test tray had not looked appetizing to her. *She stated the insulated carts work best if the room trays are served within 10 to 15 minutes. Interview on 10/2/24 at 11:45 a.m. with social service designee E revealed: *She was the complaint coordinator for the facility. *Resident concern forms were located inside the black box by the facility's bulletin board in the hallway as she was told to put the forms inside the box. *In the past, she had mentioned food complaints to dietary manager D but did not keep a record of those conversations or the complaints. *For concerns voiced at the monthly resident council meeting she would verbally inform the respective department manager of the concern. *She did not fill out a concern form for the concerns raised at resident council. *She had only two concern forms in the past six months. Continued interview with social service designee regarding food complaints at the 9/10/24 resident council meeting revealed: *She had talked to administrator A about resident 17's suggestion and was told the resident's suggestion would not work. *She had not discussed the food complaints with dietary manager D. Interview on 10/2/24 at 12:06 p.m. with administrator A revealed: *She was aware of concerns with cold food on the meal trays delivered to residents' rooms. *She and DON B attended the individual resident care conferences and she stated they would note the concerns expressed but do not use the concern forms. Interview on 10/2/24 at 12:30 p.m. with DON B revealed: *She was aware of cold food complaints regarding resident room trays. *A dietary aide delivers the insulated food cart to the nursing unit hallway and certified nursing assistants (CNAs) deliver the food trays to the resident rooms. *She would have expected room trays to be delivered to resident rooms within 15 minutes. *She was not sure if this was happening. *The policy on resident room trays was requested. Interview on 10/2/24 at 12:55 p.m. with CNA L revealed: *There were ten room trays for breakfast. *There were six room trays for lunch. *She was not sure how many supper room trays there were as she did not work the evening shift. *It usually took her about 10 minutes to pass the meal trays to the residents' rooms. Review of the provider's Resident Grievance Form revealed: *A space at the top of the form for the resident's name and room number. *The first section indicated to Describe the concern in detail: *The second section indicated What was done resolve [sic] issue and department that resolved issue. *The third section indicated Are you happy with the way the issue was handled and resolved? *A space at the bottom of the form for: -The resident's signature and date. -The department staff's signature and date. The policy on resident room trays was not received by the end of the survey.

Based on interview, record review, and policy review, the provider failed to provide a bed-hold notice to the resident or their representative when transferred to the hospital for one of one sampled resident (26). Findings include: 1. Inteview on 9/30/24 at 2:00 p.m. with resident 26 revealed she had thought she went to the hospital recently but forgot what for. 2. Review of resident 26's electronic medical record (EMR) revealed: *She was transferred to the hospital on 8/13/24. -Her power of attorney (POA) was notified of her transfer. -There was no documentation the bed hold information was given to the resident or her POA. *On 8/19/24 she returned to the facility from the hospital. 3. Interview on 10/2/24 at 8:18 a.m. with social sevices designee E regarding resident 26's bed hold notice revealed: *She had never received the bed hold notice from the nurses. *She knew for certain it had not gotten done. *She had stated it was the nurse's responsibility to complete the bed hold notices when a hospital transfer occurred. 4. Interview on 10/2/24 at 10:02 a.m. with director of nursing B revealed: *There was no bed hold notice for resident 26's hospital transfer on 8/13/24. *The social services designee was ultimately responsible for ensuring bed hold notices were completed. 5. Review of the provider's undated Bed Hold Policy revealed: *As per the admission agreement, the facility must transfer or discharge a resident when the facility determines that such action is appropriate in order to meet the resident's needs for healthcare services. *Private Pay Residents: provider will hold the bed for an agreed upon length of time. *Medicaid Residents: provider will hold the bed for up to five (5) consecutive days for each separate and distinct medically necessary hospital stay. *There was no documentation for Medicare residents. 6. Review of the provider's Admission Agreement revealed it did not include information about bed hold policies. 7. Review of the provider's Admission Handbook revealed: *Bed Hold Policy: If desired accommodations at facility may be reserved for a resident during times they are on a leave from the facility, either for a leave of absence or a hospital leave. A bed hold policy will be given prior to a leave.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to protect three of five sampled residents (2, 3, and 4) from mistreatment, intimidation, verbal abuse, and physical abuse by one of one certified nurse assistant (J). Findings include: 1. Review of the provider's FRI online report submitted to the SD DOH on 6/30/24 revealed: *Resident 2 was not feeling well on the evening of 6/29/24. She had vomited several times. *Certified nurse assistant (CNA) J was seen by another CNA to have been getting frustrated with resident 2, told resident 2 to shut up, and swatted resident 2's hands away from her incontinence brief. *CNA J was interviewed about the situation and CNA J denied saying shut up to the resident and swatting the resident's hands. *She was assigned educational videos to watch about coping skills, how to calm down in difficult caregiving situations, anger management, and people living with dementia. *CNA J was allowed to return to work after her time of suspension, completing the information noted above, and signing a performance improvement plan. 2. Observation and interview on 7/22/24 at 4:18 p.m. with resident 2 revealed: *She was appropriately dressed and sitting in her wheelchair in her room. *Her call light and teddy bear were on the floor at her feet, and her lap blanket appeared to have been pushed away slightly. *She was watching a show on the television. *She repeated I'm lost multiple times. *Her room was clean and free from clutter. *Surveyor picked up the call light from the floor and gave it to resident 2. She was able to understand the purpose of the button. *She pressed the button. 3. Observation on 7/22/24 at 4:32 p.m. with CNA P revealed: *She answered resident 2's call light. *Resident 2 was not able to verbalize any needs. -She repeated, I'm lost. *CNA P calmly reminded her that she was safe, her family knew where she was, she was in the nursing home, and that supper was soon. *Resident 2 calmed down and continued to watch her show. Interview at that time with CNA P revealed: *It was normal for resident 2 to repeat the same phrase. *She was taught to calmly remind the resident about where she was at and address any of her needs. *She was not aware of any recent allegations of staff having been rough or rude to resident 2. 4. Interview on 7/22/24 at 4:37 p.m. with resident 12 and at 5:05 p.m. with resident 13 revealed that neither of them had any concerns with their safety. They both felt free from abuse and neglect. 5. Interviews on 7/23/24 from 11:00 a.m. to 12:55 p.m. with residents 5, 6, 7, and 8 about feelings of safety revealed they all expressed positive feelings of living at that facility, and they had no concerns regarding their safety. 6. Interviews on 7/23/24 at 1:20 p.m. with CNA F and at 4:05 p.m. with CNA G regarding how staff treated residents revealed: *CNA F denied that she had witnessed any staff member mistreating a resident verbally or physically. *CNA G indicated she had no concerns about resident safety or how residents were treated by other staff members. 7. Interview on 7/23/24 at 1:42 p.m. with CNA L about reporting alleged violations revealed: *She was able to verbalize the correct reporting procedures. *She had not reported any incidents recently. *She was not aware of the situation with resident 2. *There were two incidents that she knew a different CNA reported last week. -Both incidents involved CNA J. -One incident involved resident 3 having been stuck behind a door, and CNA J yelled and banged on that door. -The other incident involved resident 4, but she could not recall the details. -She was not present for either incident but heard about them from a coworker. 8. Observation on 7/23/24 at 1:57 p.m. of resident 3 in her room revealed: *She was resting in bed with her eyes closed. *She was snoring. *Her bed was in a lower position. *There was a fall mat on the floor next to her bed. 9. Observation and interview on 7/23/24 at 1:59 p.m. with resident 4 revealed: *She was laying on her left side on her bed. She was covered by a blanket. *She was able to converse but was saying nonsensical words and was having difficulty expressing herself. 10. Interview on 7/23/24 at 2:36 p.m. with licensed practical nurse (LPN) D revealed: *She was aware of the incident between CNA J and resident 2, however, she was not there that day. *She was briefed about the situation. *She was not aware of any incident where a CNA was banging loudly on a resident's door. 11. Interview on 7/23/24 at 2:44 p.m. with CNA I about the incident between CNA J and resident 2 revealed: *She confirmed she had worked that day. *Resident 2 had vomited several times during that shift. *CNA J was assigned to resident 2 and had called for help with getting her cleaned up and changed. *A different CNA assisted CNA J, so she did not know all the details. *She believed the CNA who helped CNA J had a good working relationship with CNA J and would not try to get CNA J in trouble. 12. Interview on 7/23/24 at 2:56 p.m. with nurse aide (NA) M about the incidents involving residents 3 and 4 revealed: *One incident involved resident 3 and CNA J around supper time approximately two to three weeks ago. *Resident 3 wheeled herself into her room and closed the door behind her, had gotten her wheelchair stuck, and the staff were not able to open the door. -She walked by resident 3's room and heard banging. Resident 3 was saying, Help, I'm stuck. -She tried to provide verbal directions to resident 3 to maneuver herself away from the door. -She was not able to open the door. *NA M was not assigned to resident 3's hallway that day, and one of her assigned residents had pressed their call light. -NA M asked CNA J to assist resident 3 and went to answer her assigned resident's call light. *She heard CNA J yell and swear loudly at resident 3 to open the door. -She could not recall what specifically was said. *She reported that incident to administrator A the same day. *Another incident happened last Friday, 7/19/24. -She indicated this incident was the most concerning to her and stated it broke my heart. *Last week, CNA J became upset with resident 4. -Resident 4 was at risk for falling and had repeatedly attempted to stand up and walk herself without assistance. -CNA J wheeled resident 4 out of her room and to the CNA station. -Resident 4 attempted to stand up from her wheelchair. -CNA J forcefully put her hands on resident 4's shoulders and sat her back down in her wheelchair. -CNA J said to the staff at the CNA station, Here, you watch her, and walked away. *CNA G asked CNA J what was going on and if she was okay. -CNA J talked loudly back at CNA G in a rude manner. -CNA G requested that CNA J not speak to her in that manner. -NA M waved at registered nurse (RN) C to get her attention so she could help diffuse the situation. -NA M volunteered to switch residents with CNA J. -She reported that incident to administrator A immediately. *Later that evening, while NA M was helping resident 4 get ready for bed, resident 4 was agitated, fidgeting, and repeatedly said, He's a hateful person. He's a hateful person. -She asked resident 4, Who's a hateful person? -NA M stated CNA J came into resident 4's room, [resident 4's] face fell , and she whispered [to NA M], 'Him, he's a hateful person,' and she pointed at [CNA J]. -NA M again reported her concerns to administrator A that same day. 13. Interview on 7/23/24 at 4:23 p.m. with CNA J about the above incidents revealed: *She most often as assigned List A which included residents 3 and 4. *Regarding the incident resident 2: -She felt really bad for resident 2 because she [resident 2] was vomiting a lot. -She did what she was trained to do and cleaned her up, changed her, and repositioned her, and evidently someone that was working with me thought I told her [resident 2] to shut up. I would never tell a resident to shut up. -She denied saying Shut up to the resident. -She denied swatting the resident's hands. -She received education after that incident about coping skills and residents with dementia. *She had worked at that facility for six years. *If she needed help from another staff member, she would have used the radios to call for help. -She stated, Sometimes I feel the other staff ignore me. *She denied any other reportable incidents. 14. Interview on 7/23/24 at 4:49 p.m. with administrator A regarding the above incidents revealed: *She confirmed CNA J needed reminders to Watch her words, her tone. *One of the other CNAs came to her The other day and told her [CNA J] is a little cross with the residents. *She said regarding CNA J, she doesn't understand dementia. *After NA M reported the incidents to her the previous week, she texted director of nursing (DON) B. -DON B had worked a nurse shift that evening. -She told DON B to tell [CNA J] she has to watch her interactions. *Administrator A said, [CNA J] has a hard time with 'those residents' as in dementia. *She confirmed she knew about the incident between CNA J and resident 3. *She initially denied knowledge of the incident between CNA J and resident 4. -[CNA J] has had trouble with [resident 4] but I'm not aware of that particular incident. -However, when detailing the incident further, especially when resident 4 expressed He's a hateful person, administrator A did remember that incident. *She kept a daily log of conversations she has had throughout the day. -She could not remember exactly when NA M reported those incidents. 15. Interview on 7/24/24 at 9:33 a.m. with RN C revealed: *She was currently the staff development coordinator and would resume the DON role when DON B moved. *She was not aware of any of the incidents regarding CNA J. *Last Friday (7/19/24), she was at the nurse's station and a CNA flagged her down. -CNA G and O were heated because they didn't think CNA J was treating residents the best. -She denied hearing the staff yell at each other. -She denied observing CNA J forcefully sit resident 4 down into her wheelchair. *She coordinated the monthly staff training day. *If a CNA needed more experience or training on a particular subject, DON B would have taken care of that as she was directly responsible for the nursing staff. *She confirmed that CNA J was up to date with the required training topics. 