Every finding on record at Strand-Kjorsvig Community Rest Home

A. Based on South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI) report review, record review, interview, and policy review, the provider failed to investigate staff-reported incidents of potential resident abuse involving contracted travel licensed practical nurse (LPN) (K) when he allegedly called resident 18 an insulting name, and allegedly had been overly aggressive with resident 16 after the resident grabbed and twisted housekeeper Q's arm. Failure to investigate these allegations prevented the provider's ability to determine if abuse occurred and to mitigate the risk of future abuse to the residents who resided at the facility.Findings include:1. Review of the SD DOH FRI dated 11/11/25 revealed the alleged abuse between LPN K and resident 16 occurred on 11/9/25 at 7:30 p.m. The report had been completed by director of nursing (DON) B. The report indicated that resident 16 was not capable of participating in the investigation. According to the report, LPN K had been overly aggressive with resident 16 on 11/9/25. DON B had become aware of that incident on 11/11/25. The DON stated that she interviewed housekeeper Q who was involved in that incident. Resident 16 grabbed, squeezed, and twisted housekeeper Q's arm. LPN K had intervened and forcibly removed resident 16 from housekeeper Q. The report indicated that housekeeper Q had stated LPN K had been more aggressive with resident 16 than he needed to be. The FRI indicated two residents had reported that same incident. One resident reported LPN K had resident 16 up against the wall, and the resident's feet were not touching the floor. The second resident had stated LPN K had hit resident 16 and shouted at him. The report indicated that LPN K had escorted resident 16 to his room and remained in resident 16's room with him for approximately 10 minutes. LPN K had stood in front of resident 16's recliner in an intimidating stance and if resident 16 attempted to stand LPN K would make him sit back down. The report indicated that LPN K's contract was terminated effective immediately on 11/11/25. Resident 16 did not show any signs of injury or bruising related to that incident on 11/9/25. There were no vital signs taken at the time of that incident. Resident 16 had been up and walking around as his usual and did not show any adverse effects related to that incident. The incident on 11/9/25 was not reported to the police, and the SD DOH report had been rejected back to the facility's provided email, with additional questions about the report. The questions were not answered and a final report was not completed by the facility. 2. Interview on 8/13/26 at 11:11 a.m. with DON B revealed she had completed an investigation regarding the alleged abuse of resident 16 that occurred in November 2025. She did not have documentation to support the investigation she had done. She stated the investigation information would have been on the risk management form in the electronic medical record (EMR) system, but she could not find that documentation. She stated that she did substantiate the abuse and that LPN K was terminated. She could not remember who the residents were that had seen that incident take place. DON B was not able to provide the name of who had seen LPN K escort resident 16 back to his room and kept him in his recliner in an intimidating manner. She was not aware that her original FRI report had been rejected by the SD DOH due to unanswered questions regarding the alleged abuse. She acknowledged that she had received rejected reports in the past to her email address, and she would submit a different report when that happened. She stated she was pretty sure [housekeeper Q] had reported that information to her, but she did not have documentation from her investigation. She stated she did interview LPN K but she did not have the date of that inveterview and he had told her he had lost his temper. She did not have that interview documentation. She was not sure why staff had not reported that incident to her right way. DON B acknowledged that the police were not notified of that incident. DON B stated she directed her investigation toward abuse and she substantiated abuse and terminated LPN K. 3. Interview on 8/13/26 at 12:27 p.m. with assistant DON (ADON)/social services designee (SSD) C revealed that DON B was responsible for reporting potential abuse incidents to the SD DOH and for completing investigations. ADON/SSD C helped with the investigations as directed by DON B. 4. Review of the 11/11/25 SD DOH FRI report revealed that on 11/11/25, director of nursing (DON) B was notified that resident 18 had a fall on 10/30/25. Contracted travel licensed practical nurse (LPN) K went to resident 18's room and called him an insulting name. Former certified nurse assistant (CNA) L was in the room and heard the interaction. The FRI report indicated that CNA L did not report this to the DON because she was afraid of retaliation from contracted travel LPN K. Registered nurse (RN) M reported the incident to DON B after she heard about the situation from CNA N. DON B and assistant DON (ADON)/social service designee (SSD) C talked to resident 18 about the incident and verified he was called a derogatory name but he did not want to repeat what contracted travel LPN K called him. DON B terminated contracted travel LPN K and provided education to former CNA L about the importance of reporting incidents immediately. The report did not indicate the dates that DON B and ADON/SSD C talked to resident 18, contracted travel LPN K was terminated, or the date CNA L was provided education occurred. 5. Interview on 8/13/26 at 1:41 p.m. with administrator A and DON B revealed that after the incidents between resident 16, resident 18, and LPN K, they did not interview any other residents or staff to gauge the extent of the alleged abuse by LPN K. Administrator A said that once they learned of the allegations, they suspended LPN K and then terminated his contract. He was not allowed to come back. Administrator A questioned why other residents and staff would need to be interviewed as part of an investigation into the alleged abuse, as they eliminated all risk from him because he was not allowed to return. He confirmed he was not involved in those investigations. 6. Interview on 8/13/26 at 6:11 p.m. with DON B and ADON/SSD C regarding the allegation of staff-to-resident verbal abuse between LPN K and resident 18 revealed that the event happened on 10/30/25 but DON B was not informed about it until 11/11/25. CNA L was afraid of retaliation by LPN K, so she did not report it to DON B right away. CNA L no longer worked there. She expected all staff to report allegations of abuse and neglect to her or a charge nurse immediately. Since LPN K was the charge nurse on 10/30/25, she expected the staff to report the event directly to her. She did not have documentation that former CNA L received education regarding reporting. She had documentation that some staff received abuse, neglect, and reporting education. 7. Review of the provider's 1/23/18 Abuse, Neglect and Exploitation policy revealed that It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The facility will establish policies and procedures on abuse, neglect. pertaining to the following components: Investigation and staff identification of allegations; Training requirements for new and existing staff and in-service training for nurse-aides; reporting and response. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conduction. Components of an investigation should include: Identifying staff responsible for the investigation;.Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.within specified timeframes;.Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect,.and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan. The Administrator should follow up with the government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. B. Based on record review, interview, and policy review, the provider failed to investigate potential incidents of resident abuse for two separate resident altercations reviewed involving residents 15 and 24, and residents 7 and 22. Findings include: 1. Review of resident 22's EMR revealed that his 7/1/26 BIMS assessment score was 4, indicating his cognition was severely impaired. On 3/31/26 at 7:44 p.m., a progress note by DON B revealed that an unidentified CNA reported to her that resident 22 had his hands on an unidentified female resident's breasts. The progress note stated that DON B told resident 22 that he was not supposed to touch anyone and he replied okay. Interview on 8/13/26 at 6:11 p.m. with DON B regarding the above progress note revealed that she confirmed there was no investigation or change in resident care plans after the incident where resident 22 was witnessed by staff to be grabbing resident 7's breasts. Review of resident 7's EMR revealed that there was no progress note made about the above incident. There was no evidence to support that her POA or PCP were made aware of the potential resident to resident sexual abuse that occurred on 3/31/26. Her 5/31/26 BIMS assessment score was 3, indicating her cognition was severely impaired. 2. Review of resident 24's EMR revealed that a 6/17/26 at 4:40 p.m. progress note by ADON/SSD C indicated that resident 24 squeezed another resident's arm and caused a skin tear. Review of the 6/17/26 SD DOH FRI report indicated that resident 15 notified ADON/SSD C that resident 24 squeezed her arm and caused a skin tear. Resident 15's arm wound was treated, her vital signs were assessed, and resident 24's psychiatric provider was notified. A staff member was assigned to be with resident 24 one-on-one for additional supervision and safety. Resident 15 and 24's care plans were reviewed. Review of resident 24's EMR revealed that her 8/18/26 BIMS assessment score was 99, indicating she could not complete that assessment. Review of resident 15's EMR revealed that her 5/31/26 BIMS assessment score was 4, indicating her cognition was severely impaired. Email communication with the SD DOH on 8/13/26 at 10:11 a.m. revealed that the provider submitted an initial FRI report regarding the 6/17/26 incident between residents 15 and 24, but no final report or investigation conclusion was submitted to support a thorough investigation was completed. Interview on 8/13/26 at 7:02 p.m. with DON B revealed that she typically submitted the final report to the SD DOH along with the information requested by the SD DOH for the initial report. She confirmed that she did not further investigate the incident involving resident 24 causing a skin tear to resident 15. 3. Review of the provider's 1/23/18 Abuse, Neglect and Exploitation policy revealed that The facility will establish policies and procedures on abuse, neglect. pertaining to the following components: Investigation and staff identification of allegations; Training requirements for new and existing staff and in-service training for nurse-aides; reporting and response. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an investigation should be conduction. Components of an investigation should include: Identifying staff responsible for the investigation;.Investigating different types of alleged violations; Identifying and interviewing all involved persons, including the alleged victim, alleged perpetrator, witnesses, and others who might have knowledge of the allegations; Focusing the investigation on determining if abuse, neglect, exploitation, and/or mistreatment has occurred, the extent, and cause; and Providing complete and thorough documentation of the investigation. When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.within specified timeframes;.Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect,.and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services. The Administrator should follow up with the government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies.

Based on observation, interview, and policy review, the provider failed to ensure that the staff followed standard safe food service practices regarding handwashing and glove use when serving food by one of one cook (J) during one of two meals observed.Findings include:1. Observation on 8/13/26 at 11:27 a.m. in the kitchen revealed that cook J brought some dirty dishes to the dishwashing area and used the water sprayer to spray down a sheet pan. She did not wash her hands afterwards. She then went over to the clean silverware and picked up a spoon. She went over to the microwave, pulled out the bowl of green beans that had been reheating, stirred the green beans with the spoon, and placed the bowl of green beans back in the microwave. She set the spoon on the counter in front of the microwave. After that, she washed her hands.2. Continued observation on 8/13/26 at 11:41 a.m. in the kitchen revealed that cook J was wearing a pair of gloves on her hands. She picked up a rag from the sanitizer bucket and wiped up some spilled food on the counter. She did not change her gloves or wash her hands before starting to serve the resident's food. She picked up the clean plates by placing four of her fingers on top of the plate (touching the surface of the plate that the resident's food would touch), with her thumb supporting the bottom of the plate. This had the potential to transfer germs from her gloved hands onto the clean plates.Several times throughout the observation, cook J would touch her face, push up her glasses, and wipe her forehead with the back of her gloved hand. She changed gloves a few times throughout the observation, but did not wash her hands before putting on a new pair of gloves.3. Interview on 8/13/26 at 2:18 p.m. with cook J revealed that the training and orientation she received when she started working at the facility was online training videos. She knew that she was supposed to have washed her hands and changed gloves after touching her face, and when her hands were visibly soiled. She was not aware of the potential to transfer germs from her hands onto the clean plates with the way she was picking up the plates. 4. Interview on 8/13/26 at 4:54 p.m. with administrator A revealed that dietary manager E was no longer at the facility for an interview. He confirmed that the above observations were breaks in hand hygiene.5. Review of the provider's 2026 Handwashing Guidelines for Dietary Employees policy revealed that dietary employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single use articles and also in the following situations: .After hands have touched anything unsanitary i.e., garbage, soiled utensils/equipment, dirty dishes, etc.; After hands have touched bare human body parts other than clean hands (such as face, nose, hair etc.); After handling chemicals and before beginning to work with food; While preparing food, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; .Before donning [putting on] gloves for working with food; .After engaging in any activity that may contaminate the hands.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to report incidents to the SD DOH within the required time frame regarding one of one sampled residents (18) who experienced verbal abuse by a staff member and failed to report incidents regarding five of five sampled residents (3, 7, 11, 22, and 24) who experienced potential resident to resident physical and sexual abuse incidents that were required to be reported. Findings include:1. Review of the 11/11/25 SD DOH FRI report revealed that on 11/11/25, director of nursing (DON) B was notified that resident 18 had a fall on 10/30/25. Contracted travel licensed practical nurse (LPN) K went to resident 18's room and called him an insulting name. Former certified nurse assistant (CNA) L was in the room and heard the interaction. The FRI report indicated that CNA L did not report this to the DON because she was afraid of retaliation from contracted travel LPN K. Registered nurse (RN) M reported the incident to DON B after she heard about the situation from CNA N on 11/11/25. DON B and assistant DON (ADON)/social service designee (SSD) C talked to resident 18 about the incident and verified he was called a derogatory name but did not want to repeat what contracted travel LPN K called him. DON B terminated contracted travel K and provided education to former CNA L about the importance of reporting incidents immediately. That FRI report indicated the incident occurred on 10/30/25 and was not reported to the SD DOH until 11/11/25, which was 12 days after the incident allegedly occurred. 2. Review of resident 3's electronic medical record (EMR) revealed that a progress note on 8/4/26 at 4:51 p.m. by ADON/SSD C indicated that she responded to an incident in resident 3's room, where resident 11 went into resident 3's room and slapped him. Resident 3 then slapped resident 11 across the face making her glasses fly into the hallway. Resident 3's sons were in the room during the event. On 8/4/26 at 5:29 p.m., a progress note by ADON/SSD C revealed that she notified DON B and resident 3's power of attorney (POA) of the incident that occurred in resident 3's room. Review of Resident 11's EMR revealed that her POA was notified of the incident as well on 8/4/26 at around 5:00 p.m. There was no evidence to support that this event was reported to the SD DOH. 3. Review of resident 24's EMR revealed that on 5/20/26 at 9:00 p.m., a progress note by LPN R indicated that resident 33 stomped on her [resident 24] foot, grabbed the resident's chest, and shoved the resident. This action was unprovoked. Resident [24] did not fall to the floor. Staff intervened immediately and separated the residents. The progress note included that her vitals were within normal limits and she did not have any skin injuries. There was no evidence that resident 24's or resident 33's POAs or primary care providers (PCPs) had been notified of the incident, and no evidence that the SD DOH had been notified. 4. Review of resident 22's EMR revealed that on 3/31/26 at 7:44 p.m., a progress note by DON B revealed that an unidentified CNA reported to her that resident 22 had his hands on a female resident's breasts. The progress note stated that DON B told resident 22 that he was not supposed to touch anyone and he replied okay. There was no evidence that this situation was reported as potential sexual abuse to the SD DOH. There was no evidence to support that this situation was reported to either resident's POAs or PCPs. 5. Review of resident 24's EMR revealed that on 1/18/26 at 2:16 p.m., a progress note by RN S indicated that resident 11 was standing in front of resident 24's room screaming at resident 24. Resident 24 was yelling for help. Resident 11 had ahold of resident 24's hand. Resident 11 had caused a skin tear to resident 24's left hand. There was no evidence that this event was reported to the SD DOH as potential resident to resident physical abuse. 6. Interview on 8/13/26 at 12:27 p.m. with ADON/SSD C revealed that DON B was responsible for reporting and investigating potential abuse incidents to the SD DOH. ADON/SSD C assisted with the investigations directed by DON B. 7. Interview on 8/13/26 at 1:41 p.m. with administrator A and DON B revealed that, in reference to the incident where resident 22 had his hands on another female residents' breasts, it was administrator A's expectation that all incidents of potential resident-to-resident sexual abuse should have been reported to the appropriate agencies and investigated. DON B confirmed that she was aware that, on 3/31/26, resident 22 had his hands on each of resident 7's. She said that the reason she did not report that interaction as potential sexual abuse is because resident 7 initiates or invites that stuff. She confirmed that both resident 22 and resident 7 were cognitively impaired. DON B also indicated that the incidents involving resident 24 should have been reported to the SD DOH. Record review at that time revealed that resident 22 had a Brief Interview for Mental Status (BIMS) score of 4, and resident 7 had a BIMS score of 3, indicating their cognition was severely impaired. 8. Interview on 8/13/26 at 6:11 p.m. with DON B and ADON/SSD C revealed that DON B thought she had reported the 8/4/26 physical altercation between resident 3 and resident 11. When she logged in to the State Department of Health self-reporting system, she confirmed that event had not been reported. Regarding the allegation of staff-to-resident verbal abuse between LPN K and resident 18, the event happened on 10/30/25 but DON B was not informed about it until 11/11/25. CNA L was afraid of retaliation by LPN K, so she did not report it. CNA L no longer worked there. She expected all staff to report allegations of abuse and neglect to her or a charge nurse immediately. Since LPN K was the charge nurse on 10/30/25, she expected CNA L to report the event directly to her. She did not have documentation that former CNA L received education regarding abuse reporting after that incident. She had documentation that some of the staff received education about abuse, neglect, and mandatory reporting. 9. Interview on 8/13/26 at 6:45 p.m. with DON B revealed she was not aware that the incident between residents 11 and 24 had occurred. She expected staff to notify her of potential abuse incidents and accidents so she could report them to the SD DOH as needed. 10. Review of the provider's 1/23/18 Abuse, Neglect and Exploitation policy revealed that It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. The facility will establish policies and procedures on abuse, neglect. pertaining to the following components: Investigation and staff identification of allegations; Training requirements for new and existing staff and in-service training for nurse-aides; reporting and response. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written. When abuse, neglect or exploitation is suspected: Immediately report all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies.within specified timeframes;.Taking all necessary actions as a result of the investigation, which may include, but are not limited to, the following: Analyzing the occurrence(s) to determine why abuse, neglect,.and what changes are needed to prevent further occurrences; Defining how care provision will be changed and/or improved to protect residents receiving services; Training of staff on changes made and demonstration of staff competency after training is implemented; Identification of staff responsible for implementation of corrective actions; The expected date for implementation; and Identification of staff responsible for monitoring the implementation of the plan. The Administrator should follow up with the government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final within 5 working days of the incident, as required by state agencies. 11. Review of the provider's undated Incidents and Accidents policy revealed, It is the policy of this facility for staff to report, investigate, and review any accidents or incidents that occur or allegedly occur, on facility property and may involve or allegedly involve a resident. The purpose of incident reporting can include: Assuring that the appropriate and immediate interventions are implemented and corrective actions are taken to prevent recurrences and improve the management of resident care. Conducting root cause analysis to ascertain causative/contributing factors as part of the Quality Assurance Performance Improvement (QAPI) to avoid further occurrences. Alert risk management and/or administration of occurrences that could result in claims or further reporting requirements. Meeting regulatory requirements for analysis and reporting of incidents and accidents. Licensed staff will report incidents/accidents and assist with completion of any investigative information to identify root causes. The following incidents/accidents require an incident/accident report but are not limited to: Alleged abuse,. Resident to resident altercations. If an incident/accident was witnessed by other people, the supervisor or designee will obtain written documentation of the event by those that witnessed it and submit that documentation to the Director of Nursing and/or Administrator.