16. Interview on 7/24/24 at 10:28 a.m. with DON B regarding the above incidents revealed: *She had addressed CNA J's gestures and facial expressions with her before as people with dementia pick up on that. *She had provided quite a bit of informal training to CNA J about her attitude. *After the incident with resident 2, she provided formal training to CNA J on teamwork. *Regarding other incidents with CNA J: -Staff brought up concerns regarding her yelling. -On 7/19/24, she started her shift at 10:00 p.m. and she spoke with CNA J about her actions. She informed her that was the last warning before termination. -Once you bring her [CNA J's] attention to a problem, she fixes it for a while. 17. Interview on 7/24/24 at 11:03 a.m. with administrator A about the above incidents revealed: *She confirmed she was not informing the other department heads, like RN C the staff development coordinator, about certain incidents in an attempt to maintain confidentiality. -If an incident involved a CNA, she would have only let DON B know about the situation. -She had not considered bringing the staff development coordinator into the conversation. *Her investigation process included to: -Review schedules. -Interview those staff who were on shift and were involved. -Speak to each person individually. -Try to maintain confidentiality. *She felt the incidents involving CNA J and residents 3 and 4 were probably true because the staff member that reported those incidents was reliable. 18. Interview on 7/24/24 at 12:12 p.m. with CNA K about the incident between resident 2 and CNA J revealed: *She had worked that day and that resident 2 was not feeling well. *It was stressful. *She helped CNA J with resident 2 as she had vomited multiple times. *She confirmed she heard CNA J tell the resident to shut up. *Later on during that same shift, while she helped CNA J to get resident 2 to bed: -Resident 2 had been pulling at her incontinence brief. -She confirmed she saw CNA J swat resident 2's hands and said, You don't need to be messing with that. *She was not aware of any other specific incidents involving CNA J. *Each shift [CNA J] has some behavioral issues, such as being rude to residents and staff or raising her voice. 19. Review of resident 2's electronic medical record (EMR) revealed: *On 6/29/24, she vomited and had loose stools that began early in the morning. *There was no indication of the 6/29/24 allegations of verbal or physical abuse in the progress notes. *There was no indication in the progress notes that her family or representative was contacted regarding the alleged verbal or physical abuse on the evening of 6/29/24. *Her care plan included the following: -I was admitted because I need your help and support to manage with these health issues: .Anxiety disorder .[Unspecified] dementia . -I have the potential to have problems communicating and have problems with my memory because I have Alzheimer's dementia . I show this by having the inability to remember things that happened a short time ago, .a short attention span, increased disorientation, confusion about time, .at this time I repeatedly cry out 'help', talk about being 'lost' . --I need my aides to help me the same way every time, tell my nurse about any pain I have, offer me fluids, allow me to wander while assuring me that I am safe/give me directions if I start talking about being 'lost', acknowledge that you understand me, remind me of where I am, keep my items in the same place, face me and speak clearly when talking to me, allow time for me to respond . -I like to be comfortable because I have suspected pain. I show this by having changes in facial expression especially putting shoes on. --I need my aides to be extra gentle with me, ask me if I hurt, tell the nurse if I hurt, be patient with me, distract me with conversation. 20. Review of resident 3's care plan revealed: *I was admitted because I need your help and support to manage with these health issues: Adult failure to thrive .other symptoms and signs involving cognitive functions and awareness, other encephalopathy, unspecified severe protein-calorie malnutrition. *I have problems with my memory because I was hospitalized due to failure to thrive, abnormal weight loss, severe protein-calorie malnutrition, psychiatric or mood disorder (depression, anxiety), [hypertension], behaviors. I show this by having a BIMS [Brief Interview for Mental Status] score suggesting severe cognitive impairment, impulsivity, wandering, agitation. -I need my aides to help me the same way every time, tell my nurse about any pain I have, offer me fluids, make sure I am active and kept busy, allow me to wander, acknowledge that you understand me, keep my items in the same place, use safety devices .allow time for me to respond .make sure I'm wearing my glasses. *I have the potential to feel sad, anxious, I may also experience side effects from my medications because I have a diagnosed mood disorder (depression and anxiety) .have a cognitive impairment, can't move around well, .take psychotropic medications, .BIMS suggests severe cognitive impairment, behavioral symptoms, sundowning . -When I feel this way I feel down or depressed, can't relax or sleep, may not feel like eating, yell, shout, or scream . --I need my aides to ask me if I'm having pain, offer me a snack or drink, help me call my family, check on me, reassure me, offer me choices, ask me how I'm feeling today, .help me do as much for myself as I can, record my behaviors . *I like to be comfortable because I sometimes hurt, have arthritis . I show this by [complaints of] pain in my abdomen related to previous bladder cancer and surgery, back pain. -I need my aides to ask me if I hurt, tell the nurse if I hurt, be patient with me, distract me with conversation, help me to change position. 21. Review of resident 4's EMR revealed: *She was admitted on [DATE]. *She had a pattern of frequently standing up and ambulating without assistance, which resulted in a few falls. *A Summary Note on 6/13/24 read, Late onset Alzheimer's disease, able to redirect during the day with behaviors but increased agitation during the evening hours. Wears tabs monitor, she will frequently staff, walks with the assist of 2 [staff]. Often strikes out at staff, try to redirect by walking with her the assist of 2, assist her to the bathroom, offer snacks and attempt 1:1 [one to one] sessions. Speech is unclear, can't verbalize needs. *A Progress Note from 6/18/24 read, .Last evening, she required 1:1 staffing to assure her safety - she repeatedly stood up while holding on to her [wheelchair]. She insists on following a couple staff, but did not seem to tire .Agitated state lasted more than 1.5 hrs [hours] with [1:1] staffing. *She was experiencing increased agitation on 7/13/24 when she was continually attempting to stand by herself, was resistive to cares, and she was attempting to bite and scratch staff. *There were no progress notes related to any behaviors or increased agitation on 7/19/24, which was when the alleged physical abuse occurred, and NA M said that resident 4 showed fear and repeated He's a hateful person. *There was no indication that her family or representative had been notified regarding the alleged abuse that occurred on 7/19/24. *Her care plan included the following: -I was admitted because I need your help and support to manage with these health issues: Alzheimer's disease with late onset, Dementia in other diseases classified elsewhere with mood disturbance, Major depressive disorder . -I have problems communicating, and am forgetful because I have a history of Alzheimer's dementia, do not hear well, emotions affect my ability to communicate, problems with my speech patterns. I show this by having a BIMS that suggests severe impairment, having the inability to recognize people, the inability to remember things that happened a short time ago . --I need my aides to help me the same way every time, tell my nurse about any pain I have, offer me fluids, make sure I am active and kept busy, allow me to wander, acknowledge that you understand me -I have the potential to feel anxious, angry, sad, confused or forgetful, I may also experience side effects from my medications because I have a diagnosed mood disorder (depression and anxiety), moved here recently, have a hard time carrying on a conversation, have a cognitive impairment . --I need my aides to ask me if I'm having pain, offer me a snack or drink, present tasks to me one at a time, follow my toileting plan, check on me, reassure me, be aware of my stressors . -I need to have someone help me because I am unaware of safety risks . I have the potential to fall down and hurt myself because I have dementia/Alzheimer's disease. In the past I have fallen, and I have a history of getting anxious, upset, or angry (pinch, grab and scratch staff), trying to move around without help . --I need my aides to use a pressure pad in bed, [wheelchair] and recliner; use the following assistive devices to be able to better help me: walker .wheelchair; .frequently check on me; encourage me to use assistance . 22. Review of CNA J's employee file revealed: *She started on 4/11/18 and passed all the reference and background checks. *She was up to date with the required education topics. *After the allegations against CNA J on 6/29/24, an investigation was initiated. -Verbal accounts were gathered from resident 2 and all staff on shift at the time of the incident. -CNA J was suspended from work on 6/30/24 while the investigation was completed. -She returned to work on 7/1/24. *An Employee Performance Improvement and Disciplinary Action Plan - Written Warning was given to CNA J. -Identify problem: Failure to consistently fulfill duties of [a] CNA according to facility standards in a manner that promotes dignity of each person and treating them with respect, consideration and kindness. -Standard not being met: allegation of verbal abuse and intimidation of a resident. -Employee fails to meet standard for following reasons: On June 29, 2024 there were reported interactions with a resident who was ill . [CNA J] denied yelling 'shut up' to a resident and she denied touching the resident's hands (which was reported as swatted her hands away from the brief) . There is no reason to believe that the party who reported the allegation has anything against [CNA J]. She was told that there have been other instances in which she was guided to lower her volume and/or be attentive to her tone of voice. -The allegation made appears to be credible although [CNA J] adamantly denies . -There were no signatures or dates anywhere on the document. *DON B followed up with CNA J on each day she worked to audit her actions and behaviors. -7/14/24 - I [DON B] worked 6p-10:30p nursing shift: .[resident 4] tried to bite the nurse after using the bathroom .she was pushing her and pinching her during the shift. [CNA J] was supported in managing/coping with behaviors by DON. She gave evidence of her frustration (body language and facial expression) and was reminded about people with dementia being able to pick up on such things . -7/15/24 - [Resident 3] [was] very busy during the shift .trying to get up without assistance multiple times; She said that [resident 3] was yelling out and this makes her frustrated. She was reminded about coping techniques including working as a team. -7/19/24 - [Resident 3] was yelling at others .[CNA J] was observed to be tense, but admitted that other than trying to make sure [resident 3] is safe, there is not a lot to do that is effective in redirecting her when she is like this. -7/20/24 - Soke with [CNA J] about concerns from co-workers being impatient and loud when giving directions/guidance with behavioral issues. *The provider had a system where progress notes could be submitted associated with each employee: -7/20/24: concerns about quality of care - the administrator has heard concerns from [CNA J's] co-workers about her being impatient and being loud in giving guidance/intervening in behavioral issues. [CNA J] was counseled about the need to be attentive to how her actions and verbalizations are being interpreted. She was told that with her last warning, it was noted that if there would be an allegation that is anything other than unsubstantiated, this would result in termination of employment. -6/6/24: .At times, when a resident is particularly agitated, you might need reminders to speak at a lower volume and to remember 'Q-TIP' (quit taking it personally). -6/6/23: Other CNA came walking by the desk with a resident and said that she voided in another resident's closet. While that CNA took the resident to get cleaned up, [CNA J] was asked by the nurse to 'Please go clean the urine up out of that resident's room, because housekeeping is out of the building and said resident has family in their room' Instead of doing what was asked of her she went into another resident's room, not cleaning up the mess. Staff finally emerged from the other resident's room once she heard that the urine was cleaned up by someone else. -10/12/21: concerns about quality of care .received report that [CNA J] spoke very harshly to a resident in dining room. Spoke to another resident who reported the issue .Spoke to [CNA J] about this witnessed behavior, she informed me that she had already spoken to [administrator A] .discussed what resident reported (CNA yelling at resident across room in dining room) .discussed better ways to handle the situation instead of yelling at resident .discussed understanding the perception of someone watching what was occurring and how it may have looked to them .discussed walking across the room and speaking discreetly to a resident, not yelling from across the room. -6/29/21: spoken to concerning some reported incident of saying 'shut up' to resident, [CNA J] denies this happening, also reminded not to speak about personal things in front of residents when taking care of them. -5/13/19: resident came back from living room [at 2:30 p.m.] requesting to use the bathroom; [CNA J] said ok and walked the opposite way; 15 minutes later writer found [CNA J] in cafeteria eating a donut; writer stated '[resident] needs to use the bathroom,' [CNA J] said 'I'm going.' 23. Review of the provider's 7/19/24 updated Abuse, Neglect and Misappropriation of Resident Property policy revealed: *Policy: Residents at [facility] will be treated with dignity and respect. No resident of this facility will be mistreated, abused or neglected. *This abuse plan has been implemented to protect our residents. The responsibility for carrying out this plan will ultimately lie with the Administrator and the staff employed by [facility] but involves every person in contact with residents. *Residents have the right to be free from verbal, .physical, and mental abuse, involuntary seclusion, neglect . Residents must not be subjected to abuse by anyone . *Neglect is defined as the failure to provide the goods or services necessary to maintain the health or safety of a resident. Neglect is also defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. *Physical Abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. It may include .striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching . *Emotional or Psychological Abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. It includes .verbal assaults, insults, threats, intimidation, humiliation, and harassment.Examples of verbal abuse include .yelling, screaming, using demeaning language to ridicule; insulting; and swearing at residents.Signs associated with emotional or psychological abuse include recent or sudden changes in behavior, unjustified fear, unwarranted suspicion, .new or unexplained depression, lack of interest, or change in anxiety level. *The following could happen if abuse is not reported: The situation could get worse, the resident could get seriously injured, the resident could become ill, the resident could die, the person could abuse other residents . *Conflict between residents, between residents and staff, or between staff members directly influences the quality of life of residents. Often, abuse situations occur as a result of conflicts that get out of control. *Prevention: Information will be provided to residents, families and staff informing them on how and to whom they may report concerns, incidents and grievances without the fear of retribution. The facility will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur. *The most frequent abusers are caregivers and family members. Abuse usually happens because the person is overwhelmed by their own problems as well as those of the person for whom they are providing care. *Many factors contribute to abuse by staff including low staff ratios, inadequate supervision of staff, lack of empathy for elderly, staff personal problems, more severely ill residents, low wages, abusive or belligerent residents, job frustration, high staff turnover, cultural differences, lack of skills training and high stress. - .Mental and emotional signs and symptoms of stress include .anger; .inappropriate behavior like screaming, yelling, striking or hitting . *Process: -Identification: Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; staff will determine the direction of an investigation. -Investigation: Alleged violations will be investigated and will be reported to proper authorities by the administrator, director of nursing or their representative -Protection: Residents will be protected from harm during an investigation. Staff may need to be reassigned to other areas or suspended until the investigation is completed. -Reporting/Response: The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries on unknown source and misappropriation of resident property immediately to the administrator or their representative. -The SD Department of Health must be notified immediately but not later than 2 hours if serious bodily injury occurred, within 24 hours of incident if no serious bodily injury. -Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person. -The results of the investigation must be reported to the SD Department of Health, [the local police department] (if required to notify), and the SD Department of Human Services (if required to notify) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. -The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further abuse while the investigation is in progress. The facility must analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. -If the alleged violation is verified, appropriate corrective action, which may include termination of employment, will be taken to prevent further occurrences.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure resident property was not taken by one of one housekeeper (H) Failure to ensure the protection of resident property violated a resident's right to be free from misappropriation of resident property. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following notification of the incident. Findings include: 1. Review of the provider's 7/17/24 FRI submitted online to the SD DOH revealed: *On 7/13/24, a bag of resident 11's clothes were discovered in one of the housekeeper's (H) closets. *The family [resident 11's family] was asked if the clothing was to be discarded, and both parties said no. *There was another shirt found in the same housekeeper's closet that belonged to a resident who had recently passed away. * .she [housekeeper H] has been spoken to .several times about donated clothing being taken home[,] the clothes are meant to be for the residents not staff. *Housekeeper H was interviewed and said, that she didn't get permission because when the resident was admitted she did not have many clothes, so items of clothing were donated to her, those were the ones she took. *She also said the clothes that she took were not new, they looked [NAME] looking. *[Housekeeper H] also said another resident's shirt was in the cleaning closet, but she found that in someone else's closet and before she could return the item, the resident passed away. *It has been reviewed with [housekeeper H] that she must obtain permission from family through social services before removing .items from resident rooms. Once permission is obtained, supervisor will accompany staff removing articles from room. *The clothes were discovered in the housekeeper's closet on 7/13/24, the event was reported to the administrator on 7/15/24, and the administrator attempted to submit the required reporting on 7/15/24, 7/16/24, and 7/17/24. -They were able to submit the report on 7/17/24. The provider implemented systemic changes to ensure the deficient practice does not recur was confirmed after: *Interviews with several residents throughout the facility revealed no one reported any missing personal items. *Interviews with housekeeper H and other staff (nursing, housekeeping, and laundry staff) confirmed they were knowledgeable of the revised Personal Items Inventory policy, the procedure for handling resident's clothing that might have needed to be replaced due to wear and tear, and about a resident's right to be free from misappropriation of property. *Record review confirmed staff were educated on the provider's updated Personal Items Inventory policy and procedure on 7/22/24. Based on the above information, non-compliance at F602 occurred on 7/13/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/22/24, the non-compliance is considered past non-compliance.

Based on interview, record review, and policy review, the provider failed to report allegations of abuse to the required entities in the required timeframe for two of two incidents of alleged abuse involving two of three sampled residents (3 and 4). Findings include: 1. Interview on 7/23/24 at 1:42 p.m. with certified nursing assistant (CNA) L about reporting of alleged violations revealed: *She was able to verbalize the correct reporting procedures. *She had not reported any incidents recently. *There were two incidents that she knew a different CNA reported last week. -Both incidents involved CNA (J). -One incident involved resident 3, and the other incident involved resident 4. -She was not present for either incident but heard about them from a coworker. 2. Refer to F600, finding 12. 3. Interview on 7/23/24 at 4:49 p.m. with administrator A regarding those incidents revealed: *After nurse aide (NA) M reported the incidents to her the previous week, she texted director of nursing (DON) B. -DON B had worked a nurse shift that evening. -She told DON B to tell [CNA J] she has to watch her interactions. *Administrator A said, [CNA J] has a hard time with 'those residents' as in dementia. *She confirmed she knew about the incident between CNA J and resident 3. *She initially denied knowledge of the incident between CNA J and resident 4. -[CNA J] has had trouble with [resident 4] but I'm not aware of that particular incident. -However, when detailing the incident further, especially when resident 4 expressed He's a hateful person, administrator A did remember that incident. *She kept a daily log of conversations she has had throughout the day. -She could not remember exactly when NA M reported those incidents. *She confirmed she had not reported either incident to the South Dakota Department of Health (SD DOH). 4. Review of the provider's submitted reportable incidents for the past three months confirmed the incidents regarding residents 3 and 4 had not been reported to the SD DOH or other required entities. 5. Review of the provider's 7/19/24 updated Abuse, Neglect and Misappropriation of Resident Property policy revealed: *Policy: Residents at [facility] will be treated with dignity and respect. No resident of this facility will be mistreated, abused or neglected. *The following could happen if abuse is not reported: The situation could get worse, the resident could get seriously injured, the resident could become ill, the resident could die, the person could abuse other residents . *Process: - .Reporting/Response: The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries on unknown source and misappropriation of resident property immediately to the administrator or their representative. -The SD Department of Health must be notified immediately but not later than 2 hours if serious bodily injury occurred, within 24 hours of incident if no serious bodily injury. -Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person. -The results of the investigation must be reported to the SD Department of Health, [the local police department] (if required to notify), and the SD Department of Human Services (if required to notify) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Based on interview, record review, and policy review, the provider failed to investigate two of two reported allegations of abuse experienced by two of three sampled residents (3 and 4). Findings include: 1. Refer to F609, finding 1. 2. Refer to F600, finding 12. 3. Interview on 7/23/24 at 4:49 p.m. with administrator A regarding the alleged incidents revealed: *One of the other certified nursing assistants (CNAs) came to her The other day and told her [CNA J] is a little cross with the residents. *After nurse aide (NA) M reported the incidents to her the previous week, she texted director of nursing (DON) B. -DON B had worked a nurse shift that evening. -She told DON B to tell [CNA J] she has to watch her interactions. *She confirmed she knew about the incident between CNA J and resident 3. *She initially denied knowledge of the incident between CNA J and resident 4. -[CNA J] has had trouble with [resident 4] but I'm not aware of that particular incident. -However, when detailing the incident further, especially when resident 4 expressed He's a hateful person, administrator A did remember that incident. *She kept a daily log of conversations she has had throughout the day. -She could not remember exactly when NA M reported those incidents. *She confirmed she had not reported either allegation to the required entities, and she had not investigated either incident further. 4. Interview on 7/24/24 at 11:03 a.m. with administrator A about the alleged incidents revealed: *She confirmed she was not informing the other department heads, like registered nurse (RN) C the staff development coordinator, about certain incidents in an attempt to maintain confidentiality. -If an incident involved a CNA, she would have only let DON B know about the situation. -She had not considered bringing the staff development coordinator into the conversation. *Her investigation process included to: -Review schedules. -Interview those staff who were on shift and were involved. -Speak to each person individually. -Try to maintain confidentiality. *She felt the incidents involving CNA J and residents 3 and 4 were probably true because the staff member that reported those incidents was reliable. *She indicated that she started an investigation into the allegation involving resident 4 and CNA J and had submitted an initial report to the South Dakota Department of Health. 5. Review of the provider's 7/19/24 updated Abuse, Neglect and Misappropriation of Resident Property policy revealed: *Policy: Residents at [facility] will be treated with dignity and respect. No resident of this facility will be mistreated, abused or neglected. *This abuse plan has been implemented to protect our residents. The responsibility for carrying out this plan will ultimately lie with the Administrator and the staff employed by [facility] but involves every person in contact with residents. *Process: -Identification: Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; staff will determine the direction of an investigation. -Investigation: Alleged violations will be investigated and will be reported to proper authorities by the administrator, director of nursing or their representative -Protection: Residents will be protected from harm during an investigation. Staff may need to be reassigned to other areas or suspended until the investigation is completed. -Reporting/Response: The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries on unknown source and misappropriation of resident property immediately to the administrator or their representative. -The SD Department of Health must be notified immediately but not later than 2 hours if serious bodily injury occurred, within 24 hours of incident if no serious bodily injury. -Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person. -The results of the investigation must be reported to the SD Department of Health, [the local police department] (if required to notify), and the SD Department of Human Services (if required to notify) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. -The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further abuse while the investigation is in progress. The facility must analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. -If the alleged violation is verified, appropriate corrective action, which may include termination of employment, will be taken to prevent further occurrences.

Based on interview, observation, and policy review, the provider failed to follow their policy to ensure a controlled medication (one easily diverted by staff) was securely stored for one of one (1) resident. Findings include: 1. Interview on 7/23/24 at 12:46 p.m. and again at 2:09 p.m. with medication aide (MA) E revealed: *Resident 1 received Tramadol (a controlled pain medication) 50 milligrams (mg) tablet twice daily. *The Tramadol 50 mg tablets were kept in the same location as other scheduled dose medications and were not double-locked. *She was aware Tramadol was a controlled substance medication. *Controlled medications that were for PRN (as needed) use were stored in the double-locked drawer are were counted at shift change. *Scheduled controlled medications were counted before and after they were administered. *She confirmed they do not count the scheduled controlled medications at shift change. 2. Interview on 7/24/24 at 9:47 a.m. with licensed practical nurse (LPN) D revealed: *PRN Tramadol was stored in the double-lock box in the medication cart. *Only the scheduled controlled medications like Tramadol and Clonazepam (a sedative) are kept with other scheduled medications. 3. Observation on 7/24/24 at 10:32 a.m. with MA E revealed: *She removed a current Tramadol dosing card for resident 1, from the top drawer of the medication cart. *That drawer was only secured by one lock. 4. Interview on 7/24/24 at 11:58 a.m. with director of nursing (DON) B revealed: *Scheduled Tramadol is kept with other scheduled medications in the medication cart. *PRN narcotic medications are in the double-lock drawer. *This is the provider's normal practice for controlled medications. *The double-lock drawer is not big enough for all the controlled medications. *She agreed that having the scheduled Tramadol doses with other scheduled medications did not follow their current Controlled Substance-Narcotic Medication Management Policy. 5. Review of the provider's 7/14/23 Controlled Substance-Narcotic Medication Management policy revealed: *All scheduled II-V medications are maintained in separately locked, permanently affixed compartment of the medication cart. *All controlled substances, including ER narcotic kit and medications in the refrigerator, must be counted at each shift change.

Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) had an investigation completed following falls with injuries. Findings include: 1. Observation and interview on 8/7/23 at 4:25 p.m. with resident 27 while he was sitting in his wheelchair revealed: *He had fallen a few times but could not remember when. *He used his wheelchair for mobility. *He had worn glasses and was hard of hearing. Review of resident 27's electronic medical record (EMR) revealed: *On 5/26/23 at 3:30 p.m. he had an unwitnessed fall. *He was able to move all of his extremities. *He had complained of head pain and the loss of vision in his left eye. *Vital signs were taken and documented as follows: -Temperature: 97.3 -Pulse: 50 beats per minute normal is (60-100) -Respirations: 20 per minute -B/P: 119/79 -Oxygen level: 83% on room air normal is (90-100%) --Oxygen had been applied. *Resident was transferred by staff to his bed using the total mechanical lift. *The resident did have a few scratches on his head and one large goose egg on the left side of his head and another one on the top side of his head. *His neurological exam was within normal limits. (assessment of mental status, level of consciousness, eyes reaction to light, arms and legs strength, sensation, and gait) *He was taking Eliquis (blood thinner) 2.5 mg twice a day to prevent blood clots. *The resident was transferred to the emergency room for further evaluation. Interview on 8/9/23 at 4:30 p.m. with director of nursing (DON) B regarding the investigation and the reporting of the above fall revealed: *She was on medical leave when the incident occurred. *The nurse who was working at that time is no longer employed with the provider and had not reported the incident. *Certified nursing assistant could have completed the incident reports. *No report or through investigation had been completed by any other member of the nursing staff. 2. Observation on 8/8/23 at 10:30 a.m. of resident 32's wounds to her left leg during a dressing change revealed: *She had a medial wound measurement of 5.0 centimeter (cm) x 2.0 cm. *She had a lateral wound measurement of 7.0 cm x 5.0 cm *Both areas were painful to the touch. Review of resident 32's EMR revealed the following: *On 4/26/23 at 9:19 p.m. resident was transferred by a certified nurse aide (CNA) I with the sit-to-stand lift when the resident begun to allow her arms to chicken wing and hung from the waist strap on the lift rather than standing straight up. *CNA I unhooked the safety belt and assisted the resident to the floor and then called for help. *On 6/17/23 at 11:36 a.m. the resident was being transferred by CNA J with the sit-to-stand mechanical lift when the resident started to bend her legs and put arms straight up and started to fall. *CNA J attempted to return the resident to her chair, but she was slipping out of the sit-to-stand mechanical lift and caught her left lower leg against the lift causing two skin tears and a hematoma (bruise). Review of resident 32's updated August 2023 care plan revealed: *She was suppose to have been transferred with the help of 1 person and the mechanical Hoyer lift (total body lift). *The resident should have been transferred with one person and the sit-to-stand mechanical lift. Interview on 8/9/2310:33 a.m. with CNA H regarding the different types of mechanical lifts and the staff required to use them revealed: *The Hoyer was a full-body mechanical lift which requires two staff persons to operate. *The sit- to- stand mechanical lift could have been operated by one staff person depending on the resident it may have required two staff persons. Interview on 8/9/23 3:37 p.m. with CNA G regarding resident 32's wound to her left legs revealed: *She had received the wounds as a result of using the sit-to-stand mechanical lift. Interview on 8/10/23 at 8:33 a.m. with DON B regarding resident 32's two incidents with the sit-to-stand mechanical lift, reporting of the event, and completing a through investigation revealed: *Resident 32 was discharged from physical therapy on 4/4/23. *The resident wanted the nursing staff to pull her up from a seated position instead of standing while using the sit-to-stand mechanical lift. *She was not re-evaluated by the physical therapists for transfer safety with the sit-to-stand lift. *Therapy participates in weekly Medicare meetings and that was when the resident falls were discussed. *They had discussed resident 32's 6/17/23 incident in their Medicare weekly meeting, but no re-evaluation by therapy had been completed. *CNA's could have used a different mechanical lift if the resident's condition had required more staff assistance. *DON B had not felt that the incident with resident 32 was reportable due to the resident's pre-existing fragile skin. *All nursing staff were able to report incidents on their internal reporting system. *Once a report had been made, then a email would be sent to the administrator A and DON B for follow up. Interview on 8/10/23 at 1:47 p.m. with administrator A regarding reportable incidents revealed she: *Stated that the CNAs had just recently gained access to report incidents. *Was not aware of the incident with resident 27. *Stated that she was unsure about whether or not resident 32's incident was reportable. Review of the provider's July 2023 Policy for Abuse, Neglect and Misappropriation of Resident Property policy revealed: *Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse: staff will determine the direction of an investigation. *Alleged violations will be investigated and will be reported to proper authorities by the administrator, director of nursing or their representative. *The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property immediately to the administrator or representative. *The results of the investigation must be reported to the SD Department of Health within five working days of the incident.

Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) who had falls with injuries were reported to the South Dakota (SD) Department of Health after falls with injuries. Finding include: *One of one sampled resident 27 required a transfer to the emergency room for further evaluation and treatment. *One of one sampled resident 32 had sustained injuries to her left leg from improper use of the sit-to-stand mechanical lift. *Refer to F609.

Based on observation, interview, record review, and policy review, the provider failed to prevent the development of a heel pressure ulcer, follow physician's orders for the treatment of [REDACTED]. Findings include: 1. Review of resident 30's medical record revealed:*She had been admitted on [DATE] following a fall with a [MEDICAL CONDITION] and hospitalization . *She had a significant infection to the surgical site and had required additional surgeries, a wound vac, and other treatments. *She had impaired mobility and required extensive assistance from staff for her activities of daily living. *Her 6/12/19 Brief Interview for Mental Status assessment score of ten indicated she had moderate cognitive impairment. *Her Braden Scale assessment scores from admission through 7/1/19 indicated she was at mild to moderate risk for developing a pressure ulcer. *On 6/5/19 she was noted to have developed a pressure ulcer to her left heel. -It was documented as a suspected deep tissue injury. Review of resident 30's current 7/30/19 physician's order listing and (MONTH) 2019 treatment administration record (TAR) included the following pressure ulcer treatments:*Apply heel protector left foot daily at all times when in bed. *Check left heel, apply cushion dressing daily. *Assess left heel 1 x (time) wk (week). Tuesday AM. -All those orders were started on 6/5/19 after the ulcer was identified. *Air mattress to bed daily was started on 6/26/19. -That was initiated after the pressure ulcer had developed. Observations and interviews throughout the survey with resident 30 revealed:*On 7/29/19 at 5:00 p.m. she was sitting in her wheelchair in her room. -She had a cushion in the seat of her wheelchair and was wearing regular shoes. -She indicated she had some issues with her leg and skin, but she thought they were all healed up. *On 7/30/19 at 9:17 a.m. she was sleeping while sitting in her wheelchair in her room with her shoes on. *On 7/30/19 at 10:40 a.m. she was sleeping in her recliner with her shoes on. -The pressure ulcer was observed with licensed practical nurse (LPN) B while the resident slept. *On 7/30/19 at 11:34 a.m. she continued sleeping in her recliner with only her right shoe on. *On 7/30/19 at 1:27 p.m. she was sitting in her wheelchair in her room with her shoes on. *She was not observed in her bed or using the heel boot at any of the above observation times. -The heel boot was in a box on the floor in her room. Observation and interview on 7/30/19 at 10:40 a.m. with LPN B during resident 30's weekly wound assessment revealed:*She was the nurse responsible for the weekly skin assessments and documentation. -She completed those on Tuesdays. *There was also a wound nurse consultant who visited monthly to assist them with residents' wounds. *She was sleeping in her recliner with both of her shoes on. *LPN B removed the resident's left shoe and sock and measured the ulcer. -There was no dressing on it. *The ulcer was approximately pencil-eraser sized with a brownish/black scab-like area covering it. *She stated the current treatment was to paint it with [MEDICATION NAME] and leave it open to air, because that was the wound nurse's recommendation. -That was not what the current 6/5/19 physician's orders indicated for using a cushion dressing. -There was no physician's order for using [MEDICATION NAME] to the ulcer area. *She did not stage the ulcer since she was not a registered nurse, but it would have been listed in the previous documentation. *She confirmed the resident had developed the pressure ulcer after her admission. *She left the resident's left shoe off when leaving the room. *When questioned if anything had changed with her shoes she stated: -She did not feel the ulcer was related to her shoe. -They felt it had been from when she was laying in bed. *When asked about interventions for the prevention or treatment of [REDACTED]. -Indicated the foam heel boot that was in her room was used only when she was in bed. -Could wear her shoes during the rest of the day. *The only preventative intervention she mentioned was the heel boot for when the resident was in bed. -That had been started after the development of the ulcer. Interview on 7/30/19 at 2:11 p.m. with resident 30's representative revealed she: *Was aware her mother had developed a pressure ulcer to her heel about a month or so ago. *Was not sure how that ulcer had occurred, but she thought it was healing now. *Had not seen the ulcer herself and was unsure what type of treatment the staff had been using for it. Review of resident 30's wound documentation by the designated wound nurse LPN B revealed:*A 6/6/19 entry indicated a new facility-acquired pressure ulcer to her left inner heel was noted on 6/5/19. -It had been staged as a suspected deep tissue injury with black wound tissue. --There were no notes to support a cause of the suspected deep tissue injury. -Treatment was a dry gauze dressing. -Interventions were: Support surfaces for bed: mattress: pressure redistribution, other support surfaces: heel lifts or heel suspension device, vitamins and supplements: vitamin C, zinc. --There was no mentione if those interventions were new or if they had been in place prior to the ulcer developing. *A 6/11/19 entry reflected the same left inner heel ulcer with: -treatment of [REDACTED]. --There was no mention of a dressing. -Interventions were the same as 6/6/19 with the addition of a wound consultant nurse. --There were no notes about what that nurse consultant's recommendations were or when she had seen the ulcer. *A 6/18/19 entry indicated the ulcer now had necrotic tissue: firmly adherent, hard, black eschar. -Treatment: yes OTA (open to air) no cover dressing ankle bootie. --That indicated no dressing would have been used and had not specified what the ankle bootie was. *A 6/27/19 entry of the same left heel ulcer with no change in treatment listed. *A 7/3/19 entry again stated the treatment was open to air. *The 7/9/19 and 7/16/19 entries reflected the same ulcer with a treatment of [REDACTED]. *A 7/23/19 entry indicated the same treatment of [REDACTED]. *A 7/30/19 entry continued the open to air treatment and now mentioned a heel boot as an intervention. -That was the first mention of using a heel boot despite it being ordered on [DATE]. Review of resident 30's 7/30/19 care plan and undated certified nursing assistant (CNA) care plan revealed:a. *Her care plan had the following undated needs/approaches: *For skin: I need my nurses to reduce pressure and friction between myself and my bed or chair, evaluate my skin under tubing and other devices that are in direct contact with my skin, monitor my nutrition or hydration intake, check my skin with cares, review interventions that are listed on my MAR (medication adminstration record)/TAR and note that skin concerns may be addressed in other areas of my nurse charting within my entire medical record - these sources may be updated prior to my formal care plan review/care conference. -Those appeared general and not individualized for the resident. *For pain: I need to be comfortable because I sometimes hurt, have a hard time getting around, have sore knees, have a pressure wound to my left inner heal (heel), have a healing surgical wound R/T (related to) a hip fx (fracture) surgery. -The heel boot was not mentioned as an intervention. --There were no specific interventions listed for the left heel pressure ulcer. b. The undated CNA care plan had not mentioned her pressure ulcer or use of the heel boot. *There were no dates listed for when interventions were implemented or changed on either of those care plans to support when those had occurred. Interview on 7/31/19 at 10:06 a.m. with health unit coordinator [NAME] regarding the CNA care plans sheets revealed:*She updated the CNA care plan sheets when the CNAs told of her things that needed to be changed or added. -That usually happened on Fridays. *She had not been