Based on record review, interview, and policy review, the provider failed to ensure that the risks and benefits information of receiving the pneumococcal vaccines were documented as provided in the resident's electronic record (EMR) to one of one sampled resident (9) who refused pneumococcal vaccination. Findings include:1. Review of resident 9's EMR revealed he admitted to the facility on [DATE]. He received an unspecified formulation of the pneumococcal conjugate vaccine (PCV) on 12/1/15 and 1/30/17. According to the PnuemoRecs Vax Advisor App (resource for the Centers for Disease Control and Prevention's current adult vaccine recommendations), resident 9 needed one dose of either PCV15, PCV20, or PCV21 to have his pneumococcal vaccines up to date. There was no documentation that he was offered and refused the pneumococcal vaccine. 2. Interview on 8/13/26 at 5:33 p.m. with director of nursing (DON) B and assistant DON (ADON)/social service designee (SSD) C revealed that resident 9 did not want vaccinations at the facility. They confirmed they did not have documentation that he was provided education regarding the risks and benefits of receiving the pneumococcal vaccines. Typically, the facility received a form that was sent by the pharmacy to indicate which vaccines the resident wanted or did not want. They did not have this for resident 9. 3. Review of the provider's 7/27/26 RSV, Influenza, Covid-19 and Pneumococcal Vaccination policy revealed that In order to reduce the disease-morbidity and mortality associated with RSV, influenza and pneumococcal disease, RSV, influenza and pneumococcal vaccines are offered to all residents per the CDC guidelines found on the CDC website. The resident's medical record includes: Documentation that the resident and/or resident's legal representative was provided education regarding the benefits and potential side effects of the influenza and/or pneumococcal immunization. Documentation of any refusals to be vaccinated.

Based on menu review, observation, and interview, the provider failed to ensure one of two dietary staff (cook J) followed the menu serving sizes for each diet offered which had the potential to affect all residents within the facility, and failed to substitute a nutritionally adequate replacement for the pureed garlic bread for three of three residents (6, 11, and 17) who required a pureed diet.Findings Include:1. Review of the provider's lunch menu for 8/16/26 showed that the planned meal included lasagna, a layered lettuce salad, garlic bread, chocolate vanilla swirl pudding, and milk. For the regular diet, serving sizes consisted of a two inch by two inch piece of lasagna (approximately three quarters of a cup), one cup of layered lettuce salad, one slice of garlic bread, one half cup of pudding, and eight ounces of milk. The mechanical soft diet used the same serving size for the lasagna and substituted green beans for the layered lettuce salad; however, the menu did not indicate a serving size for the green beans. The pureed diet included the same meal items and serving sizes as the regular diet, with each item served in pureed form. For the cardiac diet, the serving sizes for the lasagna and garlic bread matched the regular diet. In place of the layered lettuce salad, the menu listed lettuce salad without a serving size. Instead of pudding, individuals on the cardiac diet received a fruit of choice, along with skim milk. The diabetic diet followed the same serving sizes for the lasagna and layered lettuce salad but provided half a slice of garlic bread and substituted a fruit of choice for the pudding; skim milk was also provided. The small portions diet kept the same serving sizes for the lasagna and milk but reduced the lettuce salad to one quarter cup, the garlic bread to half a slice, and the pudding to one quarter cup.2. Observation on 8/13/26 at 11:41 a.m. revealed that cook J was using tongs for the lettuce salad, and a blue-handled one-quarter cup scoop for the pudding, the pureed green beans, and pureed lasagna. For the residents on a pureed diet, she used one scoop (about a quarter cup) for the pudding, two full scoops (about a half cup) for the pureed lasagna, and two full scoops (about a half cup) for the pureed green beans. There was no pureed garlic bread prepared, and she did not replace that menu item with a nutritionally adequate substitute. There were three residents who received the pureed diet: residents 6, 11, and 17. For the other meals, cook J used the tongs to portion about one-half cup of lettuce salad onto the plates. She did not use a measuring tool to accurately portion one cup of lettuce salad onto the plates. [NAME] J used the blue handled scoop to portion one scoop (about a quarter cup) of pudding rather than the one-half cup listed on the menu.3. Interview on 8/13/26 at 2:18 p.m. with cook J revealed that the training and orientation she received when she started working at the facility was online training videos. She confirmed she did not look at the lunch menu for the serving sizes because she was running late. She eyeballed it when estimating the amount of salad that she placed on the resident's plate and thought she had served about one cup.4. Interview on 8/13/26 at 4:54 p.m. with administrator A revealed that he expected staff to follow the facility menu serving sizes.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to protect the residents' right to be free from verbal abuse for one of one sampled resident (18) who was called an insulting name by one of one contracted travel licensed practical nurse (LPN) (K).Findings include:1. Review of the 11/11/25 SD DOH FRI report revealed that on 11/11/25, director of nursing (DON) B was notified that resident 18 had a fall on 10/30/25. Contracted travel licensed practical nurse (LPN) K went to resident 18's room and called him an insulting name. Former certified nurse assistant (CNA) L was in the room and heard the interaction. The FRI report indicated that CNA L did not report this to the DON because she was afraid of retaliation from contracted travel LPN K. Registered nurse (RN) M reported the incident to DON B after she heard about the situation from CNA N.DON B and assistant DON (ADON)/social service designee (SSD) C talked to resident 18 about the incident and verified he was called a derogatory name but did not want to repeat what contracted travel LPN K called him. DON B terminated contracted travel LPN K and provided education to former CNA L about the importance of reporting incidents immediately. The report did not indicate the dates that DON B and ADON/SSD C talked to resident 18, contracted travel LPN K was terminated, or the date CNA L was provided education occurred.2. Review of resident 18's electronic medical record (EMR) revealed that he admitted to the facility on [DATE]. His 4/25/26 Brief Interview for Mental Status (BIMS) assessment score was 13, which indicated that he was cognitively intact. He had a diagnosis of mild cognitive impairment (a slight decrease in memory and thinking skills that is worse than normal aging). He had psychiatric services started on 11/6/25.3. Interview on 8/11/26 at 4:14 p.m. with resident 18 revealed that he hardly remembered the November 2025 incident where the male nurse called him an insulting name, he was not bothered by it, and he felt safe in the facility.4. Interview on 8/12/26 at 8:45 a.m. with certified medication aide (CMA) O revealed that she had not heard any staff talk meanly to the residents. If she did, she would report it to the nurse or DON B. She recalled receiving education about abuse, neglect, and mandatory reporting.5. Interview on 8/12/26 at 8:54 a.m. with RN P revealed that she was not aware of any staff member being verbally abusive towards residents. She would report allegations of abuse to DON B. She recalled completing education about abuse, neglect, and reporting.6. Interview on 8/13/26 at 12:27 p.m. with ADON/SSD C revealed that she went with DON B to interview resident 18 regarding the verbal abuse incident that occurred on 10/30/25 by contracted travel LPN K. Resident 18 reported that a male nurse called him some names.DON B was responsible for reporting all potential abuse incidents to the SD DOH and for completing investigations. ADON/SSD C helped with the investigations directed by DON B.7. Interview on 8/13/26 at 1:41 p.m. with administrator A and DON B revealed that after the incidents between resident 16, resident 18, and LPN K, they did not interview any other residents or staff to gauge the extent of the alleged abuse by LPN K. Administrator A said that once they learned of the allegations, they suspended LPN K and then terminated his contract. He was not allowed to come back. Administrator A questioned why other residents and staff would need to be interviewed as part of an investigation into the alleged abuse, as they eliminated all risk from him because he was not allowed to return. He confirmed he was not involved in those investigations.8. Interview on 8/13/26 at 6:11 p.m. with DON B and ADON C regarding the allegation of staff-to-resident verbal abuse between LPN K and resident 18, the event happened on 10/30/25, but she was not informed about it until 11/11/25. The staff person that reported it to her (CNA L) was afraid of retaliation by LPN K, so CNA L did not report it to DON B. The staff member who reported the event to DON B no longer worked there. She expected all staff to report allegations of abuse and neglect to her or a charge nurse immediately. Since LPN K was the charge nurse on 10/30/25, she expected former CNA L to report the event directly to her. She did not have documentation that former CNA L received education regarding abuse reporting after that incident. She had documentation that some of the staff received education about abuse, neglect, and mandatory reporting. They confirmed that not all staff received the education at the in-service, and there was no monitoring system in place to ensure staff and resident interactions remained free from verbal abuse. 9. Review of the provider's 1/23/18 Abuse, Neglect and Exploitation policy revealed that It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse. 'verbal abuse' means the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The facility will establish policies and procedures on abuse, neglect. pertaining to the following components: Investigation and staff identification of allegations; Training requirements for new and existing staff and in-service training for nurse-aides; reporting and response. The facility will provide ongoing oversight and supervision of staff in order to assure that its policies are implemented as written.

Based on interview, record review, and policy review, the provider failed to ensure the quality assessment and assurance (QAA) committee had included the required members of at least one of who was the administrator, owner, a board member, or other individual in a leadership role. The provider had no evidence of the administrator, owner, board member, or other designee having attended QAA meetings at least quarterly for 15 months of meeting attendance records reviewed (February 2024 through May 2025). Findings include: 1. Interview on 5/7/25 at 10:49 a.m. with medical director (MD) N regarding the provider's QAA and Quality Assessment and Performance Improvement (QAPI) meetings and program revealed: *She attended QAPI meetings quarterly and did not recall seeing administrator A present at those meetings routinely. *She was unaware of how often administrator A was at the facility or how often he attended the QAPI meetings in the past two years. *She expected that the administrator would be involved in identifying and correcting areas of concern identified in the QAPI program. -She indicated the facility could use his support. 2. Interview on 5/8/25 at 11:22 a.m. with director of nursing (DON) C regarding QAA and QAPI revealed: *She was responsible for overseeing the facility's quality management program, including QAA committee meetings and QAPI projects. *The QAA committee was expected to meet monthly. *The provider's QAPI committee was comprised of department managers and DON C. *The medical director and the consultant pharmacist attended QAPI meetings quarterly. *Administrator A attended the QAPI meeting that week for the first time in quite a while. *Administrator B had been at the facility approximately three hours a week for the last couple of months, but she had not attended a QAPI meeting. *She had requested that another QAA member be assigned the responsibility for overseeing the QAPI program. 3. Review of the provider's previous 15 months of monthly QAPI Meeting Attendance records revealed: *Between 2/13/24 and 5/6/25, administrator A attended two QAPI meetings. -He attended on 6/25/24 and 5/6/25. *None of the meetings were attended by the owner, a board member, or another individual in a leadership role. Review of the providers' reviewed 12/1/23 QAPI plan policy revealed: *Governance and Leadership: -The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program and for: 1) Identifying and prioritizing problems based on performance indicator data. 2) Incorporating resident and staff input that reflects organizational processes, functions, and services provided to residents. 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness. 4) Setting clear expectations for safety, quality, rights, choice, and respect. 5) Ensuring adequate resources exist to conduct QAPI efforts. *The QAPI program will be structured to incorporate input, participation, and responsibility at all levels. The Governing Body and QAPI Committee of the nursing center will develop a culture that involves leadership-seeking input from nursing center staff, residents, their families, and other stakeholders; encourages and requires staff participation in QAPI initiatives when necessary; and hold staff accountable for taking ownership and responsibility of assigned QAPI activities and duties. *QAPI Committee Members were listed as: Medical Director, Director of Nursing, Administrator, Infection Control Officer, Environmental Manager, Activities Director, Social Services Designee, Dietary Manager, and Business Manager. Refer to F835 and F865.

Based on interview and policy review, the provider failed to ensure they had an effective quality assurance and performance improvement (QAPI) program that identified and corrected quality deficiencies when they occurred throughout the facility and that performance improvement projects (PIP) had been thoroughly identified, implemented, or monitored regarding medication administration and storage, care plans, the completion of assessments, oxygen equipment use, trauma informed care, safe food storage, and infection control. Findings include: 1. Interview on 5/8/25 at 11:22 a.m. with director of nursing (DON) C regarding quality assessment and assurance (QAA) and QAPI revealed: *She was responsible for overseeing the facility's quality management program, including QAA committee meetings and QAPI projects. *Each department manager conducted their own audits, discussed those audits with the QAPI committee, and implemented any plan needed for correction. *The QAPI committee was currently looking at areas that included restraints, skin infections, and ensuring call lights were within reach. *The QAPI committee's current PIP was focused on improving communication with the medical provider regarding laboratory results. *She was unaware of areas of non-compliance regarding : -Medication administration and storage concerns related to resident self-administration of medications, accountability, storage, labeling, and notification to the provider when medications were withheld. -Baseline Care Plan concerns related to providing those to the resident/representative within 48 hours of admission. -Care Plan revisions accurately reflected the current care needs of the residents. -Ensuring that assessments were completed as ordered by the physician, and weekly skin assessments were completed by a licensed nurse. -Proper cleaning, storage, and supervision of oxygen equipment, -Trauma-informed care assessments were completed on residents who were identified as having Post Traumatic Stress Disorder (PTSD) -Safe food storage in the kitchen. -Infection Prevention and Control related to the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP), antibiotic stewardship, and training requirements of the infection preventionist. *She stated the QAPI committee was not aware of the issues above. *She confirmed their QAPI process had not been effective in identifying those quality issues that could have impacted the residents' care. *She had requested that another QAA member be assigned the responsibility for overseeing the QAPI program. Review of the providers' reviewed 12/1/23 QAPI plan policy revealed: *The QAPI program will aim for safety and high quality with all clinical interventions and service delivery . by ensuring our data collection tools and monitoring systems are in place and are consistent for proactive analysis, system failure analysis, and corrective action. *The scope of the QAPI program encompasses all types and segments of care and services that impact clinical care, quality of life, resident choice, and care transitions . *The governing body, administrator, and/or management firm are responsible for the development and implementation of the QAPI program and for: 1) Identifying and prioritizing problems based on performance indicator data . 3) Ensuring that corrective actions address gaps in the system and are evaluated for effectiveness . Refer to F554, F655, F657, F658, F695, F699, F755, F761, F812, F835, F868, F880, F881, and F882.

Based on interview, observation, record review, policy review, and job description review the provider failed to ensure the facility was operated under the supervision of administrator A to ensure quality management and the overall well-being of all 26 residents in the facility. Findings include: 1. Interview on 5/6/25 at 4:35 p.m. with administrator A regarding his schedule revealed: *He tried to be in the building weekly. *If he was unavailable, administrator B would be in the building once a week. *Administrator B started coming to the building once a week in January 2025. *Director of nursing (DON) C, business manager (BM) O, and dietary manger E were to be in the building on a full-time basis. 2. Interview on 5/7/25 at 9:59 a.m. with administrator B regarding department managers' time in the building revealed: *She did not know administrator A's schedule. *She was the full-time administrator for another facility. *If administrator A was unavailable, she would be in the building one day a week. *She started coming to the building on a weekly basis in January 2025 to help implement a new quality improvement plan. *The maintenance supervisor worked 10 hours a week and was on-call. *The minimum data set (MDS) coordinator worked in the facility on Mondays and Tuesdays and would work remotely after that. 3. Interview on 5/8/25 at 9:04 a.m. with licensed practical nurse (LPN)/social services designee (SSD) D regarding her schedule revealed: *She normally worked on Mondays and Thursdays as the SSD. *She would also fill in as a charge nurse when needed. *If a new resident admission was scheduled for a different day, she worked it out with DON C to cover the admission process. 4. Interview on 5/8/25 at 10:23 a.m. with administrator A regarding the day-to-day operations of the facility revealed: *He was the administrator of record for the facility. *DON C and BM O addressed most of the day-to-day activities in the building. *If there was an issue they could not address, they contacted administrator A or administrator B. *Administrator A or administrator B would come to the building and address the situation that day. *He agreed there were a lot of management issues delegated to DON C and BM O to ensure resident services were being provided and the regulation requirements were being met. 5. Interview on 5/8/25 at 11:44 a.m. with DON C regarding administrative oversight revealed: *Most of the facility's administrative duties fell upon her and BM O. *She stated she struggled to do her job as the DON while covering for other departments, including administration. *She would address issues in other departments, which took time away from completion of her director of nursing responsibilities. *If she had a major issue, she would call or email administrator A. *Administrator A's response time was not always timely. *Her responsibility of over-seeing the quality assurance meetings were turned over to administrator B as of 5/5/25 to lighten her work load. BM O was out of the office during the survey and unavailable for an interview. Review of the provider's undated Administrator job description revealed: *The primary purpose of your job is to direct the day-to-day functions of the facility in accordance with current federal, state, and local standards, guidelines, and regulations that govern long-term care facilities to assure that the highest degree of quality care can be provided to our residents. *As the Administrator, you are delegated the administrative authority, responsibility, and accountability necessary for carrying out your assigned duties. *Every effort has been made to identify the essential functions of this position. However, it in no way states or implies that these are the only duties you will be required to perform. The omission of specific statements of duties does not exclude them from the position if the work is similar, related, or is an essential function of the position. *Plan, develop, organize, implement, evaluate, and direct the facility's programs and activities. *Ensure that all employees, residents, visitors, and the general public follow established policies and procedures. *Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility. *Assist the Infection Control Coordinator, and/or Committee, in identifying, evaluating, and classifying routine and job-related functions to ensure that tasks involving potential exposure to blood/body fluids are properly identified and recorded. *Assist the Quality Assurance and Assessment Committee in developing and implementing appropriate plans of action to correct identified quality deficiencies. Refer to F554, F655, F657, F658, F695, F699, F755, F761, F812, F865, F868, F880, F881, and F882.