aware of resident 30's pressure ulcer or a foam boot, or those would have been added to the form. *She indicated the CNA care plans were what they used to take care of the residents. *If they had not been updated the CNA might not have known about the intervention they should have been using. Interview on 7/31/19 at 10:10 a.m. with CNA C regarding resident 30 revealed:*She was aware the resident had a pressure ulcer on her left heel. *The staff put the heel boot on her only when she was in bed. *She had not ever seen a dressing on the area, so she was not sure what the nurses were doing for a treatment to it. *She confirmed the CNA care plan form had not been updated regarding the resident's pressure ulcer or using the heel boot, and it should have been. -That CNA care plan form was what the CNAs used as the reference to take care of the residents. Interview on 7/31/19 at 10:13 a.m. with CNAs G and H regarding resident 30 revealed:*They were aware of the resident's pressure ulcer. -They were unsure how long it had been there. *Neither of them had seen a dressing in place to that area. *They confirmed the CNA care plan sheet had no mention of the pressure ulcer or the use of the heel boot. -They felt it should have been updated since the CNAs worked different units, and sometimes they also had temporary agency staff come to assist them. Interview and record review on 7/31/19 at 10:21 a.m. with registered nurse (RN) F regarding resident 30 and her above pressure ulcer revealed:*RN F worked as a charge nurse and also assisted with residents' care plans and care conferences. *She was aware of the resident's pressure ulcer. *She confirmed the pressure ulcer treatment and physician's orders should have been followed. -[MEDICATION NAME] was not ordered but was what the wound nurse had been documenting as the treatment being used. --She was unsure why that was being documented that way. -If there was no dressing in place to her heel as in the above observation and notes then the physician's order had not been followed. *The physician's orders reflected all the interventions for her heel pressure ulcer had been implemented after the wound had developed. *She confirmed the care plan had not supported when interventions were added or changed since there were no dates. -She thought that was related to their electronic medical record, and the way they had to enter the information. *She agreed the heel boot intervention was not listed on the resident's care plan or CNA care plan, and it should have been. *The resident had fragile skin and according to her Braden Pressure Ulcer assessment scores she was at moderate risk for skin breakdown. -There were no guidelines of what interventions should have been implemented when a resident was at risk for breakdown. --Those would have been determined based on each resident's needs. *She confirmed the documentation had not supported the current interventions were implemented prior to the development of her heel ulcer. Interview and record review on 7/31/19 at 4:22 p.m. with the director of nursing regarding resident 30 revealed:*The documentation had not supported the preventative measures having been implemented prior to the resident developing a facility-acquired pressure ulcer. *She expected the physician's orders for treatment to have been followed, and the documentation to have supported that. *The care plan should have been individualized and updated to reflect the resident's current needs. -She confirmed it was difficult to support when the care plan changes would have been made with no dates to support the changes. Review of the provider's revised 12/20/18 Pressure Ulcer policy and procedure revealed:*The goal is to identify residents at risk for developing a pressure injury and to ensure that a treatment plan is in place for residents with pressure injuries.*The purpose included: To define interventions for prevention of pressure injuries.*Identification of residents at risk for pressure injuries included: Develop a plan of care based on areas of risk, rather than on the total assessment score. For example if risk stems immobility, address turning, repositioning and the support surface . *Prevention of pressure injuries included: -Reassess, reevaluate and revise interventions when progress is not noted. -Inspect the skin at least daily for signs of pressure injury, especially non-blanchable [DIAGNOSES REDACTED]. -Assess pressure points, such as the sacrum, coccyx, buttocks, heels, ischium, trochanters, elbows and beneath medical devices. *Treatment and monitoring of wounds included:-Document treatment orders on treatment forms and in Pressure Injury Book.-Reduce or eliminate causative factors of friction, shearing, pressure and moisture.-Weekly documentation on pressure injury report form in the Electronic Charting System and in the Pressure Injury Book. *Interventions that could have been implemented included: -Avoid positioning resident on the pressure injury. -Raise heels off of bed with pillow under lower legs and ankles. *Care planning included: -The Person Centered care plan will address problems, goals and interventions directed toward prevention and/or resolution of pressure injuries and/or skin integrity concerns. -Resident and Family will be informed of risk factors for developing a pressure injury and current status of skin with treatment and interventions in use during care planning.

Based on observation, interview, record review, manufacturer's instructions review, and policy review, the provider failed to ensure three of four sampled residents (3, 8, and 12) identified at risk for skin breakdown had received appropriate pressure ulcer interventions to prevent new pressure ulcers from occurring or current pressure ulcers from worsening. Findings include: 1. Review of resident 8's medical record revealed: *He had admitted on [DATE]. *His [DIAGNOSES REDACTED]. *His 4/18/17 Brief Interview for Mental Status (BIMS) examination score was fifteen indicating he had no cognitive impairment. *On admission he had no pressure ulcers. Interview on 5/22/17 at 4:20 p.m. with registered nurse (RN) D following initial tour regarding resident 8 revealed: *He had a dressing change daily to his right upper inner thigh area. *She was unsure if it was a pressure ulcer, but thought it had been there since he had been admitted . Observations on 5/22/17 at 6:10 p.m. and on 5/23/17 at 7:57 a.m. of resident 8 in the dining room revealed:*He was in an electric wheelchair at the dining room table sitting near his wife. *He was eating and drinking independently. Observation and interview on 5/23/17 at 8:35 a.m. with resident 8 and his wife in his room revealed he:*Was in his electric wheelchair watching television. *Confirmed he was admitted with his wife in August from home. *Had used the wheelchair for a long time and had brought it with him when he came to the facility. *Had MS for about forty years and was getting more weak due to the disease process. *Needed staff to help him with transferring using the stand-lift to get from the wheelchair to his recliner, the bed, or the toilet due to his weakness. Observation and interview on 5/23/17 at 9:25 a.m. with certified nursing assistant (CNA) F during resident 8's transfer from his wheelchair to the recliner revealed:*She used a stand-lift to move him. *There was no cushion in his recliner. *He had a saddle-type foam cushion in his wheelchair that was there when he had been admitted . *Once he was in the recliner he was still in a sitting-type of position. Observations on 5/23/17 at 11:45 a.m. and at 1:35 p.m. revealed: *He was sitting in his electric wheelchair in the dining room during lunch and using his computer in his room afterward. *He had been sitting up in the wheelchair for longer than the physician, wound nurse, and care plan had recommended of one to two hours at a time. -The pressure ulcer policy recommended sitting only one hour at a time. Observation and interview on 5/23/17 at 2:00 p.m. with resident 8 in his room revealed: *He was laying in bed on his back. *The air overlay on his mattress was flat and had no air in it. -The air pump was on and the tubing appeared connected. *He thought the air mattress had been like that for awhile; he had heard it leaking one day. -He was unsure if staff checked on it or not. -He he had not told them about it and he did not like it. *He currently had a pressure ulcer on his buttocks that had not been there when he was admitted . -He recently was on intravenous (IV) antibiotics for an infection in that pressure ulcer. *His buttocks only hurt if he sat too long. *Prior to admission he had sores on his buttocks but not in the same area as it was now. *He used a catheter intermittently for quite a few years, but a few months ago they started leaving the catheter in continuously due to him leaking urine frequently. *He had bowel problems due to his MS and had incontinence at times. *He was unsure when the current pressure ulcer had started, but he thought it was healing. *His physician had told him he needed to lay down more to get the pressure off his buttocks. *Dietary gave him additional protein items with his meals to help him heal the ulcer too. Observation and interview on 5/23/17 at 2:20 p.m. with RN A and resident 8 in his bed revealed:*She was completing his dressing change to his pressure ulcer. *She thought he had been admitted with that pressure ulcer, but it had gotten worse. *He had recently been on IV antibiotics for a month due to a drug-resistant infection in the pressure ulcer. *He had several scarred and darkened areas to both buttocks. -There was a large area of purple-like skin to his right buttock. --That area blanched when the nurse tested the skin. *His skin was fragile, and he was at high risk for further skin breakdown and pressure ulcers. *His current pressure ulcer was large, approximately golf-ball sized, and was located at his right ischial tuberosity. -It had a large amount of slough covering most of the wound. -She did not measure the area, since it was not due for weekly measurements that day. *She performed the dressing change. -She applied a moderate amount of [MEDICATION NAME] gel into the wound and around the edges. -Then she covered the area with an Allevyn dressing. -She stated the dressings came off the area frequently due to the location and his incontinence. *She applied Periguard barrier cream with zinc to the other areas of scarring on his buttocks. *She confirmed the air overlay on his mattress was flat. -No one had told her it was not working properly. *She was unsure of the process for checking the air overlay, but thought there was a check sheet for them. *The air overlay should have been functioning properly in order to provide appropriate pressure relief. Interview on 5/23/17 at 3:40 p.m. with RN G regarding resident 8 revealed she:*Was one of the case managers, and she worked on residents' care plans. *Was unsure of the process for checking the air overlays on the mattresses, but she thought it was on the resident's treatment administration record (TAR). *Confirmed the resident was at high risk for developing pressure ulcers and had a history of [REDACTED]. -He had no pressure ulcers on admission, but his skin was fragile. *Was aware the wound nurse consultant had been working with them on his current pressure ulcer. *Had been requested to provide copies of all of the resident's medical records pertaining to his skin concerns and ulcers. Review of resident 8's 5/22/17 care plan revealed:*He had self-care deficit problems and interventions that included:-Limited to extensive assistance of one staff person for bed mobility, grooming, dressing, bathing, toileting, and repositioning. -That area had been initiated on 4/24/17. *His pressure ulcer, impaired skin integrity problem, and interventions included: -Skin assessment per policy. -Administer medications/treatment as ordered and evaluate. -Air mattress. -Boost supplement. -Limit sitting to sixty minutes at a time. --That area had been initiated on 4/25/17. --The resident did not have an air mattress, it was an air overlay. Review of resident 8's interdisciplinary progress notes from his admission on 8/22/16 through 5/23/17 revealed:*On admission 8/22/16: -Has no skin problems or [MEDICAL CONDITION] present.-No pressure relief devices for bed or chair, no turning/repositioning program, no nutrition/hydration interventions to manage skin problems, no ulcer or surgical wound care, no nonsurgical dressings applied, no ointments or medications applied. -His skin risk asssessment score was sixteen indicating he was at mild risk for skin concerns. *On 9/18/16 Area of redness on his bottom around anal area, with 2 approx.5 cm (centimeter) superfiscal (superficial) open areas close to the anal area . -There was no further mention of those areas. *On 10/13/16 he had new stage two pressure ulcers to his coccyx, left upper buttock, and right buttock. -Those had started on 10/12/16. -Interventions included: --A turning schedule with no mention of how often. --Air fluidized surface. --Nutritional supplement with no mention of what that was. -The treatment was a foam dressing. *The next assessment on 10/19/16 only mentioned the right buttock ulcer, not the left upper buttock or coccyx ulcers. *Thirteen days later on 10/31/16 the right buttock and coccyx were listed as stage one, but there was no mention of the left upper buttock ulcer. *On 11/2/16 the coccyx and right buttocks were stage one ulcers, and the left upper buttock was a stage two. *The next assessment was twenty days later on 11/22/16. -It listed stage two ulcers to the left upper buttock and right buttock, and there was no mention of the coccyx ulcer. *Fourteen days later on 12/6/16 and again on 12/8/16 the right buttock ulcer was a stage two, and there was no mention of the left upper buttock or coccyx ulcers. *Thirteen days later on 12/21/16 the right buttock ulcer was a stage one with no measurements listed. -There was no mention of the left upper buttock or coccyx ulcers. *On 12/29/16 and 1/5/17 the right buttock ulcer was now a stage three, the left buttock ulcer was a stage one, and there was no mention of the coccyx ulcer. *Eighteen days later on 1/23/17 the right buttock ulcer was back to a stage two, the left buttock ulcer was a stage one, there was an additional stage two area on the right buttock close to his rectum, and there was no mention of the coccyx ulcer. *The next assessment fifteen days later on 2/7/17 and again on 2/9/17 listed a stage one coccyx ulcer, and no mention of ulcers to the left or right buttock. *Eleven days later on 2/20/17 he had a new stage two ulcer to his right upper inner thigh, and no mention of the coccyx ulcer. *On 2/27/17 and 3/1/17 the stage two ulcer continued to his right upper inner thigh, and he had a stage one coccyx ulcer. *Twenty-one days later on 3/22/17 the stage two ulcer to his right upper inner thigh continued, and there was no mention of the coccyx ulcer. *Fourteen days later on 4/5/17 the right upper inner thigh had worsened to a stage three, and there was no mention of the coccyx ulcer. *On 4/12/17 a stage three right upper inner thigh ulcer and a stage two coccyx ulcer. *On 4/18/17 the right upper inner thigh ulcer had worsened to unstageable and measured 9 cm by 9 cm. -The coccyx was listed as a red area. *On 4/24/17 the unstageable ulcer to his right upper inner thigh continued, and the coccyx ulcer was now a stage one. *On 4/26/17 the right upper inner thigh ulcer was listed as a stage two with no mention of the other ulcers. *On 4/27/17 there was a note the wound nurse consultant had seen the resident, but there were no new orders. *On 5/1/17 the right upper inner thigh ulcer was back to unstageable, and the coccyx ulcer was a stage one. *Sixteen days later on 5/17/17 the unstageable right upper inner thigh ulcer continued, and the coccyx ulcer had worsened to a stage two. *There was no mention of the right or left buttocks ulcers after the 2/9/17 note. *There were no further assessments prior to the survey. Review of resident 8's skin assessment risk scores on the following dates were: *On 9/20/16, fifteen. *On 1/16/17, sixteen. *On 3/29/17, fourteen. *On 4/14/17, thirteen. -Fifteen and sixteen were considered mild risk for pressure ulcers. -Thirteen and fourteen were considered moderate risk. Review of resident 8's physician's progress notes and physician and family contact notes from his admission on 8/22/16 through 5/23/17 revealed: *On 9/7/16, 10/12/16, 11/16/16, and 1/11/17 the physician had seen him for routine visits, and there was no mention of skin concerns. *The first mention of any skin concern or pressure ulcers was on 3/1/17 to his family. *On 3/6/17 the wound nurse consultant saw him. *On 3/28/17 the physician examined the resident and wrote .he has some borderline skin breakdown in the upper gluteal fold area and he has a stage 3 sore at the ischial area on the right side . -He diagnosed a presure ulcer right ischial area, ordered a wound culture, occupational therapy for pressure relief especially in the wheelchair, and a physical therapy evaluation. *On 4/4/17 the physician was contacted for antitibiotics related to the pressure ulcer. *On 4/7/17 the physician ordered .Resident is only to be in electric w/c 1-2 hrs at a time, may recline in recliner or lay in bed. *On 5/9/17 the physician examined the resident and wrote .He is still being treated for [REDACTED]. He has been on [MEDICATION NAME] (IV antibiotics) for 4 weeks today. It is doing pretty well .Ischial ulcer left (right) ischial area improving on [MEDICATION NAME] treatment .Consider stopping the [MEDICATION NAME]. Will get input from the wound care nurse . -No new orders were written. *On 5/18/17 the wound nurse saw the resident, and there were new orders for silver [MEDICATION NAME] on 5/22/17. Review of resident 8's 3/30/17 occupational therapy evaluation note revealed:*One time eval only due to patient (resident) refusing to try any positioning changes due to him under the belief that his sores on his bottom are caused by a bacterial infection alone and pressure is not the issue. Pt (patient) states that he has tried other things in the past and they did not work.*Reason for referral: Pt with chronic pressure sores on his bottom - nursing reports that he has scarring from old spots that have healed and he has a new one on his L gluteal fold. * .Skilled OT services were offered to obtain appropriate wheelchair cushion and to educate staff and patient on a positioning plan to help heal his ulcer, but patient is unwilling to try any of these things at this time . Review of resident 8's 4/4/17 Therapy Communication/Screen Form revealed physical therapy had evaluated him. They felt there was no change noted for skilled therapy services to work with him. Review of resident 8's skin care physicians' orders from admission on 8/22/16 through 5/23/17 revealed:*On 10/13/16 to measure the coccyx and buttocks ulcers weekly on Wednesday mornings. *On 2/15/17 mattress - air fluidized surface when in bed daily . -He did not have an air mattress, it was an air overlay. *On 2/20/17 to measure the right upper inner thigh ulcer weekly on Wednesday mornings. *On 3/3/17 .Apply [MEDICATION NAME] to open areas and Allevyn dressing to Rt inner thigh every other day . *On 5/18/17 to apply [MEDICATION NAME] Zinc barrier cream twice a day to his coccyx peri area beneath buttock. *There was no mention of: -The Periguard barrier cream that RN A used during the observation on 5/23/17. -What treaments were in place for the ulcers that started in October 2016 and continued after that until the 3/3/17 order. Review of resident 8's wound care consultant notes revealed:*The only note was from 3/6/17, and it stated: -Asked to assess residents crease b/t (between) R buttocks & thigh and & buttocks area. Pt has MS. Requires 2 to transfer. He has some strength in his lower extremities. He indicates he would get stronger so he can transfer himself. Voices he does not like to depend on others. Has pressure releiving (relieving) cushion in WC. Buttocks area appears to be scar tissue from previous breakdown. R side are appears to blister that has unroofed- approx 3x7cm. Superficial. Periwound is clear. Requires cathing due to nuerogenic ([MEDICAL CONDITION]) bladder, but does leak on occas & mostly cont (continent) of BM. Wears a brief. Rec (recommend) to staff to apply zinc over scar tissure for protection and thin layer of [MEDICATION NAME] gel to crease area after washing w/ soap & water, apply alleyvn w/ border type dressing for protection & change qod (every other day). Discussed w/ resident pressure relief, not sitting on area more than 1 hr at a time, lifting up to relieve pressure. Also reminded to lift to transfer v. (versus) sliding . *There were no notes in the record for her visits in April or May. *After RN G requested the wound care notes a 5/23/17 faxed copy was received, and it stated: -Gluteal fold - R pink wound base =irregular edges. No odor. No s/x (signs/symptoms) of infection. Drng (drainage) on dsrg (dressing) sanguinous. Staff states he has improved on offloading. ? if edges rolled. Wound approx 3x3-superficial. Suggest Silver [MEDICATION NAME] to stimulate healing x1 then resume washing w/ soap & water & [MEDICATION NAME]. Monitor for maceration .L buttock has supericial (superficial) area approx .5 cm-suggest zinc product to area. Encourage cont'd offloading to areas. Resident cont's to have foley cath due to incontinent. -The visit date was listed as 5/23/17, but interview with RN G revealed the wound nurse had not seen him on 5/23/17; she had seen him the week before. Interview on 5/24/17 at 8:40 a.m. with CNA F regarding resident 8 revealed:*She had worked with the resident frequently since his admission. *She thought he had pressure ulcers when he had been admitted last summer. *Sometimes he did not like staff to help him with care or to lay down. *The CNAs followed their reference sheet related to specific resident care. Review of the undated CNA care sheet at the nurses station regarding resident 8 revealed:*He used an electric wheelchair. *For plan of care: Assist with cares, wife will try & do cares, need to ask & try to do them, document if refuses .Alert & orientated. Dribbles wears pull-ups. Likes to watch TV & go on computer. Should only be up in w/c for 1 hour at a time, needs to be in recliner with feet up . *There was no mention of his current pressure ulcer or previous ones. Interview and record review on 5/24/17 at 8:55 a.m. with the director of nursing (DON) and administrator regarding resident 8 revealed:*They both agreed the resident was at high risk for skin breakdown and pressure ulcers. -His admission notes indicated he was only at mild risk. *On admission he had no pressure ulcers, but he had a history of [REDACTED]. *His admission notes indicated no interventions had been implemented for preventing skin breakdown and pressure ulcers. *They agreed interventions should have been implemented on admission and as needed after that in an attempt to prevent skin breakdown. -They gave no explanation of why interventions had not been implemented on admission. *His wheelchair cushion was the one he had been admitted with from home. *The DON was unsure when they had added the air overlay mattress to his bed, but she thought it was sometime after his first pressure ulcer had started. -He did not have one placed on admission. *The air overlay should have been functioning properly to provide the intended pressure relief. *The resident was sometimes non-compliant with care, repositioning, and allowing staff to help him. -That was not documented as well as it should have been. -In the documentation received there was minimal documentation related to his refusals; most refusals related to him not wanting to transfer using the lift and wanting his wife to assist him. *They confirmed since his admission he had pressure ulcers develop to his right buttock, left buttock, coccyx, and right upper inner thigh area. *Currently the right upper inner thigh area was the only pressure ulcer they were still working with. That area: -Was documented as the thigh, but the wound consultant and physician called it the ischial or gluteal fold area. -According to the last assessment it was unstageable and measured 15 cm by 13 cm. *Previous care plans were requested for review, and the DON stated most of the care plan interventions were the same as now. *Weekly measurements and assessments of pressure ulcers should have been done by the charge nurses. -They agreed there were many times the assessments were not documented weekly, and there were sometimes up to twenty-one days in between. *The DON had been aware of the missing measurements in the past. -She had re-educated the nurses during staff meetings, but it was difficult to monitor if they were doing them every time. *She thought the wound nurse had provided the nurses with training in the past and that they had wound care training during their mandatory annual education. *They confirmed the wound assessments, measurements, staging, and locations were difficult to track and were not done consistently. *They did not have a facility designated wound care nurse or a nurse specifically trained regarding wound care. *The wound nurse consultant was an outside additional resource. -She only helped with pressure ulcers when facility staff requested her and obtained a physician's referral to have them be seen by her. *There were skin and pressure ulcer resources at the nurses station for them to use if they wanted to. Phone interiew on 5/24/17 at 10:55 a.m. with wound nurse consultant I regarding resident 8 revealed:*She had seen him three times total. *Her first visit was on 3/6/17, and then she saw him again in April and May. *She came to the facility upon request and if she needed to come more often she could have. *The facility nurses did the weekly wound assessments. *She agreed he was at high risk for pressure ulcers and further skin breakdown. *His risk factors included:-History of pressure ulcers. -Impaired mobility. -Incontinence. -Possible sensory perception problems related to his MS diagnosis. -His preference to sit in his electric wheelchair for long periods of time. *Since he was at high risk for skin breakdown he required additional interventions to attempt to prevent pressure ulcers starting on admission and ongoing after that. *She had not provided any additional training to the nurses. Interview on 5/24/17 at 11:10 a.m. with RNs G and H regarding resident 8 revealed:*They agreed there were no interventions documented as implemented on admission to prevent pressure ulcers from occurring. *He was at high risk for skin breakdown even though his skin assessment scores indicated he was at mild or moderate risk. -The scores did not appear to be accurate and they were unsure why. *He should have had more interventions implemented to prevent the pressure ulcers from occurring. *He was alert and able to make decisions regarding his care. *He had refused staff assistance with care at times and they had not documented that as well they should have. *Prevention was important to avoid pressure ulcers and not wait for them to develop and then implement interventions. 