Based on observation, interview, record review, and policy review, the provider failed to ensure enhanced barrier precautions (EBP) were followed according to the provider's policy for two of two sampled residents (25 and 79) on EBP. Findings include: 1. Observation and interview on 5/6/25 at 9:08 a.m. with resident 79 in her room revealed: *A sign on her door stated she was on EBP and included the following: -Everyone must clean their hands, including before entering and when leaving the room. -Providers and staff must also wear gloves and a gown for the following high-contact activities: --Dressing. --Bathing/showering. --Transferring. --Changing linens. --Providing Hygiene. --Changing briefs or assisting with toileting. *Device care use: -Central line, urinary catheter, feeding tube, tracheostomy. -Wound care: any skin opening requiring a dressing. *There was no personal protective equipment (PPE) (gowns, gloves, and/or protective eyewear) available for use on or near the door. *She was not sure why the sign was on her door. Review of resident 79's EMR regarding EBP revealed: *She was readmitted on [DATE] following a hospital stay for a procedure. *She had an incision with staples from that procedure, with a physician's order to keep the area clean and dry. *There was nothing identified in her EMR that indicated the need for EBP. 2. Interview on 5/7/25 with certified nursing assistant (CNA) L at 2:15 p.m. regarding the EBP sign on resident 79's door revealed: *Resident 79 had returned from the hospital on Monday (5/5/25). *She was unsure why the EBP sign was on the resident's door. *Staff were to wear a gown and gloves when providing her care if she was on EBP. *Gowns were kept in the bottom drawer of the resident's dresser. *The nurse would inform the staff if there were any changes in infection control for residents so they would know what PPE to wear when caring for the residents. 51472 3. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *There was a sign on the outside of his door to his room that indicated he was on EBP. *There was no PPE available for use on his room door or near the room's entrance. *He stated he was at the facility to receive therapy services and planned to return home after his therapy was completed. *He indicated he had a surgical wound on his right lower leg that required a daily dressing change. *He stated the staff wore gloves when they changed his dressing and assisted him with cares, but they did not wear a gown. *He was not aware of any gowns being stored in or near the entrance to his room. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. *There was a physician's order that indicated, Right ankle apply Silvadene [a topical antimicrobial cream] and change dressing daily. one time a day for surgical site. related to DISPLACED FRACTURE OF LATERAL MALLEOLUS OF RIGHT FIBULA [right ankle fracture]. Review of resident 25's care plan revealed: *An intervention for Enhanced Barrier Precautions (EBP) to be used when providing cares for [resident 25]. EBP includes ABHR [alcohol-based hand rub] to hands before entering and when leaving the room. PROVIDERS AND STAFF MUST ALSO: Wear gloves and gown for the following High-Contact Resident Care Activities: when caring for [resident 25's] left ankle wound, assisting him with dressing, undressing, bathing/showering, transferring, changing linens, providing hygiene, and changing briefs or assisting with toileting. *Resident 25's care plan indicated he required assistance from one staff for showering, dressing, toileting, and transferring. 4. Interview on 5/6/25 at 4:47 p.m. with certified nursing assistant (CNA) Q revealed: *Residents were on EBP if they had catheters or wounds. *She usually only wore gloves when providing resident cares for residents on EBP. *She indicated she had previously worn gowns but was no longer was required to because the wounds (in relation to all residents on EBP for wounds) were covered. 5. Observation on 5/7/25 at 8:28 a.m. of resident 25 in the therapy area revealed: *No staff in the therapy area were wearing a gown or gloves. *Physical therapy assistant (PTA) P placed a gait belt on resident 25, assisted him to a standing position, and walked with him with a walker, and providing continuous contact assistance without wearing any PPE. 6. Interview on 5/7/25 at 9:36 a.m. with PTA P revealed: *She had been provided education related to EBP. *She was aware of which residents required EBP by the sign that was posted on the resident's room door. *She thought she only needed to wear PPE for EBP is she was in the resident's room and had not worn PPE in the therapy area while she provided therapy services for the resident. 7. Interview on 5/7/25 at 10:02 a.m. with licensed practical nurse (LPN) I revealed: *Residents with catheters, wounds, and certain infections required EBP. *The gowns were stored in the closets in the resident rooms. *She would put on a gown as soon as she entered the room to provide cares for residents on EBP. 8. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *She was the infection preventionist (IP) for the facility. *A gown and gloves were to be worn when providing direct resident care for residents with wounds, catheters, and the residents who had multidrug-resistant organisms (MDRO), which would require the resident to be on EBP. *The same PPE required for in-room care for residents on EBP was to be worn in the therapy area for those residents. *She had not thought of providing a PPE supply to be available for use in the therapy area. *It was her expectation that all facility staff and therapy staff followed the requirements for EBP. 9. Review of the provider's February 2025 Enhanced Barrier Precaution Policy revealed: *EBP are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs) in nursing homes. Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk for MDRO acquisition (e.g., residents with wounds or indwelling medical devices). -High-contact resident activities include: --Dressing --Bathing/Showering --Transferring --Providing Hygiene --Changing linens --Changing briefs or assisting with toileting --Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator --Wound care: any skin opening requiring a dressing *Enhanced Barrier Precautions should be followed when performing transfers and assisting during bathing in a shared/common shower room and when working with residents in the therapy gym, specifically when anticipating close physical contact while assisting with transfers and mobility.

Based on observation, interview, record review, and policy review, the provider failed to ensure: *Four of four sampled residents (3, 8, 9, and 18) had been assessed to determine their ability to safely self-administer medications. *Three of four sampled residents (3, 9, and 18) had a physician's orders to self-administer those medications as directed in the provider's policy. Findings Include: 1. Observation and interview on [DATE] at 1:39 p.m. and 1:57 p.m. with resident 9 in his room revealed: *There was a nebulizer machine (a machine that converts liquid medication into an inhalable mist) on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. *He reached down and shut off that nebulizer machine, then turned it back on when the surveyor stated she would return. -He kept the nebulizer machine on the floor, so it was easy for him to reach, and it was quieter there. *He stated that the nurse would put the medication in the nebulizer mask, and he would administer his nebulizer treatment. *He hung the nebulizer mask from the tack on his calendar between the four nebulizer treatments he received each day. -He was unsure when the nebulizer mask would need to be cleaned, but thought the nurse did that once a day. *There were two unmarked clear plastic medication cups on his bedside stand, one containing a green gel and the other a light-yellow ointment. -He stated that the light-yellow ointment was a thick lotion for his feet. It would be nice if the staff would rub it in. That cream is as thick as axle grease. -The green gel was Biofreeze (pain-relieving gel) for when the therapist came and worked on his neck. *The nurse had left those creams there for him to use when he needed them. *He stated that the nurse also brought his antacid medication and left that in a small cup next to his bed for him to take when he woke up each morning. -He had been angry that the nurse would wake him up and had told the nurse he wanted to refuse that medication so he could sleep. --The nurse now left the medication on his nightstand each morning and did not wake him. Observation on [DATE] at 4:04 p.m. with resident 9 in his room revealed: *The nebulizer machine was on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. Observation and interview on [DATE] at 11:20 a.m. with resident 9 in his room during the administration of a nebulizer treatment by licensed practical nurse (LPN) F revealed: *He had a bottle of Neomycin-Polymyxin otic solution (antibiotic ear drops) on the shelf above his sink that expired in [DATE]. *There were two clear plastic medication cups on his bedside stand that contained a light-yellow ointment and were not labeled with a resident's name or the cups' contents. *After the completion of the nebulizer administration, while LPN F rinsed the nebulizer mask out in the sink, resident 9 stated he usually did not rinse out his mask after he completed his nebulizer treatments, and he would just hang it on here as he pointed to a tack on the wall beside his recliner. Observation and interview on [DATE] at 4:25 p.m. with resident 9 regarding the antibiotic ear drops in his room revealed: *The drops were from when he had an ear infection when he lived at home, a couple of years ago. *He stated he now puts a couple of drops in his ears when they itch. *He was unaware that they had expired. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had a Brief Interview of Mental Status (BIMS) assessment score of 11, which indicated he was moderately cognitively impaired. *A [DATE] physician's order for Omeprazole [an antacid] Oral Capsule Delayed Release 20 MG [milligrams]. Give 1 capsule by mouth in the morning for esophageal varices, was scheduled for administration at 6:00 a.m. every day. *A [DATE] physician's order for Ipratropium-Albuterol Inhalation Solution [an inhaled medication to ease breathing by opening the airway in the lungs] 0XXX,d+[DATE].5 (3) MG/3ML [milliliter] 1 vial inhale orally four times a day for bronchitis for 5 Days. *A [DATE] physician's order for Biofreeze External Cream 10% . Apply to [the] affected area topically every 6 hours as needed for Pain. Apply to [the] affected area up to QID [four times a day] PRN [as needed]. *A [DATE] physician's order for Aquaphor External Ointment Apply to dry skn [skin] topically as needed for Bilateral [both] feet. Apply BID [two times a day] PRN. *There was no physician's order for his self-administration of medications. *There was no documentation that he had been assessed for his ability to safely self-administer medications. *His care plan did not address self-administration of medications. Observation and interview on [DATE] at 4:38 p.m. with LPN I regarding resident 9's medication orders revealed: *Resident 9 did not have an order for the antibiotic ear drops. -She was unaware that those drops were in his room and thought his family would have brought them to him from home. *She confirmed that the light-yellow ointment was Aquaphor and the green gel was Biofreeze. *She confirmed that resident 9 did not have a physician's order for self-medication administration for any of his medications. *She stated, Nobody in the facility has a self-medication order. *She had not left medications at resident 9's bedside. *She confirmed that he would need a physician's order for his self-administration of the Biofreeze, antibiotic ear drops, and nebulizer treatments. -She did not think he needed a physician's order for the Aquaphor. 2. Observation and interview on [DATE] at 9:28 a.m. with resident 8 in his room revealed: *There was a bottle of cream with a prescription label on it on the table to the left of his chair and a bottle of powder with a prescription label on it on the shelf above his sink. *He stated he put the cream on his feet twice a day and used the powder about three times a week when he got himself washed and dressed in the morning. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. *A [DATE] physician's order for Nystatin Powder . Apply to groin folds topically two times a day .MAY KEEP NYSTATIN IN HIS ROOM. *A [DATE] physician's order for [NAME] External Lotion 0XXX,d+[DATE].5% . Apply to feet & legs topically two times a day for Dry skin MAY KEEP [NAME] IN HIS ROOM. *There was no documentation that he was assessed for his ability to safely self-administer medications. *His care plan did not address his self-administration of medications Interview on [DATE] at 4:38 p.m. with LPN I regarding resident 8's medications revealed she confirmed that resident 8 self-administered the above-listed medications, and that he had physician's orders to keep his [NAME] lotion and nystatin powder at his bedside. 51472 3. Observation and interview on [DATE] at 1:26 p.m. with resident 3 in her room revealed: *There was an assembled nebulizer mask draped over a nebulizer machine on her bedside stand. *She stated she rinsed out the nebulizer mask in the sink after she completed her nebulizer administration, reassembled the mask and then laid it on her bedside table. *She verified that she administered her own nebulizer treatment after the nurse brought in the nebulizer medication and set up the treatment. Review of resident 3's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated she was cognitively intact. *She had a [DATE] physician's order for Albuterol Sulfate Inhalation Nebulization Solutions 2.5 MG/0.5 ML [an inhaled medication to ease breathing by opening the airway in the lungs] (Albuterol Sulfate) 1 vial inhale orally three times a day and every 4 hours as needed for SOB [shortness of breath]. *There was no physician's order for her self-administration of medications. *There was no documentation that she was assessed for her ability to safely self-administer medications. *Her care plan did not address her self-administration of medications. 4. Observation on [DATE] at 2:53 p.m. of resident 18's room revealed a partial container of Vicks Vapor Rub medicated ointment was on the arm of his recliner. Review of resident 18's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 8, which indicated he was moderately cognitively impaired. *He did not have a physician's order for the Vicks Vapor Rub medicated ointment. *He did not have a physician's order for his self-administration of medications. *There was no documentation that she was assessed for his ability to safely self-administer medications. *His care plan did not address his self-administration of medications or the storage of medications in his room. 5. Interview on [DATE] at 2:47 p.m. with LPN I revealed she stated: *There were no residents who were to self-administer medications in the facility. *For a resident to self-administer medications it would have required a physician's order for medication self-administration. Continued interview on [DATE] at 2:55 p.m. with LPN I regarding the Vicks Vapor Rub medicated ointment in resident 18's room revealed: *Vicks Vapor Rub was a medicated ointment and it would have required a physician's order for administration. *Resident 18 did not have a physician's order for Vicks Vapor Rub or the self-administration of it. *He did not have a medication self-administration assessment documented in his EMR to support he was assessed for his ability to safely self-administer medication. 6. Interview on [DATE] at 9:21 a.m. with director of nursing (DON) C revealed: *She would consider medications in a resident's room that the resident was taking or applying independently, as self-administration of medication. *She expected no medications to be stored at a resident's bedside without a physician's order for self-administration. *It was their policy only nebulizer treatments were assessed for self-administration. *She was aware that resident 9 had been self-administering his nebulizer treatment, had antibiotic ear drops and prescribed creams in his room, and that a nurse had left his omeprazole at his bedside without waking him. -She verified that resident 9 did not have a physician's order or assessment for self-administration of medications. *She was aware that resident 8 had a lotion and a powder at his bedside because he had requested those, and they had obtained an order from his physician. *They had completed a self-administration assessment in 2022 when resident 8 had self-administered his nebulizers. -She confirmed there was no self-administration assessment done for resident 8's lotions or powders to ensure he was safe to self-administer those. *She verified that resident 3 did not have a physician's order or assessment for self-administration of medications. *She was unaware that resident 18 had Vicks Vapor Rub medicated ointment in his room. -She verified resident 18 did not have a physician's order or assessment for self-administration of medications. *She stated there were residents in the facility with cognitive impairment who wandered into other resident rooms. *One of the cognitively impaired residents who wandered into residents' rooms had a history of rummaging through items in other residents' rooms. *She agreed that some of their policies did not reflect their processes, and some of those policies, including those related to nebulizers, were inconsistent with other policies they had. *She confirmed there were no residents who had been assessed for self-administration of medication. *She confirmed there were no residents who had a physician's order for self-admininstration. 7. Review of the provider's [DATE] Self-Administration of Medications policy revealed: *In order to maintain the residents' high level of independence, residents who desire to self-administer medications are permitted to do so if the facility's interdisciplinary team has determined that the practice would be safe for the resident and other residents of the facility and there is a prescriber's order to self-administer. *If the resident desires to self-administer medications, an assessment is conducted by the interdisciplinary team of the resident's cognitive (including orientation to time), physical, and visual ability to carry out this responsibility during the care planning process. *For those residents who self-administer, the interdisciplinary team verifies the resident's ability to self-administer medications by means of a skill assessment conducted on a quarterly basis or when there is a significant change in condition. *The results of the interdisciplinary team assessment of resident skills and of the determination regarding bedside storage are recorded in the resident's medical record, on the care plan. For each medication authorized for self-administration, the label contains a notation that it may be self-administered. *If the resident demonstrates the ability to self-administer medications, a further assessment of the safety of bedside medication storage is conducted. *Bedside medication storage is permitted only when it does not present a risk to confused residents who wander into the rooms of, or room with, residents who self-administer. Review of the provider's [DATE] Self-Administration of Medications policy revealed: *To ensure doctor orders are followed and correctly documented, ensuring the highest level of care is provided . *The only Medications that residents . will [be] able to be self-administer[ed] are inhaled medications. Refer to self-Administration of Nebulizer Treatments. for more details. Review of the provider's [DATE] Self-Administration of Nebulizer Treatments policy revealed: * .Inhaled medications may be taken without supervision after a nurse or CMA [certified medication aide] setup, a doctor order [is] on file, and Self-Administration of Nebulizer Treatments Assessment is completed. *Resident must be evaluated by nursing for the appropriateness of their ability to self-administer Nebulizer Treatments. Assessments will be completed quarterly based on MDS scheduling. Nursing is responsible for obtaining doctor order, care planning the self-administration of inhaled meds along with any restrictions .

Based on record review, interview, observation, and policy review, the provider failed to complete a baseline care plan and provide a written summary of the baseline care plan to the resident or their representative for four of four recently admitted sampled residents (9, 19, 25, and 79) within 48 hours of their admission to the facility. Findings include: 1. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated he was moderately cognitively impaired. *His baseline care plan was initiated on 12/2/24. *The section Signature and Representative and the date had been left blank. *There was no documentation that indicated the care plan was reviewed with him, his representative, or that he had been provided or offered a copy of his baseline care plan within 48 hours of his admission. Interview on 5/6/25 at 4:25 p.m. with resident 9 regarding his care plan revealed he did not recall if anyone had reviewed his care plan or his medications with him in the first 48 hours after he had been admitted to the facility. 2. Review of resident 19's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 8, which indicated she was moderately cognitively impaired. *Her baseline care plan was initiated on 4/22/24 and indicated it was In Progress. *The following sections were incomplete: -Active diagnoses contributing to admission had been left blank. -Signature and Representative and the date had been left blank. -Signatures of Staff Completing the Baseline Care Plan had been left blank. *There was no documentation that indicated the care plan was reviewed with her, her representative, or that she or her representative had been provided or offered a copy of her baseline care plan within 48 hours of her admission. Interview on 5/7/25 at 2:49 p.m. with resident 19 regarding her care plan revealed she did not recall if anyone had reviewed her care plan or her medications with her in the first 48 hours after she had been admitted to the facility. 45683 3. Observation and interview on 5/6/25 at 8:55 a.m. with resident 79 in her room revealed she: *Could not remember the exact date she was admitted , but she knew it was in March 2025. *Had been in and out of the hospital at least two times since she was admitted due to blood loss. *Did not know what a care plan was. Review of resident 79's EMR on 5/7/25 revealed: *She was admitted on [DATE]. *Her 3/10/25 BIMS assessment score was 10, which indicated she was moderately cognitively impaired. *Her baseline care plan had been initiated on 3/3/25 but was not completed. *The baseline care plan was labeled 'Errors in the EMR. *There were no progress notes that indicated a baseline care plan was reviewed or given to the resident or her representative. 51472 4. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed he: *Was lying in bed with his eyes open and a CPAP (a machine that uses air pressure to keep breathing airways open) on. *Had a black equalizer boot (a boot used to improve stability and decreased pain and swelling) on his right leg. *Had been admitted to the facility a few weeks ago after he broke his right ankle *Stated he was at the facility to receive therapy services and planned to return home after his therapy was completed. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *His baseline care plan was initiated on 4/8/25. *His baseline care plan did not indicate his use of a CPAP machine. *His baseline care plan did not contain a signature or date that would indicate the care plan was reviewed with him, if he was offered or provided a copy of his baseline care plan or when that may have occurred. Follow-up interview on 5/7/25 at 9:42 a.m. with resident 25 in his room revealed he did not: *Recall reviewing his plan of care with a staff member. *Receive or was offered a copy of his care plan. 5. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C regarding residents' baseline care plans revealed: *The baseline care plan was initiated at the time of resident's admission. *She reviewed the baseline care plan with the resident or resident representative on admission. *She offered the resident or the resident representative a copy of the baseline care plan but stated they rarely accepted it. *She verified resident 19, 25, and 79's baseline care plans were incomplete and did not contain documentation to support that those residents' care plans had been reviewed with the residents or their representative or that a copy of the baseline care plans were offered to them. 6. Review of the provider's February 2025 Care Planning Process policy revealed: *Using an interdisciplinary approach, each resident will have an individualized plan of care which addresses the resident's current care needs and severity of condition, impairment, disability, or disease. *An interim plan of care [baseline care plan] will be developed by the Admission nurse within 24 hours after admission utilizing the resident profile. Specific care needs will be transferred to the CNA pocket care plan. -The provider policy did not contain that the baseline care plan was to be reviewed with the resident or resident representative within 48 hours of admission.

Based on observation, record review, interview, and policy review, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs for seven of twelve sampled residents (7, 8, 9, 14, 17, 19, and 25). Findings include: 1. Observation and interview on 5/5/25 at 1:39 p.m., 1:57 p.m. and again at 4:04 p.m. with resident 9 in his room revealed: *There was a large table that took up most of his room with a puzzle on it. He stated he spent much of his time working on puzzles. -He had completed several puzzles that were hung throughout the facility. *He had been admitted from [name of institution] and would be transferred to another facility. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated he was moderately cognitively impaired. *There was no documentation in his care plan that indicated his activity interests related to puzzles or his discharge plans. 2. Observations and interview on 5/5/25 at 2:35 p.m. and 5:22 p.m. with resident 17 and her husband revealed: *Resident 17 shared a room with her husband, who was an assisted living resident, and they sat in separate recliners in their room. *Resident 17 had an electric recliner that she was unable to operate independently. *Resident 17's husband stated that only he and the staff operated the resident's electric recliner when she would rest to elevate her feet. -Sometimes he needed to elevate the recliner so she could get up when it was time to go to dinner. *She did not attempt to operate the recliner on her own. *Resident 17 did not respond to any questions. Interview on 5/5/25 at 5:01 p.m. with certified nursing assistant (CNA) M regarding resident 17 revealed: *At times, she would sit in either recliner in her room. *She would follow simple directions, but did not respond to any questions asked of her. Observation and interview on 5/5/25 at 8:34 a.m. with resident 17 and physical therapy assistant (PTA) P revealed: *Resident 17 followed simple commands, walked with PTA P holding her hand, and her speech was unintelligible. *PTA P stated that resident 17 was on a maintenance and positioning program that included therapy twice a week and elevating her feet in her recliner. *PTA P had educated the staff that resident 17 was to sit in her recliner for half an hour twice a day with her feet elevated. *Resident 17 was unable to operate the remote and was to sit in her recliner with her feet elevated only when her husband was in the room. *She had never seen resident 19 touch the recliner remote. Interview on 5/7/25 at 4:07 p.m. with CNA L revealed: *Resident 17 sat with her feet elevated in the recliner only when her husband was in the room because it was safer. *She knew what care each resident required because it was in their care plan in the EMR. -She was unsure if resident 17's use of the recliner or positioning program would be included in her care plan. Review of resident 17's EMR revealed: *She was admitted on [DATE]. *Her 3/17/25 Minimum Data Set (MDS) indicated she was rarely understood or able to understand others and was severely cognitively impaired. *There was no documentation in her care plan that indicated her participation in a therapy maintenance and positioning program, or that her feet were to be elevated while in her recliner with her husband's supervision. Interview and review of resident 17's positioning program on 5/8/25 at 9:15 a.m. with director of nursing (DON) C revealed: *She was not aware that resident 17 was on a positioning program provided by PTA P. *That positioning program included the instruction to Please ensure pt [resident 17] is elevating LE's [lower extremities] in recliner at least 2X [two times] per day for edema management. Once in the am [morning] and once in PM [afternoon]. Spouse is also educated and showed how to work recliner if she does try to get up. *She expected that the positioning program and the instruction for elevating her lower extremities in the recliner to be included in resident 17's care plan. 3. Observations and interview on 5/5/25 at 2:32 p.m. and again on 5/6/25 at 2:06 p.m. with resident 19 in her room revealed: *There were signs in her room to provide reminders on where her snacks were located. *Her hands were tremoring and she rubbed her fingers together. *She answered questions with brief responses. *She was lying on her bed, and her legs were in constant movement. *There were no bed rails on her bed. Observations on 5/5/25 at 5:27 p.m. and again on 5/6/25 at 7:33 a.m. with resident 19 in the dining room revealed: *She was seated at the table in a dining room chair. *She held tightly to the chair and would scoot forward and back in that chair. *At times, she would stand and then return to sitting. *She appeared restless and anxious. *Her upper body was stiff, and her arms appeared tense. Review of resident 19's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 3, which indicated she was severely cognitively impaired. *Her diagnoses included Wernicke's Encephalopathy (a neurological condition caused by lack of vitamin B1), anxiety disorder, amnestic disorder (memory loss), and drug-induced subacute dyskinesia (a movement disorder caused by certain medications). *Resident 19's progress notes indicated: -On 4/28/24, Resident 19 .has been anxious since [the] beginning of [the] shift. -On 6/24/24, Resident brought up to [the] nurse station. Crying and shaking . PRN [as needed] Ativan [a medication for anxiety] given. -On 8/2/24, Due to her being upset, pacing, and repeatedly questioning things [she] was given Lorazepam [a medication for anxiety] again this evening. -On 10/30/24, Unfortunately her anxiety is keeping her from being distracted/redirected. She was given a prn [PRN] Ativan before lunch and [it] is not effective in managing symptoms at this time. Update provided to [physician]. -On 12/17/24, She is pacing about the facility in an anxious state. -On 2/25/25, Resident noted to be pacing up and down the hallways .PRN lorazepam given. -On 4/7/25, she is up much of the night asking for medications to help her sleep . Current PRNs are not very effective. *Her care plan indicated that resident 19 used bilateral top quarter rails to enable her independence with bed mobility, repositioning, and transfers in and out of bed, which was initiated on 5/1/24. *There was no documentation in her care plan that indicated current or past non-pharmacological interventions that had been tried to address resident 19's anxiety symptoms. Interview on 5/8/25 at 7:43 a.m. with LPN/social service designee (SSD) D revealed: *She was aware of resident 19's history of anxiety, pacing, and crying, and confirmed that those behaviors were still present. *She completed sections of the care plan related to the resident's code status, discharge to home planning, their religion, and who they received mental health services from. *She did not complete sections related to the resident's mood or behavior; she thought nursing had completed that section. Interview on 5/8/25 at 8:37 a.m. with DON C and LPN/SSD D regarding resident 19's care plan revealed: *LPN/SSD D completed bed rail assessments and care planned the use of the bed rails. *Resident 19 had been assessed for the use of bed rails, had bed rails on her bed, and then had requested that the bed rails be removed. *The use of bed rails was not removed from her care plan because resident 19 often changed her mind and forgot what she had requested, and she may want them back on the bed in the future. *DON C confirmed that resident 19's care plan should have been updated when the bed rails had been removed. *DON C confirmed that resident 19's care plan did not reflect her current care needs and interventions used to manage her anxiety, pacing, and crying, or the status of the mental health services they had been working to implement. 4. Observation and interview on 5/7/25 at 9:28 a.m. with resident 8 in his room revealed: *There was a bottle of cream with a prescription label on it on the table to the left of his chair, and a bottle of powder with a prescription label on it on the shelf above his sink. *He stated he put the cream on his feet twice a day and used the powder about three times a week when he got himself washed and dressed in the morning. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *He had a BIMS assessment score of 15, which indicated he was cognitively intact. *A 3/4/25 physician's order for Nystatin Powder . Apply to groin folds topically two times a day .MAY KEEP NYSTATIN IN HIS ROOM. *A 3/4/25 physician's order for [NAME] External Lotion 0.5-0.5% . Apply to feet & legs topically two times a day for Dry skin MAY KEEP [NAME] IN HIS ROOM. *There was no documentation in his care plan that addressed his self-administration of those medications. Interview on 5/6/25 at 4:38 p.m. with LPN I regarding resident 8's self-administration of medications revealed she was unsure if that should have been included in his care plan. 45683 5. Observation and interview on 5/5/25 at 4:07 p.m. with resident 7 in his room revealed: *He was sitting in his recliner. *He was not sure if he had been offered counseling sessions. *His biggest concern at that time was the food he was being served. Review of resident 7's EMR revealed: *He was admitted on [DATE]. *His 3/31/25 BIMS assessment score was 11, which indicated he was moderately cognitively impaired. *His diagnoses included: -Post-traumatic stress disorder (PTSD), unspecified. -Delirium due to a known physiological condition. -Personal history of other mental and behavioral disorder. -Major depressive disorder, recurrent, severe with psychotic symptoms. Review of resident 7's 4/1/25 care plan revealed: *He had a focus area of, an ADL [activities of daily living] self-care performance deficit r/t [related t]) delirium/depression/PTSD. *The goal for the area was to maintain his current level of function through the next review. *There were no interventions included in his care plan to suggest how to address issues that may arise from his PTSD. Interview on 5/6/25 at 4:36 p.m. with licensed LPN/SSD D regarding resident 7 and residents with a PTSD diagnosis revealed: *If a resident had a PTSD diagnosis, they were to be set up with an appointment with behavioral health services. *PTSD was to be entered into the care plan. *She was not aware of any interventions entered into resident 7's care plan for his PTSD that would educate staff to help him cope or to prevent potential triggers for retraumatization. 51472 6. Observation on 5/5/25 at 12:59 p.m. of resident 14's room revealed a sign on his door that read, Do Not Disturb. Review of resident 12's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *His diagnoses included anxiety disorder, major depressive disorder, hallucinations, post-traumatic stress disorder (PTSD), and vascular dementia with psychotic disturbance, mood disturbance, and anxiety. *He was a military service veteran. *There was a focus area in resident 14's care plan that stated resident 14, became angry with another resident and struck him in the left cheek with a closed fist. [Resident 14] stated he got angry when he asked this resident a question and he didn't respond to him. -Interventions for this focus area were, Staff will monitor [resident 14's] and the other resident's whereabouts in the dining room. Writer explained to [resident 14] that he is not allowed to touch anyone else. [Resident 14] voiced understanding. *His care plan did not address his behaviors, triggers, or interventions related to his diagnoses. *There was no information in the care plan related to the Do Not Disturb sign that was posted on the resident's door. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I revealed: *Staff utilized pocket care plans, the communication binder, and resident care plans to determine the care that each resident required. *She verified the pocket care plans were currently not up to date and did not include some of the more recently admitted residents and their needs. *She indicated resident 14 could get worked up at times when he thought people were stealing from him. *She was aware of an incident when resident 14 struck another resident in the face with a closed fist. *She indicated staff would talk to him after the incidents or at times when he was worked up, and he would calm. Interview on 5/8/25 at 8:59 a.m. with LPN/SSD D revealed: *She verified resident 14 had an altercation with another resident and had struck another resident in the face with a closed fist. *Resident 14's care plan had a focus area of sees mental health provider from [a nearby town] for mental health needs with an intervention that stated, Attend appointments as scheduled and PRN [as needed]. *She stated behaviors, triggers, and interventions for residents' behaviors should have been identified in their care plan. *She verified there were no behaviors or interventions related to resident 14's PTSD, anxiety, or hallucination diagnoses in his care plan. Interview on 5/8/25 at 11:53 a.m. with DON C revealed: *Resident 14 had not seen a mental health provider since early 2024. *He had not and was not seeing a mental health provider in the town indicated on his care plan on a scheduled or as needed basis. 7. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *He was lying in bed with his eyes open and a CPAP (a machine that uses air pressure to keep breathing airways open) on. *He stated he had worn his CPAP for several years and he had brought it into the facility from home when he was admitted . Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *He had diagnoses of other forms of dyspnea (difficulty breathing), and obstructive sleep apnea (intermittent airflow blockage during sleep). *His care plan did not address his respiratory diagnoses or the use of his CPAP machine. 8. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *Care plans could be updated by the direct resident care nurses, the social service designee, the Minimum Data Set (MDS) nurse, and herself. *She indicated most of the residents' care plan updates were completed by the MDS nurse. *She expected residents' care plans to be updated quarterly, annually, with a resident's significant change and any time there was a change in the care for the resident. *The residents' care plans did not reflect the current care needs and interventions that had been implemented or needed to meet those needs. *The provider had not completed any formal audits of residents' care plans but she and the MDS nurse reviewed resident care plans weekly for residents scheduled to have their quarterly or annual MDS assessments completed. 9. Review of the provider's updated February 2025 Care Planning Process revealed: *To define the personnel's responsibility in initiating and maintaining the resident's care plan. *To ensure a comprehensive, individualized plan of care for each resident. *Using an interdisciplinary approach, each resident will have an individualized plan of care which addresses the resident's current care needs and severity of condition, impairment, disability, or disease. Review of the provider's March 2025 Facility Assessment policy revealed Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information and are aware of preferences.

Based on record review, observation, interview, and policy review, the provider failed to ensure: *A physician-ordered Abnormal Involuntary Movement Scale (AIMS) assessment was completed and the results were communicated for one of one sampled resident (19) who received an antipsychotic medication. *The physician was notified of one of one sampled residents' (25) insulin having been held related to low blood sugars. Findings include: 1. Observations and interview on 5/5/25 at 2:32 p.m. and again on 5/6/25 at 2:06 p.m. with resident 19 in her room revealed: *There was a tremoring of both of her hands, and she rubbed her fingers together. *She answered questions with brief responses. *She was lying on her bed, and her legs were in constant movement. Observations on 5/5/25 at 5:27 p.m. and again on 5/6/25 at 7:33 a.m. with resident 19 in the dining room revealed: *She was seated at the table in a dining room chair. *She held tightly to the chair and would scoot forward and back in that chair. *At times, she would stand and then return to sitting. *She appeared restless and anxious. *Her upper body was stiff, and her arms appeared tense. Review of resident 19's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She had a Brief Interview of Mental Status (BIMS) assessment score of 3, which indicated she was severely cognitively impaired. *Her diagnoses included Wernicke's Encephalopathy, anxiety disorder, amnestic disorder, and drug-induced subacute dyskinesia. *A 3/13/25 physician's order: Complete AIMS assessment in 1 month and fax results. And Nursing to provide fax status update in 1 month on mood/behaviors and PRN [as needed] Lorazepam [medication used for anxiety] use. *AIMS assessments were completed on 11/3/24 and 2/23/24. *There was no documentation that an AIMS assessment had been completed since 2/23/24. *There was no documentation that the physician had been provided the results of the ordered AIMS assessment or had been provided a status update on resident 19's mood/behaviors or Lorazepam use. Interview on 5/8/25 at 8:23 a.m. with director of nursing (DON) C regarding resident 19's 3/13/25 physician's orders revealed: *DON C confirmed that resident 19's last AIMS assessment was completed on 2/23/24. *On 3/24/25, she communicated the results of resident 19's Patient Health Questionnaire-9 (PHQ-9) (an assessment of the degree of depression) to the physician. *She confirmed that they had not conducted the AIMS assessment as ordered on 3/12/25 or provided an update on the use of resident 19's Lorazepam. *She expected that the AIMS assessment would have been completed in mid-April, and the result of that assessment would have been provided to the physician along with an update on resident 19's mood/behaviors and Lorazepam use. Review of the provider's 1/1/25 revised Physician Visit and Physician Delegation policy revealed: *It is the policy of this facility to ensure the physician takes an active role in supervising the care of residents. *The Licensed Nurse should: a. Track the due dates of physician visits .e. Provide records such as weight and vital sign records, accident reports, etc. for physician review. *The Director of Nursing or Designee should: a. Conduct monthly audits for timeliness of physician visits. Review of the provider's Physician Medication Orders policy revealed it did not address the following physician orders unrelated to medications. Request for policies related to following physicians' orders resulted in the above-referenced policies. There were no additional polices for review. 51472 2. Interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *He had diabetes. *His blood sugars had been running lower than normal since he admitted to the facility and his physician had been adjusting his insulin doses. Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *He had a diagnosis of diabetes. *He had a physician's order to have his blood sugars checked before meals and at bedtime everyday. *He had a physician's order for Novolog Injection Solution 100 units/ ML (Insulin Aspart) [a fast-acting insulin] Inject 25 units subcutaneously [under the skin into the fatty tissue] with meals. Review of resident 25's April 2025 MAR and associated progress notes revealed: *4/10/25 at 5:30 p.m. his insulin was held with a progress note at 7:15 p.m. that stated Resident's BG [blood glucose or blood sugar] was 97 before supper. Resident ate supper. Writer rechecked BG and it was 128. Writer held 30 units and will recheck [blood sugar] at HS [bedtime]. *4/18/25 at 5:30 p.m. his insulin dose was held, his blood sugar was documented as 71 with a progress note at 4:15 p.m. that stated, only 71, holding. *4/19/25 at 11:30 a.m. his insulin dose was held, his blood sugar was 236 with a progress note that stated, Held due to not eating lunch. *4/19/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 88 with a progress note that stated, he is not hungry but will try to eat something. *4/20/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 72. *4/20/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 213 with a progress note that stated, Not eating supper. *4/21/25 at 5:30 p.m. his insulin dose was held with a documented blood sugar of 82, and a progress note that stated, Held due to first blood sugar 60 and after snack it went up to 82. *4/22/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 73. *4/23/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 78. *4/24/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 68. *4/24/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 102. *4/25/25 at 7:30 a.m. his insulin dose was held with a blood sugar of 95. *4/25/25 at 11:30 a.m. his insulin was held with a blood sugar of 119. *4/25/25 at 5:30 p.m. his insulin dose was held with a blood sugar of 144 and a progress note that stated, holding due to not planning to eat much. *4/26/25 at 7:30 a.m. his insulin was held with a blood sugar of 68. *4/26/25 at 5:30 p.m. his insulin was held with a blood sugar of 120. *4/27/25 at 7:30 a.m. his insulin was held with a blood sugar of 84. *4/28/25 at 7:30 a.m. his insulin was held with a blood sugar of 89. *4/30/25 at 5:30 p.m. his insulin was held with a blood sugar of 126 and a progress note that stated, Holding due to a hypoglycemic [low blood sugar] episode at HS recently. *From 4/8/25 until 4/28/25 there was no low blood sugar parameter that would indicate at what blood sugar value the insulin should have been held. *On 4/28/25 at 9:10 a.m. a progress note read, Faxed [medical director N] for parameters to hold his [resident 25's] Novolog 30 units with meals. His blood sugars have been running low, and staff has [have] been holding this at times. Sent recent blood sugars and medication list that he is on for Diabetes. Awaiting response. *On 4/28/25 there was a physician's order that stated, Hold [insulin] if blood sugar is less than 80 added to his insulin order. *Review of resident 25's May 2025 MAR revealed on 5/3/25 at 5:30 p.m. his insulin was documented as held with a blood sugar of 87. Review of resident 25's May 2025 MAR and associated progress notes revealed on 5/3/25 at 5:30 p.m. his insulin was held with a blood sugar of 87 and a progress note that stated, holding due to episodes of hypoglycemia [low blood sugar]. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I related to physician notifications revealed: *She would have notified the resident's physician via fax or a phone call is she held an insulin without a physician's order for a low blood sugar. *She was aware resident 25's insulin had been held related to low blood sugars but did not know if the physician had been notified of the low blood sugars or that his insulin had been held. *She stated if a resident's insulin was held related to a low blood sugar and the resident did not have parameters identified by the physician for when to hold the insulin for a low blood sugar, she was to notify the physician but admitted she had not always notified the physician. -If she notified the physician, she would document that in a progress note in the resident's EMR. *There was no facility identified number of resident refusals of a medication that would indicate the provider was to be notified. *After a few resident medication refusals she would talk with the resident regarding the refusals to determine why the medication was being refused and then would notify the provider. Interview on 5/7/25 at 10:50 a.m. with medical director N revealed: *It was her expectation to be notified immediately if insulin was being held for symptomatic hypoglycemia (low blood sugar) for a resident. *She stated it would be difficult to manage a resident's insulin regimen if the staff were holding insulin and she was not notified. *She was aware resident 25 was having low blood sugars and some adjustments had been made to his insulin regimen. *She recently ordered a low parameter to be added to his scheduled fast acting insulin, which indicated the low blood sugar value in which the staff were to hold his insulin. *He did not have the low blood sugar parameter for holding his insulin at the time of his admission. Documentation of the physician having been notified of the held insulin doses was requested from the facility but was not provided by the end of the survey on 5/8/25. Interview on 5/7/25 at 2:15 p.m. with director of nursing (DON) C revealed: *The facility did not have a policy regarding physician notification related to held or refused medications. *It was her expectation the physician was notified if medications were held without a physician's order. 3. Review of the provider's April 2013 Diabetes-Clinical Protocol policy revealed: *The staff will identify and report complications such as foot infections, skin ulcerations, increased thirst, or hypoglycemia. *The physician will help the staff clarify and respond to these episodes. Review of the provider's 3/5/25 Blood Pressure and Blood Sugar Parameter Policy revealed: *If blood sugar levels are above 400 or below 70 alert the provider. Unless other parameters are noted on residents' chart by their physician. *Chart communication with family and provider. Review of the provider's October 2021 Notification of Resident Changes policy revealed: *It is the policy of the facility that a resident's change in physical, medical, or psychological condition or treatment is promptly communicated to the resident, the designated resident's representative (if applicable) and the Primary Care Provider. *The charge nurse on duty at the time of the event will be responsible for immediate notification to the resident, resident representative(s) and the PCP [primary care provider] regarding the following: -c. A need to alter treatment significantly (a need to discontinue or change an existing form of treatment due to adverse consequences, or to commence a new form of treatment).