2. Review of resident 3's medical record revealed:*He was originally admitted on [DATE]. *He was recently hospitalized for [REDACTED]. *His [DIAGNOSES REDACTED]. Observation and interview on 5/22/17 at 3:45 p.m. during initial tour the with resident 3 in his room revealed:*He was laying in his bed on his back. *He was visiting with two female family members from out of state. Interview on 5/22/17 at 4:20 p.m. with RN D regarding resident 3 revealed: *He was recently hospitalized with pneumonia and had returned to the facility. *He needed more staff assistance with care since his hospital return. *The family and physician were talking about comfort care, but she was unsure if that had been ordered. *She was not aware of any skin concerns for him. Observation on 5/22/17 at 6:05 p.m. of resident 3 in the dining room revealed:*He was sitting in a Broda high-back reclining type of wheelchair at the table. *He was eating and drinking by himself with an unidentified staff person sitting beside him. Observation and interview on 5/23/17 from 8:00 a.m. through 8:30 a.m. with CNA F during resident 3's morning care in his room revealed: *She assisted him with a partial bed-bath and dressing while he was in his bed. *He was incontinent of urine. *She completed incontinence care and changed his disposable brief. *During the incontinence care there were two small areas noted to his right buttocks. -The top one appeared to be a scab. -The bottom one appeared to be a superficial open area, approximately pencil-eraser sized. *She informed the surveyor she saw those areas the day before when she had assisted him. *She applied Periguard barrier cream to his buttocks and stated that was what staff had been using for those areas. *She stated staff should have notified the nurse when they saw areas like those on his buttocks. -She had told the nurse the day before. *She used a total mechanical lift to transfer him from his bed to his Broda wheelchair. Observations of resident 3 on 5/23/17 at 9:45 a.m. in his room, at 11:45 a.m. through 12:20 p.m. in the dining room, and again at 1:35 p.m. in his room revealed he was still sitting in the Broda wheelchair. Observation and interview on 5/23/17 at 3:10 p.m. with RN A and resident 3 in his room revealed:*He was laying in bed on his back. *She had told the staff to lay him down after lunch. *She first stated she was not aware of any skin concerns for him and nothing had been reported by the CNAs. *When she rolled the resident to his left side in the bed she then stated she knew about the areas. *She agreed there were two areas on his right buttocks. -The top area was a scab. -She measure the bottom area as 0.1 cm by 0.4 cm and called it a stage two pressure ulcer. *She applied Periguard barrier cream to his buttocks. *She stated he was frail, was not eating well, and had needed more staff assistance since his recent hospital return. *He had not had a pressure ulcer prior to his hospitalization or when he returned earlier that month. *He was considered high risk for skin breakdown and pressure ulcers. *His air overlay on his mattress was functioning properly. *The cushion in his Broda wheelchair was the one that had came with from the chair from the vendor. *He should have been laid down in-between meals for pressure relief. Review of resident 3's 5/22/17 care plan revealed:*A problem of potential for impaired skin integrity and potential for pressure ulcers. *Interventions for that problem included:-Skin assessment per policy. -Monitor lab values. -Monitor nutrition or hydration interventions to manage skin problems. -Assist with hygiene and general skin care. -Avoid hot water for cleansing. -Report changes to nurse. -Use moisturizer with care. -Keep skin clean and dry. -Keep linen clean, dry, and wrinkle-free. *There was no mention of: -The air overlay on his mattress. -A pressure relieving device for his chair. -A turning or repositioning schedule or plan. -The current pressure ulcer to his right buttocks. Review of resident 3's 5/22/17 physician's orders [REDACTED].>*Skin treatment included to do a skin assessment on re-admission 5/3/17 and weekly for four weeks. *There were no other treatments listed for his skin. *Supportive devices included double siderails when in bed for positioning. -There was no mention of the air overlay on his mattress, a pressure relieving cushion for the wheelchair, or a repositioning schedule. Interview on 5/24/17 at 8:40 a.m. with CNA F regarding resident 3 revealed: *She had told the nurse on 5/22/17 and 5/23/17 about his skin concerns on his buttocks. *She used the CNA care sheets as a reference to take care of the residents. Review of the undated CNA care sheet at the nurses station for resident 3 revealed: *He used a stand-lift or total lift for transfers depending on his fatigue. *For his plan of care: .Total cares. Reposition side to side every 2 hours. Keep as comfortable as possible. Tires easily, more confused .Air mattress, use chux, no soaker pad. *There was no mention of pressure ulcers. Review of resident 3's interdisciplinary progress notes from his admission on 12/27/16 through 5/23/17 revealed:*On 12/30/16 he had no skin prblems noted. -For treatment to skin: no pressure relief devices for bed or chair, no turning/repositioning program, no nutrition/hydration interventions to manage skin problems, no ulcer or surgical wound care, no nonsurgical dressings applied, no ointments or medications applied. Vaseline to dry skin after whirlpool last evening. *On 5/18/17 a potential for impaired skin integrity related to: Limited mobility, Diabetes, Poor nutritional status, self-care deficit for bed mobility, frequent urinary incontinence and incontinent of bowels during the assessment time frame, at risk for pressure ulcers (Braden's scores). -Interventions were the same as the 5/22/17 care plan. *On 5/19/17 Has no skin problems or [MEDICAL CONDITION] present.*On 5/22/17 warm. *On 5/23/17 pale, ashen.*There was no mention of current pressure ulcers. Review of resident 3's skin assessment risk scores revealed the following: *On 12/27/16 and 1/8/17, seventeen. *On 1/16/17, eighteen. *On 5/8/17, sixteen. *On 5/10/17, thirteen. *On 5/15/17, twelve. -Sixteen, seventeen, and eighteen were considered at mild risk for skin breakdown. -Twelve and thirteen were considered moderate risk. Interview on 5/24/17 at 8:55 a.m. with the DON regarding resident 3 revealed:*He did not have pressure ulcers prior to his hospitalization or upon his return on 5/3/17. *He had required more assistance from staff with personal care since his hospital return and was at a higher risk for skin breakdown. *His interventions for prevention of pressure ulcers should have been reviewed and individualized at the time of his re-admission and as needed following that. *She was told about his stage two pressure ulcer to his right buttock on 5/23/17. *She expected the CNAs to tell the nurse when a resident had a new skin concern. *When the nurse was told about a resident's skin concern the nurse should have assessed that area. *After the nurse assessed the area they should have contacted the physician and implemented a treatment if needed. 3. Review of resident 12's medical record revealed: *A 5/8/17 admitted . *Diagnoses: [REDACTED]. Review of resident 12's 5/12/17 Brief Interview for Mental Status revealed a score of 15 that indicated intact cognitive abilities. Interview on 5/24/17 at 9:15 a.m. with resident 12 revealed: *She had a sore on her coccyx area. *It had started after she had hip surgery in 2011. *It would heal and then reopen again. *Her daughter used medi-honey on the area and put a dressing on it. The dressing often kept coming off. *Whenever she sat or laid down she felt like she rubbed the dressing off. *She had a pressure relieving pad in her recliner and in her wheelchair. *She had a regular mattress on her bed. *She tried to lay on her side when she was in bed at night. *She had just received her weekly whirlpool bath, the bath aide had removed the Allevyn dressing before the bath. *She was unable to lift her legs in and out of bed; the staff assisted her with that. *She was walking by herself short distances in her room and in the hallway to relieve pressure on her bottom. *She had breakdown on her heels in the past. *When the staff took her socks off at night they checked her heels for any irritation. Review of resident 12's 5/8/17 at 1:10 p.m. admission nursing notes revealed: *History of [MEDICAL CONDITION] to her legs. *Has stage 1 or greater ulcer to coccyx, shearing with several cracks and/or scabbing. *Has been applying [MEDICATION NAME]. *Scaly dry patches to lower legs, feet are purple in color and callused (this is normal for resident). Review of resident 12's 5/8/17 and 5/15/17 Braden scale revealed: *Makes frequent though slight changes in body/extremity position independently. *Moderate to maximum assist to move. Can't lift without sliding on sheets. Slides in wheelchair/bed. Constant friction. *Walks occasionally during day, very short distances with/without assist. In bed/chair most of time. *Skin is occasionally moist requiring an extra linen change approximately once a day. *Eats greater than one-half meals. Eats four proteins a day. Occasionally refu

Based on observation, record review, interview, and policy review, the provider failed to ensure one of six sampled residents (2) who exhibited psychosocial adjustment issues received the timely and necessary care to address them. Findings include: 1. Observation and interview of resident 2 on 5/22/17 at 4:30 p.m. revealed he: *Was laying in his bed with eyes closed but opened his eyes when the surveyor knocked on his door. *Had lived there since last summer. *Had a flat affect. *Verbalized he didn't want to be there, and wanted to go home but said that was not going to happen. *His voice became raised and he appeared angry when he said I can't walk and asked How would you feel if you could not walk? *He talked about being a farmer and an outdoorsman who liked to hunt and fish. -Now he was unable to get out and do any of that. Random observations of resident 2 from 5/22/17 from 4:00 p.m. through 6:30 p.m. and on 5/23/17 from 7:00 a.m. though 6:30 p.m. revealed he: *Spent most of the day in his room in bed. *Did not have the television on, and the room was dimly lit. *Only came out of his room for meals, three times a day. -Did not visit with tablemates in the dining room, and did not visit with staff. *He did attend the resident group with the surveyors but did not say anything. Interview on 5/23/17 at 10:30 a.m. and 2:00 p.m. with certified nursing assistant C regarding resident 2 revealed: *He was never happy; he appeared unhappy with life. *He didn't seem to care. *He was just not happy, he was sarcastic. *He wanted to be in bed all the time. *The staff tried to do everything to make him comfortable, but nothing worked. *They left him in bed and did not get him up for meals until the last minute because he got angry. *They also put him to bed right away after meals. -All he wanted to do was sleep. Review of resident 2's 5/11/17 Minimum Data Set (MDS) assessment revealed *He was alert and oriented to person, place, and time. *His memory was intact. *He exhibited the following mood issues: -Little interest or pleasure in doing things twelve to fourteen days (nearly every day). -Moved or spoke so slowly that other people noticed nearly every day. -Had thoughts he would be better off dead or of hurting himself in some way nearly every day. -Trouble falling asleep or staying asleep or sleeping too much two to six days (several days). -Trouble concentrating on things, such as reading the newspaper or watching television several days. Further review of the mood screening on his following MDS assessments revealed: *10/14/16; nine. *11/14/16; fourteen. *11/18/16; twelve. *2/11/16; thirteen. *5/7/16; eleven. *The scoring for that assessment was as follows: -0 to 4: Minimal or no depression. -5 to 9: Mild depression. -10-14: Moderate depression. Review of resident 2's 8/7/16 through 5/23/17 Behavior and Mood charting revealed: *8/1016: Appears down, depressed or hopeless; angry and short tempered with staff. *8/13/16: Indicates he feels bad abut self, is a failure, or has let staff or family down. *8/24/6: Indicates he feels bad about self. *9/1/16: Feels tired/little energy. *9/11/16: Appears down, depressed or hopeless. *9/23/16: Appears down, depressed or hopeless. *10/3/16: Feels tired/little energy, appears down, depressed or hopeless. *11/1/16: Feels tired/little energy, appears down, depressed or hopeless. Little interest or pleasure in doing things. *11/15/16: Indicates he feels bad about self, is failure, or has let self or family down. Little energy. *12/5/16: Distressed about current health status and/or living arrangement. *1/16/17: Feels tired/little energy, seems more tired. *2/27/17: Feels tired/little energy, appears down, depressed or hopeless. *3/29/17: Feels tired/little energy. *4/10/17: Little interest or pleasure in doing things. *4/27/17: Short tempered/irritable. States You don't do anything for me. Refuses to assist staff with repositioning, trouble falling or staying asleep. *5/15/17: Cursing at others, resident very rude to CNA (certified nursing assistant name)because he was down on the whole word and CNA took the brunt of the complaint. Review of resident 2's physician's orders [REDACTED]. *[MEDICATION NAME] (antipsychotic) 0.5 mg (milligram) tablet twice day in the morning and at bedtime. -They were to monitor for socially inappropriate/disruptive behavior and sexual comments. *[MEDICATION NAME] (antidepressant) 40 mg tablet daily at bedtime. -That was given for [MEDICAL CONDITION]. Review of resident 2's 8/17/16 through 5/23/17 physician's progress notes revealed: *8/17/16: (Name) is a new admission here [MEDICAL CONDITION](cardiovascular accident). He is working with Physical, Occupational and Speech Therapy. Initially he did have some behavioral outbursts and some inappropriate language that does seem to be improving. -A (assessment): Major [MEDICAL CONDITION] anxiety and behavioral difficulties. *10/5/16: (Name) is doing okay, but does still definitely test position for major [MEDICAL CONDITION]. He also continues to have some inappropriate comments to care givers. -For his depression he had been on an SSRI which was not really helping so we switched that to [MEDICATION NAME] and for a while we thought that was helping at 0.5. mg. but he continues to have significant inappropriateness so at this point lets try and increase that dose. -A: (assessment) Depression not well controlled. -P (Plan) Increase his [MEDICATION NAME] to 1 mg at HS (bedtime). *10/2616: (Resident's name) is frustrated that he is just not improving a lot. He has had [MEDICAL CONDITION] is very discouraged. -He also likely will not be able to be out of the nursing home at this point. *11/8/16: He is a little frustrated with his condition. I did clarify with him that he really is requiring 24 hour care and will likely not be able to return home. He is wondering if maybe he could get closer to home to maybe the (nursing home name). *3/17/17: Increase in lethargy. Mental slowing. Review of resident 2's nursing note/physician's contact revealed: *11/11/16: Spoke with (physicians nurse) and updated on report made by facility social worker. Social worker received a call from wife stating that (name) has been calling her and asking her to bring a gun to him so he can shoot