Based on observation, interview, record review, and policy review, the provider failed to follow their policies for controlled medications (medications with risk for abuse, addiction, and potential theft) to ensure accurate counts and complete documentation of those medications in one of one medication cart and one of one refrigerators that contained controlled medications. Findings include: 1. Observation and interview with licensed practical nurse (LPN) F on 5/6/25 at 9:40 a.m. of a binder labeled Narcotic Binder on the east medication cart revealed: *A form in the front of the binder was labeled Control E-Kit [emergency kit for controlled medications] Shift Count. *The area for the month and year o that form was blank. -LPN F verified that form was for May 2025. *That Control E-Kit Shift Count form had six medications identified on it: -Tramadol [ a pain medication] 50 mg [milligrams] PO [by mouth]. -Oxycodone [a pain medication] 2.5 mg tab PO. -Morphine [a pain medication] 10 mg/0.5 ml [milliliters] PO/SL [sublingual] . -Hydrocodone/APAP [a pain medication] 5/325 mg PO. -Lorazepam[an antianxiety medication] 0.5 mg PO . -Lorazepam 2 mg/ml IM/IV [intermuscular/intravenous]. *That Control E-Kit Shift Count form had locations to document for each day of the month for both day and night counts that included: -The number of pills or syringes counted. -The initials of the persons that counted those medications with an indicator that there was to be two persons. *The Controlled E-Kit Shift Count form documentation indicated: -On 5/1/25 there was no second staff's initials for the day count and no count or initials for the night count. -On 5/2/25 no documentation was completed. -On 5/3/25 there was no count or initials for the day count, and no second staff's initials for the night count. -5/5/25 there was one missing initial for the night count. *Another form labeled Narcotic E-Kit Numbers was in the narcotic binder. -That form had areas for each day to document two staff's signatures for the First Shift and Second Shift and a number on the E-Kit lock tags for the Gray Cupboard E-Kit, the East Narc [narcotic] Drawer E-Kit, and the Fridge E-Kit. -On 5/2/25 there were no numbers documented in the three columns and the second shift only had one signature documented. 2. Interview on 5/6/25 at 9:50 a.m. with LPN F revealed: *The Controlled E-Kit shift count form was how the staff documented the counts emergency supply of controlled medications. *The controlled medications were to be counted at the change of shift by the oncoming and outgoing staff to verify the medications counts were accurate. *Each one of the three different emergency medication kits were sealed with a numbered tag. *The Narcotic E-Kit Form was where the tag numbers on each kit were documented to be sure no had broken the tag and accessed the kit without prior authorization from the pharmacy to remove a medication for administration to a resident. *The numbers on the identified tags were to be checked and documented at change of shift by two staff members on the Narcotic E-Kit Numbers form. *LPN F verified there was incomplete documentation on both forms for May 2025. *LPN F stated the controlled substances prescribed to individual resident were sent from pharmacy in a bubble pack medication card system and stored in a locked drawer in each medication cart. *The individual residents'controlled medications were counted at each change of shift but there was no form to document that count had occurred for those medications. 3. Interview on 5/6/25 at 10:22 a.m. with LPN I revealed: *The controlled medication counts were to be completed on the E-Kits and for each resident that was prescribed a controlled medication at the change of each shift by two nursing staff members authorized to administer medications. *The E-Kit controlled substances were stored in the east medication cart within the locked drawer and in a locked compartment in the refrigerator. *The signatures on the forms were to indicate that the controlled medication counts were completed and accurate and the tags were checked and found to be in place and the tag numbers were accurate. *There was no location to document the individual residents' controlled medications counts had been completed or who completed those counts to verify the accuracy of the amount of those medications present. 4. Review of April 2025 Control E-Kit Shift Count form revealed: *The day counts did not have documentation of the second staff member's initials ten times. *The night counts did not have documentation of the second staff member's initials nine times. Review of March 2025 Control E-Kit Shift Count form revealed: *The day count was missing documentation of the count on 3/17/25 and did not have documentation of the second staff member's initials nine times. *The night counts did not have documentation of the second staff member's initials seven times. Review of February 2025 Control E-Kit Shift Count revealed: *The day count was missing documentation of the count two times and did not have documentation of the second staff member's initials seven times. *The night count was missing documentation of the count two times and did not have documentation of the second staff member's initials five times. Review of January 2025 Control E-Kit Shift Count revealed: *The day count was missing documentation of the count five times and did not have documentation of the second staff member's initials eleven times. *The night count was missing documentation of the count three times and did not have documentation of the second staff member's initials thirteen times. Review of December 2024 Control E-Kit Shift Count revealed: *The day count was missing documentation of the count seven times and did not have documentation of the second staff member's initials nine times. *The night count was missing documentation of the count five times and did not have documentation of the second staff member's initials twelve times. 5. Review of April 2025 Narcotic E-Kit Numbers revealed: *On 4/3/25 no tag numbers were documented, and one signature was documented for the first shift and the second shift. *On 4/29/25 no tag numbers were documented. *Only one signature was documented for either the first or the second shift seven. 6. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *It was her expectation that all controlled medications were to be counted by two licensed staff members or certified medication aides (CMA) at every change of shift. *The counts were to be documented on the Control E-Kit Shift Count in the front of the narcotic binder. *The signatures on the document would indicate the controlled medication counts had been completed and the counts were accurate. *The tag numbers were to be verified and documented as accurate by two staff members, and she expected that to have been completed at the same time the controlled medications were counted. *She was aware there was no location to document the counts were completed and by which staff members for the residents' controlled medications. -She did not feel that there needed to be a form to document that. The staff were to complete the counts at the change of shifts and were to notify her if there was a discrepancy. *She verified without the documentation of the counts of the residents' controlled medications she would not be able to determine who or when the last count had been completed. *She was not aware of the frequency of missing or incomplete documentation on the Control E-Kit Shift Count forms or the Narcotic E-Kit tag numbers. 7. Review of the provider's 11/5/15 Storage of Facility E-Kit Documentation policy revealed Emergency controlled substances [medications] must be stored in a double lock system and verified shift to shift. Review of the provider's 12/1/15 Emergency Kits policy revealed A Control E-Kit Shift Count will be used by facility staff to keep track and use for counting controlled case medications shift to shift on a monthly basis. Review of the provider's undated Narcotic Count policy revealed: *Narcotics [controlled medications] will be counted by licensed nursing personnel to assure they are properly accounted for at the beginning and ending of each shift. *The on-going and off-going nurse at shift change will perform a physical count of the narcotic drawer. *Each nurse will sign the narcotic count sheet when the count is completed. Review of the provider's November 2017 Controlled Medication Storage policy revealed: *At each shift change or when keys are surrendered, a physical inventory of all Schedule II, including refrigerated items, is conducted by two licensed nurses or per state regulation and is documented on the controlled substances accountability record or verification of controlled substances count report. *Current controlled medication accountability records are kept in the MAR [medication administration record] or narcotic book.

Based on observation, interview, record review, and policy review the provider failed to ensure: *Medications with shortened expiration dates [medications that, after opening, expire prior to the manufacturer's expiration date] were labeled properly and disposed of after having outdated for three sampled residents (3, 14, and 79) and one random resident (24) in two of two medication carts and one of one treatment cart. *Daily temperatures of one of one refrigerator containing medications were monitored and document according to the provider's policy for twelve of twelve months reviewed in 2024 and two of two months (March and April) in 2025. *Daily temperatures of one of one area used to store medications was monitored and documented according to the provider's policy. *Medication labels matched the current physician orders for four of four sampled residents (15, 19, 22, 25) according to the provider's policy. Findings include: 1. Observation and interview on 5/6/25 at 7:30 a.m. with licensed practical nurse (LPN) during medication pass revealed: *Resident 19's gabapentin (medication for seizures or nerve pain) pharmacy medication label read 400 mg (milligrams) give 1 cap three times daily and her order on the medication administration record (MAR) read gabapentin 100mg, give 400 mg three times daily. *Resident 15's midodrine (medication for low blood pressure) pharmacy medication label read give 10 mg three times per day and her MAR stated 5 mg give two tabs daily with meals. *Resident 15's duloxetine (medication for depression) pharmacy medication label read give 60 mg give one cap daily and her MAR stated 30 mg, give 2 caps in the morning. 2. Observation and interview on 5/6/25 at 9:50 a.m. of the medication carts with LPN F revealed: *Resident 22's Lantus (long-acting insulin) insulin label with the directions for administration was covered by the opened and expired label and was not readable. *Resident 79's Trelegy Ellipta inhaler (medication to treat breathing problems) was opened. -The box had a sticker that had a location to document the medications opened date and expirations date, but neither the opened date nor the expired date were written on the sticker. *Resident 3's Trelegy Ellipta inhaler was opened. -The box had a sticker that had a location to document the medications opened date and expirations date, but neither the opened date nor the expired date were written on the sticker. *Resident 79's Ventolin HFA (fast acting medication for breathing problems) inhaler was opened and was not marked with the date it was opened. *Resident 24's Latanoprost (medication used to treat increased pressure in the eye) eye drops were marked as opened on 3/21/25 and had an expiration date identified as 5/2/25. *Resident 14's Latanoprost eye drops were opened and dated on 3/20/25 with an expiration date of 5/1/25. *LPN F was not aware there were medications with shortened expiration dates after they were opened or removed from the refrigerator other than insulin. *She verified the Latanoprost eye drops for residents 14 and 24 were outdated and remained in the medication cart for potential use. *There was a reference in the drawer of the medication cart that was identified as MEDICATIONS WITH SHORTENED EXPIRATION DATES. 3. Review of the undated Medication with Shortened Expiration Dates reference revealed: *Ventolin HFA inhalers were to be discarded 12 months after the removal from its protective pouch. *Latanoprost eye drops were to be discarded six weeks after opening. *Trelegy Ellipta inhalers were to be discarded six weeks after opening the foil tray. 4. Observation, interview, and record review on 5/6/25 at 10:21 a.m. in the room located behind the nurses' station with LPN I revealed: *LPN I identified the black locked refrigerator in the room as the refrigerator that was used to store residents' medications. *She stated the temperature inside the refrigerator was measured and documented daily by the night nurse. -She verified there were dates with missing medication refrigerator temperatures for 2024 and 2025 on the documentation sheets. *She was aware there were medications with shortened expiration dates after opening and was aware of the reference in the medication cart to help identify those medications. 5. Review of the documentation of the medication refrigerator temperatures for 2024 revealed: *January had three days without a documented temperature. *February had five days without a documented temperature. *March had six days without a documented temperature. *April had nine days without a documented temperature. *May had five days without a documented temperature. *June had seven days without a documented temperature. *July had six days without a documented temperature. *August had one day without a documented temperature. *September had six days without a documented temperature. *October had one day without a documented temperature. *November had five days without a documented temperature. *December had six days without a documented temperature. Review of the documentation of the medication refrigerator temperature for 2025 revealed: *March had one day without a documented temperature. *April had six days of documented temperatures that were out of the acceptable temperature range of 36 to 46 degrees Fahrenheit. -Five of those days the temperature of the medication refrigerator was 34 degrees Fahrenheit. -One day the temperature of the medication refrigerator was 32 degrees Fahrenheit. 6. Observation and interview on 5/6/25 at 2:33 p.m. of the treatment cart with LPN I revealed: *She would be unable to determine what the expiration date of a medication with a shortened expiration date was without the date documented that the medication was opened. *There was a container of Silver Sulfadiazine cream that was labeled as stock supply and dated as opened on 2/4/24. *Resident 25's Tresiba (long-acting insulin) injectable pen's pharmacy label indicated he was to receive 100 units daily and his MAR indicated he was to receive 90 units daily. -There was no label or indication on the Tresiba pen that the dose of the medication had been changed. *She was aware there were labels on oral medications and insulins that did not match the orders in the MAR and there was no indication the order had been changed on those medications' labels. *She stated that pharmacy did not replace the labels on medications when the orders changed. *The facility utilized certified medication aides to administer medications. *She agreed she could not complete her checks for the correct medication doses when the labels and the MAR did not match but she would administer medications according to the instructions in the MAR. 7. Interview on 5/7/25 at 2:15 p.m. with director of nursing (DON) C revealed: *The did not have a room identified as a medication room. *Medications were stored in the locked cabinets and refrigerator located behind the nurses' station desk if they were not stored in the medication cart. *She stated the facility did not have a policy or documentation log for room temperatures where medications were stored. Interview on 5/8/25 at 11:30 a.m. with DON C revealed: *She was aware there were medications with shortened expiration dates after being opened or removed from refrigeration. *It was her expectation that all medications were dated with the date they were opened. *If there was an ordered medication dose change staff was supposed to apply a label on the medication container that indicated there had been a dose change. *She agreed the MAR and the pharmacy label not matching increased the risk for a medication error especially with the use of CMAs that may not be able to identify medications and could not calculate dosages. *After review of the documentation for the medication refrigerator temperatures she verified there was missing documentation of temperatures and there were temperatures in April that were outside of the acceptable range. *She was not aware there was documentation and temperatures outside of the acceptable range. *The temperature of the area where the medications were stored was not being monitored and documented. *She agreed the temperature of the room could not be verified as within an acceptable range if the temperature was not monitored and documented. 8. Review of the provider's 6/1/24 Medication: General Rules policy revealed: *Only pharmacy can replace labels on medications. For order changes involving time changes or frequency changes, 'order change, see chart' labels may be used until the pharmacy replaces the label on medication. *Medications will be given adhering to the 'Six Rights'. Right DRUG, Right RESIDENT, Right ROUTE, Right DOSE, Right MED FORM and Right TIME. *The person administering the medication will also be responsible for Checking expiration dates. Review of the provider's 2/1/25 Medication Storage in the Facility policy revealed: *Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are [to be] immediately removed from inventory, disposed of according to procedures for medication disposal, and reordered from the pharmacy, if a current order exists. *All medications are maintained within the temperature ranges noted in the United States Pharmacopeia (USP) and by the Center for Disease Control (CDC). -1) Room Temperature 59 [degrees] F [Fahrenheit] to 77 [degrees] F (15 [degrees] C [Celsius] to 25 [degrees] C. -2) Controlled Room Temperature (the temperature maintained thermostatically) 68 [degrees] F to 77 [degrees] F (20 [degrees] C to 25 [degrees] C). -3) Refrigerated 36 [degrees] F to 46 [degrees] F (2 [degrees] C to 8 [degrees] C) with a thermometer to allow temperature monitoring. *The Facility should maintain a temperature log in the storage area to record temperatures at least once a day. *Medications in multi-dose packaging will have a beyond-use dating of 60 days or manufacturer's expiration date if less than 60 days. *The nurse will check the expiration date of each medication before administering it. *No expired medication will be administered to a resident. *All expired medications will be removed from the active supply and destroyed in the facility, regardless of [the] amount remaining.

Based on interview, and record review, the provider failed to ensure that one of one designated infection preventionist (director of nursing C) had completed specialized training in infection prevention and control. Findings include: 1. Interview on 5/8/25 at 9:34 a.m. with director of nursing (DON) C revealed: *She was the designated infection preventionist for the facility. *She was haired on 10/7/21. *She had started the Center for Disease Control's (CDC) specialized infection prevention and control training, Nursing Home Infection Preventionist Training course, in October 2022. *She did not have a certification of completion for the Nursing Home infection Preventionist Training Course. *She was not aware that she had not completed the entire course. Record review of DON C's certificates of completion of modules of the CDC's Nursing Home Infection Preventionist Training Course revealed: *Module 1- Infection Prevention and Control Program with a completion date of 10/5/22. *Module 2- The Infection Preventionist with a completion date of 10/5/22. *Module 3- Integrating Infection Prevention and Control into the Quality Assurance Performance Improvement Program with a completion date of 10/5/22. *Module 4- Infection Surveillance with a completion date of 10/5/22. *Module 5- Outbreaks with a completion date of 10/5/22. *DON C had not completed 18 of the 23 modules required for completion of that course.

Based on interview, policy review, and record review, the provider failed to implement an effective antibiotic stewardship program according to their policy related to: *Ensuring residents' symptoms were present and documented prior to contacting their physicians related to potential infection. *Reviewing infections and antibiotics for possible trends. *Completing and annual summary of antibiotic use in the facility and reporting that to the QAPI committee. *Having an antibiogram (a table that shows which antibiotics are most likely to be effective against specific bacteria) done every 18-24 months to guide development or revision of antibiotic use protocols. *Following up annually with physicians regarding antibiotic use for residents. Findings include: 1. Interview on 5/8/25 at 9:34 a.m. with director of nursing (DON) C regarding the facilities antibiotic stewardship program and policy revealed: *She was the infection preventionist for the facility and was in charge of the antibiotic stewardship program. *The facility used a situation-background-assessment-recommendation (SBAR) form that was based off McGeer criteria for infection surveillance and monitoring. *The SBAR form was used for suspected respiratory, urinary, and soft tissue infections of the residents. *DON C stated the facility was not 100% compliant with the use of the SBAR form when a resident had symptoms of urinary tract infections because she felt they [the staff] know when a resident had a change in their health status. *When asked what not 100% compliant meant she stated the facility was noncompliant almost always. *She stated if the staff waited for all the symptoms required with the criteria on the SBAR form to obtain a urinalysis (UA) order from the physician then the resident would have been more ill than if the urinary tract infection (UTI) was identified earlier. *DON C stated she had discussed this with medical director N and at times medical director N would refuse the order request for a UA by stating the resident required more symptoms for a UA to be ordered. *DON C was responsible for ensuring the facility received all lab and other diagnostic testing results that had been ordered at the facility and following up with the resident primary physician regarding the results. *She tracked the facility's use of antibiotic by printing out a report that was provided by the facility's contracted pharmacy that listed the antibiotics used by residents for the dates selected when the report was run. -That report included the resident name, the name of the antibiotic or antifungal medication with the instructions for use, when the medication was dispensed, when the medication was started, and the number of days the medication was administered. -That report did not include the diagnosis or indication for use of the medication, if the antibiotic was determined appropriate or necessary upon the receipt of the results of the diagnostic testing had been received. *She did not monitor infections related to the resident's location within the facility to identify potential clusters of residents with infections. *The only tracking she completed related to illness and antibiotic use was reviewing the monthly antibiotic use that was documented in the report provided by the facilities contracted pharmacy during the monthly Quality Assurance and Performance Improvement (QAPI) meeting after she removed the antibiotics that were taken by residents for the prevention of infections from the report. Continued interview and review of the provider's 3/22/18 Antibiotic Stewardship Program policy with DON C revealed: *She had not been following the policy in the following areas: -She talked about the antibiotic use monthly but did not complete an annual summary. -There were no antibiotic stewardship meetings held as the facility policy indicated. -She did not complete random audits for resident's antibiotic use. -She did not track one outcome measure associated with antibiotic use monthly. -The facility did not have an antibiogram to review. -She did not follow up with the prescribing physicians annually regarding their use of antibiotics for the residents. Continued interview on 5/8/25 at 11:30 a.m. with DON C revealed she was not aware that the facilities infection rate for UTIs for long-stay residents was above the state and national average according to the facilities reported quality measures. 2. Review of the providers 3/22/18 Antibiotic Stewardship Program policy revealed: *It is the policy of this facility to implement an Antibiotic Stewardship Program as part of the facility's overall infection prevention and control program. The purpose of the program is to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. *The program includes antibiotic use protocols and a system to monitor antibiotic use. -a. Antibiotic use protocols: --i. Nursing stall shall assess residents who are suspected to have an infection and complete a Medical Care Referral Form prior to notifying the physician. --ii. Laboratory testing shall be in accordance with current standards of practice. --iii. The facility uses the (CDC's [Center for Disease Control] NHSN [National Healthcare Safety Network] Surveillance Definitions) to define infections. --iv. The Loeb Minimum Criteria are used to determine whether or not to treat an infection with antibiotics. *Random audits of antibiotic prescriptions shall be performed to verify completeness and appropriateness (process measure). *At least one outcome measure associated with antibiotic use will be tracked monthly, as prioritized from the facility's infection control risk assessment and other infection surveillance data. Examples include: tracking C. difficile infections, antibiotic resistance, or adverse drug events related to antibiotic use. *At least annually, feedback shall be provided on the facility's antibiotic use data in the form of a written report shared with administration, medical and nursing staff, and the QAA [quality assessment and assurance] Committee. *A review of the facility's antibiogram will be performed every 18-24 months to guide development or revision of antibiotic use protocols or prescribing practices. *At least annually, each attending physician shall be provided feedback on his/her antibiotic use data in the form of a written report. *Documentation related to the program maintained by the Infection Preventionist, including but not limited to: -a. Action plans and/or work plans associated with the program. -b. Assessment forms. -c. Antibiotic use protocols/algorithms. -d. Data collection forms for antibiotic use, process, and outcome measures. -e. Antibiotic stewardship meeting minutes. -f. Feedback reports. -g. Records related to education of staff, residents, and families. -h. Annual reports. Review of the provider's 10/12/17 Infection Reporting policy revealed The Infection Preventionist will report findings of surveillance activities, including at a minimum incident rates and types of infections, to the QAA committee, physicians, and other appropriate staff. 3. Review of the provider's March 2025 Facility Assessment revealed: *We track and trend infections. *We have monthly infection control meetings and quarterly QAPI meetings with our medical director, consulting pharmacist and Leadership team to discuss any issues. *We have developed an Antibiotic Stewardship Policy and Procedure and have educated our staff, medical providers, pharmacy consultant, residents and their families.

Based on observation, interview, record review, and policy review, the provider failed to assess two of two sampled residents (7 and 14) who had a diagnosis of post-traumatic stress disorder (PTSD) for their potential needs and interventions relating to trauma. Findings include: 1. Observation on 5/5/25 at 12:59 p.m. of resident 12's room revealed: *He had a sign on his door that read, Do Not Disturb. *He had military decor in his room. Review of resident 12's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *His diagnoses included anxiety disorder, major depressive disorder, hallucinations, post-traumatic stress disorder (PTSD), and vascular dementia with psychotic disturbance, mood disturbance, and anxiety. *He was a military veteran. *He had a history of suicidal thoughts, chemical dependency, visual hallucinations that were distressing to him. *He had a history of chemical dependency. *His care plan did not address behaviors, and triggers, or interventions related to his diagnoses. *There was an incident on 4/10/25 where resident 14 struck [resident 20] in the left cheek with a closed fist. *It was documented in the provider's investigation, Resident 14 stated that resident 20 had opened his door and peeked in and then shut the door. [Resident 14] went out and asked [resident 20] what he wanted. [Resident 20] did not answer [resident 14] and this made him angry so he punched him. 2. Interview on 5/6/25 at 4:22 p.m. with director of nursing (DON) C revealed the provider did not have a policy for addressing residents with a history of trauma or trauma informed care. 3. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I revealed: *Resident 14 had PTSD related to his military service. *She indicated resident 14 could get worked up at times when he thought people were stealing from him. *She was aware of an incident when resident 14 struck another resident in the face with a closed fist. *She indicated staff would talk to him after the incidents or times when he was worked up and he would calm. 4. Interview on 5/8/25 at 8:59 a.m. with LPN/social service designee (SSD) D revealed: *There were no assessments that were being completed for residents related to trauma informed care. -She asked about trauma on a resident's admission to the facility and made note. --There was no documentation able to be located regarding that in resident 14's EMR. *Resident 14's care plan had a focus area of sees mental health provider from [another town] for mental health needs with an intervention that stated, Attend appointments as scheduled and PRN [as needed]. *She was unable to locate documentation of resident 14 having attended appointments with the identified mental health provider. *She stated behaviors, triggers, and interventions for the behaviors should have been identified in the resident's care plan for staff to be able to meet their needs. *She verified there were no behaviors or interventions related to resident 14's PTSD, anxiety, or hallucination diagnoses in his care plan. 5. Interview on 5/8/25 at 11:53 a.m. with director of nursing (DON) C revealed: *Resident 12 had not seen a mental health provider since early 2024. *He had not and was not seeing a mental health provider on a scheduled or as needed basis as his care plan indicated. 45683 6. Observation and interview on 5/5/25 at 4:07 p.m. with resident 7 in his room revealed: *He was sitting in his recliner. *He was not sure if he had attended any counseling sessions. *His biggest concern at that time was the food he was being served. Review of resident 7's EMR revealed: *He was admitted on [DATE]. *His 3/31/25 BIMS assessment score was 11, which indicated he was moderately cognitively impaired. *His diagnoses included: -Post-traumatic stress disorder, unspecified. -Delirium due to known physiological condition. -Personal history of other mental and behavioral disorder. -Major depressive disorder, recurrent, severe with psychotic symptoms. Review of resident 24's 4/1/25 care plan revealed: *He had a focus area of, an ADL [activities of daily living] self-care performance deficit r/t [related to] delirium/depression/PTSD. *A goal to maintain current level of function through the next review. *No interventions to suggest how to address any issues that may arise from his PTSD. 7. Interview on 5/6/25 at 4:36 p.m. with LPN/SSD D regarding resident 7's PTSD diagnoses revealed: *If a resident had a PTSD diagnosis, they were set up with an appointment with behavioral health services. *PTSD was entered into the resident's care plan. *She was not aware of any interventions that would directly address a resident's PTSD. *She confirmed she had not completed a trauma-informed care assessment for resident 7. 8. Review of the provider's March 2025 Facility Assessment policy revealed: *Manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individuals with depression, trauma/PTSD, other psychiatric diagnoses, intellectual or developmental disabilities. *Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. Make sure staff caring for the resident have this information and are aware of preferences. A policy for trauma informed care was requested on 5/7/25 from administrator B but one was not provided by the end of the survey on 5/8/25.

Based on observation, record review, interview, and policy review, the provider failed to ensure: *Proper infection control practices had been followed for cleaning and storage for two of two sampled residents (9 and 25) who required respiratory devices (Continuous Positive Airway Pressure (CPAP) machine (a device that uses air pressure to keep breathing airways open) and a nebulizer), had appropriate cleaning and storage. *One of one sampled resident (25) receiving oxygen at night had a current physician order for use of a CPAP machine, and was care planned. Findings include: 1. Observation and interview on 5/5/25 at 1:39 p.m. and 1:57 p.m. with resident 9 in his room revealed: *There was a nebulizer machine (a machine that converts liquid medication into an inhalable mist) on the floor to the left of his recliner. *He sat in his recliner and held his nebulizer mask to his face to administer the medication. *He reached down and shut off that nebulizer machine, then turned it back on when the surveyor stated she would return. -He kept the nebulizer machine on the floor, so it was easy for him to reach, and it was quieter there. *He stated that the nurse would put the medication in the nebulizer mask, and he would administer his nebulizer treatment. *He hung the nebulizer mask from the tack on his calendar between the four nebulizer treatments he received each day. -He was unsure when the nebulizer mask would need to be cleaned, but thought the nurse did that once a day. Observation and interview on 5/6/25 at 11:20 a.m. with resident 9 in his room during the administration of a nebulizer treatment by licensed practical nurse (LPN) F revealed: *After the completion of the nebulizer administration, while LPN F rinsed the nebulizer mask out in the sink, resident 9 stated he usually did not rinse out his mask after he completed his nebulizer treatments, and he would just hang it on here as he pointed to a tack on the wall beside his recliner. Review of resident 9's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included chronic obstructive pulmonary disease, cancer of his right lung, pulmonary embolism, and bronchitis. *He had a Brief Interview of Mental Status (BIMS) assessment score of 11, which indicated he was moderately cognitively impaired. *A 5/1/25 physician's order for Ipratropium-Albuterol Inhalation Solution [an inhaled medication to ease breathing by opening the airway in the lungs] 0.5-2.5 (3) MG/3ML [milliliter] 1 vial inhale orally four times a day for bronchitis for 5 Days. *A 5/6/25 physician's order for Ipratropium-Albuterol Inhalation Solution .0.5-2.5 (3) MG/3ML 1 vial inhale orally every 4 hours as needed for bronchitis. *There was no documentation in his EMR that his nebulizer mask and tubing were to have been cleaned, by whom, or how often that should have been completed. 51472 2. Observation and interview on 5/5/25 at 1:44 p.m. with resident 25 in his room revealed: *He was lying in bed with his eyes open and a CPAP (a machine that uses air pressure to keep breathing airways open) on. *He stated he had worn his CPAP for several years and he brought it into the facility from home when he was admitted . Review of resident 25's EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was 15, which indicated he was cognitively intact. *He had diagnoses of other forms of dyspnea (difficulty breathing), and obstructive sleep apnea (intermittent airflow blockage during sleep). *There was no physician's order for the use of his CPAP in his EMR. *There was no documentation in his EMR that indicated his CPAP mask and tubing was being cleaned. *His initial baseline care plan did not indicate the use of the CPAP. *His current care plan did not address his respiratory diagnoses or the use of his CPAP machine. Follow up interview on 5/7/25 at 9:40 a.m. with resident 25 in his room revealed: *The nurses would empty and refill his CPAP reservoir with distilled water every night and as needed. *No one had cleaned his CPAP tubing or mask that he was aware of since admission. 3. Interview on 5/7/25 at 9:48 a.m. with licensed practical nurse (LPN) I revealed: *Nebulizer delivery devices were to be replaced weekly on Fridays by the night nurse. *The replacement of the devices was to be charted in the resident's medication administration record (MAR). *Nebulizer deliver devices were to be rinsed out and cleaned after each use by running them under tap water. *The mask and tubing of the CPAP machine were to be cleaned weekly by the night nurse with a vinegar and water solution. *The cleaning of respiratory devices were to be charted in the resident's MAR. *She was unsure of the exact process used for the cleaning of the CPAP mask and tubing by nights since resident 25 wore his CPAP mask at night. 4. Interview on 5/8/25 at 11:30 a.m. with director of nursing (DON) C revealed: *Nebulizer delivery devices were to be replaced weekly and that was to be documented in the resident's MAR. *It was her expectation the nebulizer deliver devices were to be disassembled, rinsed out with tap water, and left to dry on a towel after every use for infection control purposes. *The nebulizer machine was to be stored in a location such as on a bedside table not in the floor. *The mask and the tubing of the CPAP machine was to be cleaned weekly with a vinegar and water mixture by the night nurse. *The cleaning of the CPAP machine was to be documented in the resident's MAR. *She was not aware there was not a physician's order for resident 25's CPAP use. *She was not aware the cleaning of the CPAP tubing and mask was not being documented in resident 12's MAR. *She was not aware resident 12's care plan did not address his CPAP use. *She would expect there to be a physician's order for the CPAP, and the cleaning of the CPAP was documented in the EMR. *She agreed the some of the facility policies did not reflect the provider's processes and practices, and some of the policies, including those related to nebulizers, were not consistent with each other. 5. Review of the provider's June 2023 Cleaning of Durable Medical and Therapy Equipment policy revealed: *CPAP: 1) Clean tubing and mask with warm water and soap, rinse well, and hang to dry daily. *Nebulizer Treatments: Cleaning must be completed after each use. -1) Take nebulizer apart by removing tubing and setting aside. -2) Remove mouthpiece or mask and medicine cup from the top, -3) Rinse with sterile or distilled water and place on clean dry surface (be sure to use a barrier such as a paper towel) to dry after each use. -4) Let pieces air dry. Review of the provider's January 2018 Specific Medication Administration Procedures revealed: *When treatment is complete, turn off nebulizer and disconnect T-piece, mouthpiece and medication cup. *Rinse and disinfect the nebulizer equipment according to manufacturer's recommendations or: -1) Wash pieces (except tubing) with warm, soapy water daily. Rinse with hot water. Allow to air dry completely on paper towel. -2) [Once a week/three times a week/daily], disinfect the equipment by: --a. [Using a Microsteam bag in the microwave for time recommended on bag], OR --b. [Soaking for 5 minutes in 70% isopropyl alcohol and then rinse with sterile water]. *When equipment is completely dry, store in a plastic bag with the resident's name and the date on it. *Change equipment and tubing every [seven days].

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (1) by staff who did not observe the resident take her medications after preparting them, which enabled the resident to not ingest multiple doses, hide those medications in her room, and then ingest those medications all at once as an act of self-harm. Findings include: 1. Review of the providers submitted SD DOH FRI on 8/22/24 revealed: *On 8/19/24 resident 1 was transferred from the facility to the hospital for hypotension (low blood pressure) and profound weakness. *Resident was admitted to the hospital. *On 8/20/24 the ultrasound revealed a lesion on her liver and she was in liver failure. *On 8/21/24 resident 1 told hospital staff that she consumed several Tylenol on 8/17/24 in order to end her life. *Resident stated she had taken the Tylenol from her medication cup the nurses gave her and put them in a plastic container which she hid in her dressser drawer. 2. Review of resident 1's electronic medical record (EMR) revealed: *There was a 10/11/23 order for two tablets of Tylenol Extra Strength 500 milligrams (mg) to be given at bedtime. *There was no order for her to self-administer any of her medications. *Her Brief Interview for Mental Status (BIMS) score was 15 which indicated she was cognitively intact. *Her care plan stated she was seen by mental health professionals on a scheduled basis. *She was diagnosed with depression, anxiety, bipolar disorder, adult failure to thrive, and drug-induced subacute dyskinesia (a movement disorder caused by certain medications that can lead to involuntary and abnormal movements). *She required supervision/touching assistance from the staff when eating. *The staff were to monitor her for signs and symptoms of dysphagia (difficulties swallowing). *There was no documentation within the progress notes provided by nurses that the resident was self-administering her medications. 3. Record review of resident 1's mental health evaluations from 9/8/23-7/16/24 revealed: *She seen a mental health professional once a month. *She declined psychiatric help at all her visits. *She accepted psychiatric medications. *Her severe weight loss was noted and addressed which she said was intentional. 4. Observation and interview on 9/10/24 at 11:19 a.m. with resident 1 in her room revealed: *She was sitting in her recliner watching TV and had her call light within reach. *Her left eye was bloodshot and she appeared thin. *She was pleasant and open about her incident on 8/19/24. *When asked how she was doing she stated, I am very depressed. *She stated that before the incident: -The nurses would leave her Tylenol on her bedside table and leave the room. -She would put the Tylenol in a plastic container and hide it in her dresser drawer. -She was unsure how many Tylenol tablets she had saved. - She stated, I just did not want to be here anymore. *She stated after the incident the nurses would wait for her to take her medications before leaving the room. 5. Interview on 9/10/24 at 3:15 p.m. with certified nursing assistant (CNA) F regarding resident 1 revealed: *She has made excuses to get out of meals, activities, and bathing. *She consistently has refused breakfast and has only ordered a sandwhich and a pop for evening meals. *She has lost a considerable amount of weight, but she has refused to believe the numbers on the scale. 6. Interview on 9/10/24 at 5:05 p.m. with CNA's D and E regarding resident 1 revealed: *They had not seen family or friends visit her. *She had seemed very depressed, isolated herself in her room, and would barely eat. *She used to be independent in her room before her 8/19/24 incident and she now needed one staff person to assist her to complete her activities of daily living (ADLs). *She had refused to participate in activities. 7. Interview on 9/11/24 at 8:05 a.m. with director of nursing (DON) A regarding resident 1 revealed: *She believed the staff had failed her because they trusted her to take her medications by herself prior to the 8/19/24 incident *The only education that was provided regarding the resident's incident was during the informal meetings held and documented on 8/21/24 and 8/22/24 that she had with only select staff members. *She stated she would like to audit/monitor the nurses during medication administration in the future. *She had not done any medication audits or monitoring since the resident's 8/19/24 incident. *She stated the resident used to participate more in activities and meals when she stayed at the facility before, compared to now. 8. Review of the provider's 11/17/07 Medication Administration of oral medications policy revealed: *To administer oral medications in an organized, accurate, and safe manner. *10. Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. Use caution with residents who have difficulty with swallowing. *12. Follow all medication with 4 to 8 ounces (120-240mL) of water unless otherwise ordered or specified by manufacturer.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI) review, observation, record review, interview, and policy review, the provider failed to follow their medications administration policy and correctly administer medication to one of one sampled resident (1) who required hospitalization after a self-harm incident. Staff were not ensuring her medications were consumed during the administration process. Findings include: 1.Review of the provider's submitted SD DOH FRI on 8/22/24 revealed: *On 8/19/24 resident 1 was transferred from the facility to the hospital for hypotension (low blood pressure) and profound weakness. *Resident was admitted to the hospital. *On 8/20/24 an ultrasound revealed a lesion on her liver and she was in liver failure. *On 8/21/24 resident 1 told hospital staff that she had consumed several Tylenol (pain and fever-reducing medication) in order to end her life on 8/17/24. *Resident stated she had taken the Tylenol from the medication cup the nurses gave her and put them in a plastic container which she hid in her dresser drawer. 2.Review of resident 1's electronic medical record (EMR) revealed: *There was an 10/11/23 order for two tablets of Tylenol Extra Strength 500 milligrams (mg) to be given at bedtime. *There was no order for her to self-administer any of her medications. *Her Brief Interview for Mental Status (BIMS) score was 15 which indicated she was cognitively intact. *Her care plan stated she was seen by mental health professionals on a scheduled basis. *She was diagnosed with depression, anxiety, bipolar disorder, adult failure to thrive, and drug-induced subacute dyskinesia (a movement disorder caused by certain medications that can lead to involuntary and abnormal movements). *She required supervision/touching assistance from the staff when eating. *The staff were to monitor her for signs and symptoms of dysphagia (difficulties swallowing). *There was no documentation within the progress notes provided by nurses that the resident was self-administering her medications. 3.Observation and interview on 9/10/24 at 11:19 a.m. with resident 1 in her room revealed: *She was sitting in her recliner watching TV and had her call light within reach. *Her left eye was bloodshot and she appeared thin. *She stated that before her incident on 8/19/24: -The nurses would leave her Tylenol on her bedside table and leave the room. -The staff did not watch her take the medications. -When they left she would put the Tylenol in a plastic container and hide it in her dresser drawer. -She was unsure how many tablets she had saved. *She stated since after the incident the nurses now waited for her take her medications before leaving the room. 4.Interview on 9/10/24 at 1:30 p.m. with medication aide C while she was performing medication administration revealed: *There were no residents who had a self-administration order for medications. *If a resident did have a self-administration order it would have been easy to see on their electronic medical record. *She stated that after resident 1's incident on 8/19/24, director of nursing A conducted an informal meeting with her and other staff members. *The informal meeting went over the incident and how to properly administer medications to residents by ensuring the residents had taken the medication. *She was unaware if there would be any other education or meetings provided following the incident. 5. Interview on 9/10/24 at 5:05 p.m. with certified nursing assistants (CNA) D and E regarding resident 1 revealed: *They had not seen nurses leaving medications in residents' room. *They had not seen family or friends visit her. *She had seemed very depressed, isolated herself in her room, and would barely eat. *She used to be independent in her room before her 8/19/24 incident and she now needed one staff person to assist her to complete her activities of daily living (ADLs). 6.Interview on 9/11/24 at 8:05 a.m. with director of nursing (DON) A regarding resident 1 revealed: *She believed the staff had failed her because they trusted her to take her medications by herself prior to the 8/19/24 incident. *The only education that was provided was during the informal meetings held and documented on 8/21/24 and 8/22/24 that she had with only select staff members regarding resident 1's incident. *She stated she would like to audit/monitor the nurses during medication administration in the future. *She had not conducted any audits or monitored medication administration since the resident's incident. 7.Review of provider's 11/17/07 Medication Administration of oral medications policy revealed: *To administer oral medications in an organized, accurate, and safe manner. *10. Administer medication and remain with resident while medication is swallowed. Do not leave a medication in a resident's room without orders to do so along with documentation of self-administration. Use caution with residents who have difficulty with swallowing. *12. Follow all medication with 4 to 8 ounces (120-240mL) of water unless otherwise ordered or specified by manufacturer.