himself. Also reports that (name) has been calling neighbors and asking them to come and get him and take him home because he knows he has guns there and he can shoot himself. -Staff has been instructed on maintaining safety of resident and if he were to leave with some that staff is to contact the police. Review of resident 2's social service progress notes from 8/5/16 through 5/23/17 revealed: *8/1/6: Discharge plan are uncertain, depending upon how much (name) recovers from the stroke. *8/11/16: He has had some verbal behaviors and inappropriate comments directed towards staff. He can also be demanding, rude, and angry and he is easily irritated with others. -He also has a mental health history. -At this time (wife's name) is unable to care for him and there are no plans for discharge. *9/1/16: (name) has made some inappropriate comments and he can be rude to some staff members. -His antipsychotic [MEDICATION NAME] was increased this week. *11/3/16: He did discuss having ankle surgery with his physician and he is not a surgical candidate and this is upsetting for him as he was hoping to eventually walk and return home. -He spends a lot of time resting in bed as he feels most comfortable there. Will refer him for counseling once his Medicare Part A days are completed. (Name) is on an antipsychotic. *11/8/16: Name placed on waiting list of nursing home he has requested to go to. -Discharge: Has been inquiring about returning home with hired help. Visited with his wife, about this and she does not want him returning home as she will not be able to provide the care he needs. *11/11/16: Suicide statements: (Name) has made statements in the past that he would be better off dead but he doesn't have anything here to harm himself. -He was started on [MEDICATION NAME] 11/17/16 and he will receive counseling services on the counselor's next visit to the facility scheduled for 11/22/16. *There were no documented intervention notes regarding his statements with suicidal ideation or measures taken in the facility to ensure his safety. Interview on 5/23/17 at 2:15 p.m. with the social worker regarding resident 2 revealed: *When he was admitted he had a goal to return home, but his wife had said that would not happen. *This had been a very difficult adjustment for him. -He struggled with some of the staff. *He had an electric wheelchair but it was not safe for him to use it. -He was running into residents with it, so he no longer could use it. *She confirmed she had not visited him as often as she should. -He was isolated. *He took a long time to visit with. *He was being seen by a counselor. -That had recently been started in March. -She did not address why that had not started the counseling until after his Medicare Part A had ended if he needed that service. *She confirmed: -They had primarily addressed his mood and depression through the use of the antipsychotic medication and the antidepressant. -The antipsychotic medication was probably not the appropriate medication for depression. -He would have benefited from social services visits to address the adjustment to the facility, and his inability to return home. *She confirmed there were no other social service progress notes that addressed the provision of any non-pharmalogical interventions to help him adjust to his life in the nursing home, or address his behaviors. Interview on 5/24/17 at 10:30 a.m. with the activity director regarding resident 2 revealed: *He refused to come any activities. *They were hoping he would come outside with the other residents when the weather warmed up. -They had not tried to take him outside by himself. *She thought he was down and depressed about being in the facility. -He also had complaints of pain and wanted to be in bed. --They had tried different chairs to help him be more comfortable but he wanted to be in bed. *They had not been doing any individual programming with him. *She stated We have not done justice with him in activities. Review of resident 2's entire medical record revealed: *He had a psychiatric diagnostic evaluation on 1/24/17. *He had not been seen by the counselor until 2/14/17. -Further notes revealed he was seen by the counselor on 2/28/17, 3/14/17, and 3/28/17. --There were no other notes in the record. Review of the provider's February 2014 Medically Related Social Services policy revealed: *Based on the comprehensive assessment, a resident with medically-related Social Service needs shall receive appropriate treatment and services to address the identified issue. *Specifically medically-related Social Services issues include: -Adjustment to facility and routines. -Behavioral issues (causes, symptoms, interventions, sleep pattern disturbances). -Emotional issues. -Potential negative effects on resident well-being.

Based on record review, interview, label review, and policy review, the provider failed to ensure: *Appropriate measures were put in place to prevent falls for one of one sampled resident (3) with multiple falls. *Appropriate use of the whirlpool tub safety belt while bathing residents. *Storage of chemicals in a secure location. Findings include: 1. Review of resident 3's nurse's notes revealed: *On 5/20/13 she was found on the blue mat on the floor beside her bed. -She had fallen out of her wheelchair. -She was "repositioning or self-transferring without assistance." *On 6/16/13 she was was found on the floor next to her bed. -She was "repositioning or self-transferring without assistance." *On 8/5/13 she was found on the floor next to her bed. -She later complained of pain in her right leg/thigh area and was sent in for an X-ray which concluded there was no apparent injury. *On 10/8/13 she was found on the floor. -She was "repositioning or self-transferring without assistance." -She fell out of her wheelchair. *11/26/3-She slid from her chair and was lowered to the floor. *12/8/13-She was found on the floor in front of her recliner with the foot of the recliner still elevated. *12/17/13-She fell forward from her chair and landed in a sitting position with her back against the wall. 1/25/14- She had a fall to the floor. 2/12/14-She was observed on the floor. -She was "repositioning or self-transferring without assistance." -She had fallen out of her wheelchair. *She was in the bathroom and had fallen off the toilet. Review of resident 3's February 2014 Medication Administration Record revealed she was on: *BuPropon-an antidepressant. Dizziness was a potential side effect of that medication. *Quetiapine Fumarate/Seroquel (Antipsychotic). A potential side effect was weakness and drowsiness. ` Further review of the above falls revealed there was no evidence they evaluated/investigated: *When was the last time the resident had been toileted. *When was the last time the resident had been repositioned. *What medications could have contributed to the fall. *How long had she been in her bed or wheelchair. *Was her call light within reach since each time she had fallen. *Had they checked her for orthostatic hypotension? *Was she in pain prior to the fall and was that why she was attempting to reposition herself. *Who the staff person was that was responsible for the resident at that time. Review of resident 3's entire medical record revealed she had not been on a restorative program. Review of resident 3's physician progress notes [REDACTED]. There was no evidence they discussed any clinical reason for the falls. Review of resident 3's pharmacy reports from February 2013 through January 2014 revealed the pharmacist had not documented on any of her falls. An interview on 2/20/14 at 9:00 a.m. with the consulting pharmacist revealed she had not documented in her reports on the falls. She had not thought the medications she was on had caused the falls. Review of resident 3's therapy documentation revealed physical therapy (PT) and occupation therapy (OT) had completed screens on her in December 2013 following falls. They made no recommendations and stated "Resident demonstrates poor rehabilitation potential unable to follow one step commands." Interview on 2/20/14 with the consulting physical therapist revealed: *When a resident had dementia and did not have rehabilitation potential, the therapists would not work with them. *They had not worked with resident 3 according to their documentation on a positioning program. Review of resident 3's care plan revealed: *She had dementia. *On 12/17/13 and 1/25/14 they identified she had fallen. *Interventions included: -Assure pain management. -Instruct to call for help. -Sensor alarm. -Floor mat next to bed. *There were no interventions that addressed a specific toileting program or repositioning schedule. Interview on 2/19/14 at 11:00 a.m. with the director of nursing revealed: *The nursing notes were the assessments that had been completed after each fall resident 3 had. *The electronic medical record had an Unusual Reporting form that was to be completed after each fall. *These forms had not been completed by nurses after her falls. *She later acknowledged the care plan had addressed interventions to prevent an injury when the resident fell , but it had not addressed ways to prevent the falls. Review of the provider's 6/28/12 Fall Prevention and Management policy revealed: *"Medical factors which may indicate fall risk include but are not limited to: agitation or delirium, infection, toxic/metabolic condition, cardiopulmonary (heart and lungs) changes, CNS (central nervous system/brain) changes, dehydration, or blood loss, sleep disturbances, orthostatic hypotension (blood pressure drops when resident stands), and polypharmacy (multiple medication use). *"Other factors to consider are: age, history of falls, frequent toileting, impaired mobility, impaired vision, inappropriate use of assistive devices, inappropriate footwear, impaired cognition (mental), physical deficits." *"Medication categories commonly associated with injuries from falls are: antidepressants, cardiac drugs, psychotropics, antihypertensive, and diuretics." *"The fall is discussed with the Medicare Team weekly and the team discusses interventions to prevent further falls. Interventions may include but are not limited to referral for therapy screen/services, encouragement for the resident to ambulate with assistance". *"Once a fall occurs: -Assess each fall taking into account all aspects mentioned above. -Involve the pharmacist as appropriate. -Involve primary physician. -Individualize the resident's care plan." 2. Observation and interview on 2/19/14 at 8:40 a.m. of certified nursing assistant (CNA) D revealed: *She had been disinfecting the whirlpool tub. *The whirlpool tub chair had a safety belt (device the residents wore to ensure their safety during bathing) loosely wrapped around the back of the chair. *She had sprayed the chair and belt with disinfectant. *Would not have used the safety belt for all residents who received a whirlpool bath.*She would have only used the safety belt on residents that leaned forward or slid down the chair. Review of the provider's incident reports sent to the State Department of Health revealed: *On 10/24/13 an unidentified resident had just finished receiving a whirlpool bath. *The resident had slid out of the whirlpool tub chair while being moved out of the tub. *She had not been secured in the chair with the safety belt. Interview on 2/20/14 at 10:15 a.m. with the director of nurses (DON) and infection control nurse revealed the safety belt should have been used on all residents who had received a whirlpool bath. Education had been provided with a notice posted in the whirlpool tub room after the above incident occurred. Review of the provider's January 2013 Cleaning and Disinfecting the Whirlpool Tub policy revealed: *Additional information had been attached to the document. This information had been dated 12/18/13. *"All residents must be belted in the whirlpool chair." 3. Observation on 2/18/14 at 3:10 p.m. in room 212 a fifteen and one-half ounce (oz) spray can of Claire disinfectant (kills microorganisms) on the side of the resident's bathroom sink. Observation on 2/18/14 at 6:20 p.m. in an unlocked whirlpool tub room on Hummingbird Lane on a shelf next to the door revealed a fifteen and one-half oz spray can of Claire disinfectant which revealed the following caution information on the can's label: *Keep out of reach of children. *Avoid contact with eyes, skin, or clothing. *Causes moderate eye irritation. *Harmful if absorbed through the skin. *Hazardous to human and domestic pets. Observation and interview on 2/19/14 at 7:45 a.m. with housekeeping assistant F in room 212 revealed: *A spray bottle of Claire disinfectant on the side of the resident's sink. *She stated the disinfectant product was in most rooms, either on top of the paper towel dispenser or on the sink's counter in most resident bathrooms. Interview on 2/19/14 at 10:10 a.m. with licensed practical nurse B regarding the disinfectant in the resident rooms and in personal care areas. She revealed it had been used as an air freshener and was not used as a disinfectant. Surveyor: Interview on 2/19/14 at 11:30 p.m. with the DON revealed: *The staff had been using the disinfectant as an air freshener and not a disinfectant. *She had been unaware of all the cans of disinfectant located in the tub rooms and resident bathrooms. *The chemicals should not have been accessible to the residents. Review of the provider's 3/18/08 Material Safety Data Sheet for the Claire disinfectant spray revealed: *The product was harmful in contact with eyes. *The product was considered hazardous under OSHA (Occupational Safety and Health Administration). *Contact may irritate or burn eyes. *Prolonged or repeated contact could result in skin irritation and a rash. *Intentional misuse by concentrating and inhaling the product could be harmful or fatal. *Prolonged inhalation may be harmful. *Ingestion may cause gastrointestinal (stomach and intestine) irritation, nausea, vomiting, and diarrhea. Review of the provider's undated Housekeeping/Chemical Use and Storage policy revealed hazardous cleaning solutions, chemicals, poisons, and substances should have been labeled, stored in a safe place, and kept in an enclosed section separate from other cleaning materials.