Based on observation, interview, record review, and policy review, the provider failed to ensure during a world wide pandemic the facility was administered and operated in a manner to ensure the safety and overall wellbeing for all twenty-six residents in the facility. Findings include. 1. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the administrator and the director of nursing (DON) had not ensured the safe management and overall well-being of all residents in the outbreak of a pandemic (COVID-19). 2. On 12/9/20 at 5:45 p.m. an Immediate Jeopardy was identified when the facility failed to ensure: *Staff and visitors were screened for signs and symptoms of COVID-19. *A dietary aide that had COVID-19 and was symptomatic did not serve meals in the main dining room to residents that had not tested positive (widespread). *A face mask worn into a COVID-19 positive room was not worn into a non-COVID-19 room (widespread). *A COVID-19 positive resident remained in isolation for 10 days, and was not walking around the facility without a mask on (widespread). *Residents were screened and assessed for all signs and symptoms related to COVID-19 (widespread). On 12/9/20 at 5:45 p.m. the immediate jeopardy findings were discussed with DON B, Administrator A, and assistant administrator for the South Dakota Department of health via telephone conference. Administrator A revealed they would began working on their plan of correction immediately. Refer to F880, findings 1, 2, 3, 4, 5, 6, and 7. 3. Interview on 12/9/20 at 1:19 p.m. with DON B revealed: *Since having a resident test positive on 11/13/20, they had not been testing residents every three to seven days. *They tested residents only when they showed symptoms related to COVID-19. *Staff did not have set days or times to be tested . *Staff were good about letting her know if they needed to be tested . *DON B was not sure if all staff had been routinely tested every three to seven days. Refer to F886, findings 1, 2, and 3.

Based on observation, interview, policy review, and reference source review, the provider failed to implement proper infection control practices for the coronavirus (COVID-19) pandemic with the potential for exposing residents and staff to serious harm including death, by failing to: *Screen staff and visitors for all signs and symptoms related to COVID-19. *All staff and residents were tested three to seven days due to their outbreak status. *Ensure three of three nursing aides (H, K, and L) and one physical therapy staff (K) disposed of face masks or stored them safely after assisting residents that were positive for COVID-19 (2, 3, 4, 5, and 6). *Ensure residents negative for COVID-19 were not exposed to a staff that had COVID-19 and was symptomatic. *Ensure the health and safety of all staff and residents. *Ensure staff who had tested positive were not: -Working while symptomatic for one of one dietary aides (D). -Working only with positive staff and positive residents. -Working in the dining room that contained residents from both memory lane and morning glory hallways. -Utilizing the same breakroom and restroom as other staff members (widespread). *Residents were screened and assessed per Centers for Disease Control and Prevention (CDC)'s recommendations (widespread). *Ensure residents remained on isolation for ten days for one of five residents (2). These failures had the potential to expose all residents, staff, and visiting essential personnel to COVID-19, a [MEDICAL CONDITION] infection that could lead to serious harm or death. NOTICE: On 12/9/20 at 5:45 p.m. an Immediate Jeopardy was identified when the facility failed to ensure: *Staff and visitors were screened for signs and symptoms of COVID-19. *A dietary aide that had COVID-19 and was symptomatic did not serve meals in the main dining room to residents that had not tested positive (widespread). *A face mask worn into a COVID-19 positive room was not worn into a non-COVID-19 room (widespread). *A COVID-19 positive resident remained in isolation for 10 days, and was not walking around the facility without a mask on (widespread). *Residents were screened and assessed for all signs and symptoms related to COVID-19 (widespread). At the above time the administrator and director of nursing (DON) B were asked for an immediate plan of correction (POC) to ensure all staff working in the facility received education and monitoring for nationally recognized infection control procedures. PLAN: On 12/10/20 at 4:40 p.m. the DON B and administrator provided the surveyor with an email that included the final written removal plan. The written removal plan was approved by the assistant administrator for the department of health on 12/10/20 at 5:53 p.m. The facility provided the following acceptable removal plan on 12/10/20: Positive COVID Staff working with Negative Residents: Provider will have positive COVID staff work only with positive COVID residents based on staff availability and logistically assigning staff to the area of the building with the most positive COVID residents through the work schedule. Infection control policy will be updated to reflect these changes. All staff will be immediately educated on the updated policy through staff meeting held on 12/10/20 as well as through communication book located at the nurses' station. Dining assistant and all other staff will be immediately re-educated on updated infection control policy regarding positive COVID staff not working with negative residents through staff meeting held on 12/10/20 as well as through communication book located at nurse's station. And all other negative COVID residents will be audited to ensure that positive COVID staff are not working with them. Director of nursing or designee will audit staff compliance to this updated policy 3 times for one week then once per week for three more weeks and once per month for 2 more months. Director of nursing will present findings at the monthly QAPI meetings for review and recommendations. N95 masks worn by staff not changed when coming out of a positive COVID19 resident room: Provider will update infection control policy regarding n95 masks removed by staff and disposed of when leaving a positive COVID-19 resident room. All staff will be immediately re-educated on the removal and disposal on N95 masks after leaving a positive COVID resident room. Staff will DON a face shield when entering a COVID positive room and DOFF when leaving. Will be given assigned face shields. Must be cleaned with Sani wipes after each use and stored in brown bag. N95 will be stored in brown bags between use and discarded after 3/12 hour shifts or 5/8 hour shifts. Education of staff of the updated policy through staff meeting held on 12/10/20 as well as through communication book located at the nurse's station. Director of Nursing or designee will audit staff usage of N95 masks 3 times per week for one week then once per week for three more weeks and monthly for two more months. Director of Nursing will present audit findings at the monthly QAPI meetings for review and recommendations. Positive COVID Residents in isolation for 10 days after testing positive for COVID 19: Provider will update infection control policy regarding the isolation of positive COVID residents to include the 10 days of isolation needed for positive COVID residents. All other positive COVID residents will be audited to ensure they are staying in isolation for 10 days after being positive. All staff will be immediately educated on the updated policy through staff meeting held on 12/10/20 as well as through communication book located at nurse's station. Director of nursing or designee will audit staff compliance to this updated policy 3 times for one week then once per week for three more weeks and once per month for 2 more months. Director of Nursing will present audit findings at the monthly QAPI meetings for review and recommendations(.) Positive staff who are asymptomatic and able to work may work with positive and/or recovered residents. Facility will create a positive staffing schedule to assign positive staff with positive residents. Positive staff will use an open available room with private bathroom to have a break in facility. When not able to assign designated staff to non covid residents facility will provide PPE to prevent further spread of COVID. Doors closed for residents that tested positive for COVID 19: Provider will update the infection control policy to reflect that doors are to remain closed or use of another acceptable barrier in place of door being closed for positive COVID residents. Resident 2 and all other positive COVID residents will be audited to ensure they are staying in isolation for 10 days after being tested positive. Staff will be immediately educated on the updated policy through staff meeting held on 12/10/20 as well as through communication book located at the nurse's station. Director of nursing or designee will audit staff compliance to this updated policy 3 times for one week then once per week for three more weeks and once per month for 2 more months. Director of Nursing will present audit findings at the monthly QAPI meetings for review and recommendations(.) Visitors Screened upon entering the building: Provider will update the infection control policy to reflect that all visitors will be screened by staff upon entering the building. Screening will be moved to the front door. Staff will be immediately educated on the updated policy through staff meeting held on 12/10/20 as well as through communication located at nurse's station. Director of nursing or designee will audit staff compliance to this updated policy 3 times for one week then once per week for three more weeks and once per month for 2 more months. Director of Nursing will present audit findings at the monthly QAPI meetings for review and recommendations(.) Failed to ensure that residents were screened Three times a day per CDC recommendations: Provider will update the infection control policy to reflect that residents are screened 3 times per day for signs and symptoms of COVID 19 by Charge Nurse or designee when the facility has an active positive COVID resident. COVID positive residents will be assessed/screened by the charge nurse. All staff will be immediately educated on the updated policy through staff meeting held on 12/10/20 as well as through communication located at nurse's station. Director of nursing or designee will audit staff compliance to this updated policy 3 times for one week then once per week for three more weeks and once per month for 2 more months. Director of Nursing will present audit findings at the monthly QAPI meetings for review and recommendations(.) An onsite visit was completed on 12/11/20 at 11:15 a.m. to verify the immediate jeopardy removal plan. Immediate jeopardy was not removed due to the following: *All staff were not immediately educated as stated in their removal plan. *A physical therapy assistant was observed exiting a positive COVID-19 resident's room, did not change or remove her N95 mask. -She did not receive the education outlined in the immediate jeopardy plan. *A positive staff working stated she used the community break room and the staff restroom. *She was unable to name all of the four negative residents that she should not be working with. *They were not going to start their monitoring plan until the following week. *They hadn't implemented the increased screenings for residents for all the signs and symptoms of COVID-19. This surveyor entered the facility on 12/11/20 at 11:15 a.m. and was appropriately screened by registered nurse (RN) E. Interview with the director of nursing (DON) B on 12/11/20 at 11:30 a.m. revealed: *Dietary aide D was not working that day. *Staff had been educated on the items on their immediate jeopardy removal plan. *They had one positive staff working in the facility, certified nursing assistant (CNA) L. -She was to take breaks in an empty resident room and use the bathroom in that room. *They provided all staff education on 12/10/20, regarding all topics. *They would start their audits/monitoring next week. *N95 masks would be stored in each staff members locker, located in the community break room. *Screening would be done by any available nurse. *COVID-19 positive residents will be screened and assessed by an registered nurse three times per day. Observation and interview on 12/11/20 at 11:40 a.m. with DON B while touring the facility revealed: *The door was open to resident 5's room. -Resident 5 was positive for COVID-19. *Physical therapy assistant (PTA) K came out of resident 5's open doorway. *PTA K came out of resident 5's room wearing an N95 mask. *She did not perform hand hygiene and walked back to the therapy room. *Asked DON B if PTA K was wearing all of her PPE in resident 5's room. -DON B stated PTA K removed it before she left the room. Further interview on 12/11/20 at 11:45 a.m. with DON B and PTA K revealed: *PTA K stated she had peeked in resident 5's room to ask the resident assessment questions. -This was to determine how much assistance was needed by therapy for various daily activities by resident 5. *PTA K said she just peeked in positive resident's room. *When asked what she wore to peek into resident 5's room, she: -Only wore her N95 mask. -Had not worn a gown, face shield, or gloves. -She was still wearing the same N95 mask that she had worn into resident 5's room. -Normally she wore full PPE into a positive COVID-19 resident's room but she was just peeking in. -Changed her N95 after working three 12-hour shifts or five 8-hour shifts. -Had not received education on 12/10/20. -Was not aware she should remove or store her N95 mask upon leaving the room of a resident that was positive for COVID-19. Observation and interview on 12/11/20 at 12:24 p.m. with DON B and CNA L revealed: *DON B revealed CNA L was currently positive with COVID-19. *CNA L came out of resident 5's room. *DON B informed CNA L that she would get her a wipe so she could clean off her face shield. *DON B walked two doors down to a three-drawer container. -Removed a couple of packets of sani-cloth wipes, walked back, and handed one to CNA L. -She then put the remaining packets of wipes in the three drawer container outside of resident 5's room. --There were not any wipes in the three-drawer container outside of resident 5's room. *CNA L wiped off her face shield and put it back on her head. *This surveyor asked CNA L where she took breaks and she replied, the break room. *This surveyor asked CNA L what bathroom she used and she replied, the staff restroom. *She said she had received education on 12/10/20. -She said the education was to clean off her faceshield. *This surveyor inquired if because she had COVID-19 there were residents she should not work with. She indicated residents that were negative. -CNA L was aware of three of the four residents that were negative. Further interview on 12/11/20 at 12:33 p.m. with DON B about the immediate jeopardy implementation plan revealed: *They had not initiated the increased screening of those residents who were COVID-19 positive. *Not all staff had received the education on 12/10/20. -She had planned to send out a mass text to alert the other staff of the education. On 12/11/20 at 12:55 p.m. the assistant administrator with the South Dakota department of health and this surveyor interviewed DON B and administrator A. The assistant administrator with the South Dakota department of health and administrator A attended by phone. This interview revealed: *DON B felt that staff peeking in an isolation room should not have to remove their N95 mask. -This surveyor stated that she was standing inside the doorway when we saw her and she had the door open. *CNA L received the education but still had not understood what she needed to do. -This surveyor clarified PTA K was standing inside the room with the door open when they had observed her on 12/11/20 at 11:40 a.m. Immediate Jeopardy was removed on 12/14/20 at 12:48 p.m. after the removal plan implementation was verified during an onsite visit by the surveyor. After removal of the Immediate Jeopardy, the scope/severity of this citation is level F. Findings include: 1a. Observation on 12/9/20 at 10:35 a.m. upon entering the facility lobby revealed: *This surveyor was let into the building by activity assistant (M) and was brought to the nurse's station which was located in the center of the main hallway of the facility. *While waiting for DON B, this surveyor was greeted by activity assistant M , registered nurse (RN)/charge nurse C, certified nursing assistant (CNA) I, and business office manager N. -This surveyor was not screened for signs or symptoms of COVID-19 or possible exposure to COVID-19. b. Interview on 12/9/20 at 11:19 a.m. with DON B revealed: *Their current outbreak in the facility started around 11/13/20 when a resident (8) started showing symptoms of COVID-19. -They tested resident 8 and he was positive. *They had four residents (3, 4, 5, and 6) in their facility that were positive with COVID-19 at the time of survey. -They have had nine residents pass away from COVID-19 since 11/13/20. *They are testing all staff twice per week. -Did not have set days to test staff, they just know to come in. *They were only testing residents that had symptoms. *She was not aware that all residents that were negative were to be testing every three to seven days during an outbreak. *They were screening all residents for temperature (temp) and oxygen (O2) saturation (sat) once per day. *Residents that were positive for COVID-19 did not have increased screenings. -Screenings were done by the CNAs. *The nurses did an assessment when they did their medication pass. *There were COVID-19 positive staff working with residents. *They had symptoms but were able to work as long as they felt well enough to work. *They had two positive staff working in the facility. *The positive staff wore an N95 mask and faceshield when working. *Dietary aide D and CNA L were positive for COVID-19 and were working at the time of the survey. *Dietary aide D was a waitress, and runner for food, she tested positive on 12/7/20. *DON was surprised to see dietary aide D scheduled, thought she was off for a couple of days. *RN C tested positive on 11/29/20 and was working at the time of survey. *From 11/30/20 to 12/4/20 they had 5 residents (2, 3, 4, 5, and 6) who tested positive. -Resident 2, was no longer on isolation on 12/9//20. *They did not count day 10 as a day of isolation. *They had four remaining negative residents (1, 7, 9, and 10). *There was not a designated COVID-19 unit. *There were two hallways: morning glory and memory lane that had resident rooms. *Morning glory had two residents positive for COVID-19 (4 and 3) and two who were negative for COVID-19 (7 and 10). *Memory lane had three residents positive for COVID-19 (2, 5, and 6) and two who were negative for COVID-19 (1 and 9). c. Observation on 12/9/20 at 12:00 p.m. of the facility's dining room and nurses station revealed: *RN C was behind the desk wearing a surgical mask, she was the charge nurse on duty. *RN C said she was suffering from brain fog from COVID-19. -She was on day eleven after testing positive for COVID-19. *There were 10 residents in their dining room eating lunch, including resident 1, 2, and 7). *They were being served their meals and drinks by dietary aide D. *She was wearing a face shield, gloves, and a surgical mask. *She was coughing under her mask, while working. *The dining room was shared by residents from both memory lane and morning glory. d. Observation on 12/9/20 at 12:15 p.m. of memory lane revealed: *Resident 2 was walking back to his room. -He was coughing, he did not have a mask on. *His room door was open, he had precaution signs still on his door. *A blue isolation gown was hanging inside the doorway. *A three-drawer container was in the hallway beside the door. e. Observation on 12/9/20 at 12:18 p.m. of dietary aide D revealed: *She was coming out of the staff break room. -There were other staff members currently in the break room. *The breakroom was located in the main hallway across from the dining room. f. Interview on 12/9/20 at 12:24 p.m. with dietary aide D revealed she: *Had tested positive for COVID-19 two days ago. *Was not feeling well and had a cough and a lot of sinus congestion. -Was coughing while serving residents. *Was surprised she was told she could come in to work today. *Served all residents in the facility. *Was to wear a surgical mask and face shield while working. *Used the same break room and restroom as the other staff members. *They tried to socially distance while in the break room. *Had a locker in the break room. This is where all the staff lockers were located. g. Observation and interview on 12/9/20 at 12:25 p.m. with nursing aide H on memory lane revealed, he: *Was currently coming out of resident 6's room. *Only changed his N95 mask after three 12-hour shifts or five 8-hour shifts. *Wore the same N95 mask to care for all residents, regardless of COVID-19 status. *Took care of residents on morning glory and memory lane. *Went to the nurses station to disinfect his goggles. h. Interview on 12/9/20 at 1:20 p.m. with dietary manager F revealed: *She had worked at the facility for many years. *She is also in charge of activities, dietary, and was also a CNA. *They had been ok with staffing levels. *As long as staff feel ok, then positive COVID-19 staff come into work. *Dietary aide D was not wearing an N95 because she is not fit tested . *She stated positive staff do not take care of negative residents. -Surveyor mentioned resident 1 was in the dining room, dietary manager F stated, well you can't keep her in her room. *When she was asked about dietary aide D working with COVID-19 and having symptoms she revealed: -She still came to work when she had COVID-19. No one told her that she did not have to work. *They were not short on dietary staff. *They usually had two dietary staff on duty. They had three dietary staff on duty during the survey, including dietary aide D and dietary manager F. -Dietary manager F was in her office completing paperwork. i. Further observation on 12/9/20 at 1:57 p.m. of nursing aides H and J revealed: *They were distributing water to the residents on memory lane and morning glory. *The water cups were on a cart that was being moved throughout the hallways. *The only PPE they were wearing was an N95 mask. *Nursing aide H went into resident 2's room, distributed water, without putting on additional PPE. -He did not change his N95 mask. j. Further interview on 12/9/20 at 4:07 p.m. with nursing aides H and J revealed: *They wore the same N95 on for the whole shift. *No one told them it should be changed after contact with a positive resident and before contact with a negative resident. 2. Review of provider's COVID-19 resident screening/assessment monitoring forms from 10/1/20 to 12/9/20 revealed: *They screened residents once per day for temperature and O2 sat. The form also included a section for symptoms. *The form had a list of residents on both memory lane and morning glory. *There were 69 days when residents would have been screened. *Only 25 forms had completed documentation. *There were 24 days of missing forms. -The other 20 days were not completely filled out. *Only 4 of the 69 days had symptoms documented. -Those symptoms included; +COVID, positive in ISO (isolation), or ISO 3. Further interview on 12/9/20 at 5:00 p.m. with DON B revealed: *CNAs completed the resident monitoring forms, and reported any symptoms to the charge nurse. *Screening was the same for both positive and negative residents. *Typically, the charge nurse looks over the resident screening forms. *Charge nurse made the determination as to when a resident came off of isolation. *Staff did not change their N95 mask after caring for positive residents. 4. Review of provider's 11/9/20, COVID-19 Prevention and Control Guidance Policy and Procedure revealed: *Any resident showing symptoms will be quarantined and vitals taken each shift each day to assess for worsening condition. *Screening residents for signs and symptoms of COVID-19: -1. Residents are to be screening daily. -2. This will consist of Temperature and O2 sats. Will also monitor for new coughs and shortness of breath. *Assessing residents for worsening symptoms of COVID-19 that have tested positive: 1. Residents are to be assessed each shift daily that have tested positive for COVID-19 for 14 days or until no symptoms are present whichever is longer. 2. Assessments will consist of temperature, O2 sats, lung sounds, new cough, and/or new shortness of breath. 5. Review of the providers' 4/30/20 Coronavirus Surveillance policy revealed: 2. Heightened surveillance activities will be implemented to limit the transmission of COVID-19 outbreak through CDC website, and will monitor for changes in prevention, treatment, isolation and other recommendations. Screening for visitors and staff: -a. Signs or symptoms of a respiratory infection, such as fever, cough, shortness of breath, or sore throat or other symptoms of coronavirus (i.e. (for example).,) chills, muscle pain, headache, new loss of taste or smell). -b. In the last 14 days, has had contact with someone with a confirmed [DIAGNOSES REDACTED]. -c. Travel within the last 14 days to geographic areas with sustained community transmission. -d. Residing in a community where community based spread of COVID-19 is occurring. *4. Visitors will be denied entry into the facility if they exhibit any of the criteria listed above . *5. Staff who has signs and symptoms of a respiratory infection shall not report to work. Any staff that develop signs and symptoms while on-the-job shall: a. Immediately stop work, put on a facemask, and self-isolate at home. b. Inform the Infection Preventionist, and include information on individuals, equipment, and locations the person came in contact with; and c. Contact and follow the local health department recommendations for next steps such as testing and locations for treatment. *6. The facility will refer to current CDC guidance for exposures that might warrant restricting asymptomatic staff from reporting to work. *Residents will be monitored for signs and symptoms of coronavirus illness at least 1 time a day: fever, cough, shortness of breath or difficulty breathing, chills, repeated shaking with chills, muscle pain, sore throat, or new loss of taste or smell. The physician will be notified immediately if evident. Staff shall follow established procedures when COVID-19 is suspected. 6. Review of provider's Infection control: COVID-19 Testing policy and Procedure revealed: *Outbreak: a new COVID-19 infection in any healthcare personnel (HCP) or any nursing home-onset COVID-19 infection in a resident. A resident who is admitted to the facility with COVID-19 does not constitute a facility outbreak. * 3. Testing of Staff and Residents in Response to an Outbreak(.) a. In an outbreak investigation, rapid identification and isolation of new cases is critical in stopping further [MEDICAL CONDITION] transmission. b. Upon identification of a single new case of COVID-19 infection in any staff or residents, all staff and residents that may have been in close contact or who have symptoms should be tested , and all staff and residents that may have been in close contact or who have symptoms should be tested , and all staff and residents that tested negative should be retested every 3 to 7 days until testing identifies no new cases of COVID-19 infection among staff or residents for a period of at least 14 days since the most recent positive result. 7. Review of https://www.cdc.gov/niosh/topics/hcwcontrols/recommendedguidanceextuse.html, March 2020 Recommended Guidance for Extended Use and Limited Reuse of N95 Filtering Facepiece Respirators in Healthcare Settings, accessed on 12/13/20, regarding reusing N95 masks revealed: *Extended use: -Referred to the practice of wearing the same N95 for repeated close contact several patients without removing the respirator between patient encounters with patients of the same infectious pathogen. -Was used for patients who were placed together in cohorted (dedicated) units. -Was favored over reuse, because it was expected to involve less touching of the respirator and therefore less risk of contact transmission. -When practiced had required a maximum extended use period of eight to twelve hours. -Should not be worn for multiple work shifts and should not be reworn after extensive use. *Reuse of N95 masks: -Referred to the practice of reusing the same N95 for multiple encounters with residents but removing after each encounter. -The N95 was stored in between encounters to be put on again prior to the next encounter. -Restrictions were to be in place to limit the number of times the same respirator could be reused. -The provider was to refer to the N95 manufacturer regarding the maximum number of donnings or uses they recommended. *N95 respirators were to be discarded: -Following close contact with, or exit from the care area of any patient co-infected with an infectious disease requiring contact precautions. -Following use during aerosol generating procedures. -Contaminated with blood, respiratory or nasal secretions, or other bodily fluids from patients. *Hang used respirators in a designated storage area or keep them in a clean, breathable container such as a paper bag between uses, where they do not touch each other and the bag is clearly identified. *Use a pair of clean gloves when donning a used N95 and performing a user seal check. Review of https://www.cdc.gov/coronavirus/2019-ncov/hcp/respirators-strategy/index.html June 2020, CDC Strategies for Optimizing the Supply of N95 Respirators, accessed 12/13/20 revealed: *Assigning designated teams of healthcare personnel to provide care for all patients with suspected or confirmed COVID-19 could minimize respirator use when extended wear of respirators were implemented. *Extended use refers to the practice of wearing the same N95 respirator for repeated close contact encounters with several different patients, without removing the respirator between patient encounters. Extended use is well suited to situations wherein multiple patients with the same infectious disease diagnosis, whose care requires use of a respirator, are cohorted. Review of https://www.cdc.gov/coronavirus/2019-ncov/hcp/nursing-homes-responding.html, updated 11/20/20, CDC Responding to Coronavirus (COVID-19) (Covid) in Nursing Homes, accessed 12/13/20 revealed: -For a resident with new-onset suspected or confirmed COVID-19: Cohorting residents on the same unit based on symptoms alone could result in inadvertent mixing of infected and non-infected residents. -If cohorting symptomatic residents, care should be taken to ensure infection prevention and control interventions are in place to decrease the risk of cross-transmission. -If the resident is confirmed to have COVID-19, regardless of symptoms, they should be transferred to a designated COVID-19 care unit. -Counsel all residents to restrict themselves to their room to the extent possible. -Educated and train HCP (health care personnel), including facility-based and consultant personnel (e.g., wound care, podiatry, barber) and volunteers who provide care or services in the facility. Including consultants is important, since they commonly provide care in multiple facilities where they can be exposed to and serve as the source of COVID-19. -Reinforce sick leave policies, and remind HCP not to work when ill. -Reinforce adherence to standard IPC measures including hand hygiene and selection and correct use of personal protective equipment (PPE). Have HCP demonstrate competency with putting on and removing PPE and monitor adherence by observing their resident care activities. *Create a plan for testing residents and healthcare personal for [DIAGNOSES REDACTED]-CoV2(COVID-19): -Testing for [DIAGNOSES REDACTED]-CoV2, [MEDICAL CONDITION] that causes COVID-19, in respiratory specimens can detect current infections (referred to here as [MEDICAL CONDITION] testing or test) among residents and HCP in nursing homes. *Identify a space in the facility that could be dedicated to monitor and care for residents with COVID-19. -Identify space in the facility that could be dedicated to care for residents with confirmed COVID-19. This could be a dedicated floor, unit, or wing in the facility or a group of rooms at the end of the unit that will be used to cohort residents with COVID-19. -Identify HCP who will be assigned to work only on the COVID-19 care unit when it is in use. *Residents with COVID-19 should, ideally, be cared for in a dedicated unit or section of the facility with dedicated HCP (see section on Dedicating Space). -Increase monitoring of ill residents, including assessment of symptoms, vital signs, oxygen saturation via pulse oximetry, and respiratory exam, to at least 3 times daily to identify and quickly manage serious infection. Consider increase monitoring of asymptomatic residents from daily to every shift to more rapidly detect any with new sy

A. Based on observation, interview, record review, and policy review, the provider failed to ensure side rails had been assessed for safety and entrapment (getting caught in) risk for six of six sampled residents (1, 3, 5, 7, 8, and 9) reviewed and for seventeen randomly observed residents with Hil-Rom side rails. That failure created a situation of immediate jeopardy that had the potential for causing harm to all of the residents with Hil-Rom side rails. NOTICE: Notice of immediate jeopardy was given verbally to the administrator and director of nursing (DON) on 2/5/15 at 10:45 a.m. The administrator was asked for an immediate plan of correction (POC) to ensure residents were assessed for the safe use of side rails for positioning. PLAN: "On 2/5/15 at 4:25 p.m. the administrator provided the surveyors with the written (POC). The written POC dated 2/5/15 at 4:25 p.m. was accepted by the surveyors at 4:30 p.m. That immediate POC included: *Remove all bottom bed rails that have not been in use. *Take measurements on side rails/assistive devices on beds. Perform individual assessments for each resident based on their level of cognition (memory) and indication for use of assistive devices on beds. *Based on each resident assessment, the top rails will either be secured in the down position with a zip-tie strap or be removed. On the Hil-Rom beds, the rail may be left in the up position against the wall with bed brakes on so that the resident may utilize the bed controls, if the resident is assessed with [REDACTED]. *Based on the individual assessment for those that have a need/desire for a top side rail as an assistive device, accommodations will be identified to ensure the assistive devices meet the safety needs of each resident. The accommodations which will be utilized are temporary covers on the bed rails and to ill in the gaps until permanent solution is obtained. *Staff education meeting held on 2/5/15 at approximately 12:00 pm to inform staff members of the immediate concern for residents and plan of correction to address safety concerns related to assistive devices. All staff will be advised of safety concerns. *Those residents at risk for falls will be further monitored and evaluated for additional interventions to prevent falls. *Copy of assessment forms and staff education attached." During the survey on 2/5/15 at 4:30 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation from 2/3/15 through 2/5/15 at 9:30 a.m. of resident 8's bed revealed: *Four Hil-Rom 1/2 side rails attached to the bed. *Two Hil-Rom 1/2 side rails were in the up position at the head of the bed. Review of resident 8's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *Side rails to be used for repositioning. *The 3/4/14 physician's hospital discharge summary stated her principle problem was generalized weakness, inability to perform activities of daily living (ADLs), fecal incontinence, dementia (memory), and sundowning (confusion at night). *She had been admitted on psychotropic medications (mood altering). *The 2/3/15 physician's orders [REDACTED]. Review of resident 8's Minimum Data Set (MDS) assessment revealed: *3/11/14 admission MDS revealed: -The Brief Interview for Mental Status (BIMS) assessment was a three. Three indicated severe cognition (memory) impairment. -She required extensive assistance of two staff for transferring from one area to another, ambulation, dressing, toilet use, personal hygiene, and bathing. -She was unsteady. -She was occasionally incontinent (unable to control) of urine. -She had a fall history prior to admission to the facility. -She had received antipsychotic (mood altering drug), antianxiety, and antidepressant medications. -Bed rails were marked as "not used." *The 3/13/14 Care Area Assessment (CAA) identified cognition impairment, visual function, communication, urinary incontinence, behavior symptoms, falls due to unsteadiness, psychotropic drug use, and falls. Physical restraints were not marked. *11/20/14 quarterly MDS revealed: -The BIMS score was five. -She required extensive assistance of one staff person with bed mobility, dressing, toilet use, bathing, and transferring. -She required limited assistance of one with ambulation. -She was unsteady. -She was frequently incontinent of bowel and bladder. -Bed rails were marked as "not used." Review of the following fall risk evaluations revealed resident 8 scored eighteen on 3/11/14, seventeen on 6/3/14, fifteen on 8/21/14 and 11/13/14. A score of ten or above represented a high fall risk. Review of the consent for use of side rails signed by the MDS coordinator and resident 8's daughter with a date of 3/4/13 (resident 8 had been admitted on [DATE]) revealed: *Recommendations marked were to use a 1/2 partial rail for left upper and right upper sides of the bed. *Frequency recommended was at all times when the resident was in bed. *Purpose for side rail use was for repositioning. *The side rails had been requested by resident 8's daughter for security and rolling out of bed. *The side rails had been assessed by the MDS coordinator on 3/4/14, 6/3/14, 8/21/14, and 11/13/14 for the stated purpose of repositioning. Review of resident 8's updated 8/27/14 care plan approaches included side rails: use side rails to help with repositioning in bed. Interview on 2/4/15 at 4:30 p.m. with the administrator, DON, and MDS coordinator revealed: *The MDS coordinator: -Had done the educational piece of side rail usage for the residents. -Had been unaware of the safety assessment piece for side rail usage. *The DON: -Had never had side rail safety issues brought to her attention. -The facility had used the Hil-Rom beds since 2005. Preceptor: 2. Observation on 2/4/15 at 3:25 p.m. of resident 1's room revealed: *She had a Hil-Rom bed with four 1/2 side rails attached to it. *The two 1/2 side rails at the top of the bed were in the raised position. Review of resident 1's medical record revealed: *An admission date of [DATE]. *She had [DIAGNOSES REDACTED]. processes sugar), colon cancer, [DIAGNOSES REDACTED] (high fat levels), anxiety, depression, low vitamin D, and vascular dementia (decline in thinking skills). *She had been readmitted on [DATE] from the hospital after she had fallen and fractured her hip that required surgery. Review of resident 1's 1/10/15 MDS assessment revealed she: *Had a BIMS score of five (indicates severe mental impairment). *Required extensive assistance with two staff members for: -Bed mobility. -Transfers. -Toilet use. -Personal hygiene. -Bathing. *Was frequently incontinent of urine and occasionally incontinent of stool. *Had occasional pain. *Had a fall since her last assessment on 11/21/14. *Had one unstageable pressure ulcer (skin/tissue damage where the depth is unable to be seen). *Had been using a pressure reducing device for her chair and receiving pressure ulcer care. Review of resident 1's 7/10/14 care plan revealed she: *Required extensive assistance of one staff person. *Could help to reposition herself by using the side rail. *Used side rails at night to help with repositioning. *Was unable to get out of bed on her own. Review of resident 1's following fall risk evaluations revealed scores of: *Nineteen on 6/26/14. *Seventeen on 9/18/14. *Twenty on 11/21/14. *A total score of ten or above represented a high risk for falls. Review of resident 1's 1/29/15 physician's orders [REDACTED]." Review of resident 1's 7/29/13 consent for and evaluation of side rails revealed: *She had requested the use of side rails for security. *She had been unaware of safety needs. *The side rails had been recommended at all times when she was in bed. *The side rails to have been used were 1/2 partial rails on both the right and left tops of the bed. *She had been the one to sign the consent that stated she understood the risks and benefits of using side rails. 3. Observation on 2/5/15 at 8:45 a.m. of resident 9's room revealed: *She was asleep in bed. *She had a Hil-Rom bed that had four 1/2 side rails attached to it. *The two top 1/2 side rails were in the raised position. Review of resident 9's medical record revealed: *An admission date of [DATE]. * She had [DIAGNOSES REDACTED]. heart arteries), and osteoporosis (fragile bones). Review of resident 9's 11/27/14 MDS assessment revealed she: *Had a BIMS score of 15. *Required limited assistance of one staff member to help her. *Had been continent (able to control) of bowel and bladder. *Had no pain, falls, or pressure ulcers. Review of resident 9's 10/24/13 care plan revealed there had been no documentation of side rails being used. Review of her 1/29/15 physician's orders [REDACTED]." Review of resident 9's consent/evaluation for use of side rails showed: *She had requested the side rails for safety, and she had a family member request them for security. *She had 1/2 partial rails on both the left and right upper parts of the bed *Side rails had been recommended at all times when she was in bed. *Her family member had signed the consent and not the resident. Interview on 2/4/15 at 3:00 p.m. with resident 9 revealed: *She asked staff every night to put up her side rails. *She lowered the side rails herself in the morning. *She refused to go to sleep without the side rails up. 4. Random observations from 2/3/15 through 2/5/15 and testing of resident 3's bed revealed: *Four Hil-Rom 1/2 side rails were attached to his bed. *Two of the 1/2 side rails had been attached to the head of his bed and were in the up position at all times. *The other two 1/2 side rails had been attached to the foot of his bed. They had been in the down position. *The side rails had four openings within the outer frame, and testing revealed a head would fit through those openings. *While sitting on the resident's bed testing revealed between the mattress and the side rail there was enough room for a person's thigh to slide through that space. *Testing revealed when both of the side rails were in the up position a head would fit through the space in between them. Review of resident 3's complete medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *The 1/5/15 physician's orders [REDACTED]." Review of resident 3's 11/20/14 MDS revealed: *He was hard of hearing and rarely understood others. *His vision was highly impaired. *He had not been able to be interviewed to establish his current memory recall. *He was unable to ambulate and had required extensive assistance of two staff persons for transfers and moving in bed. *Bed rails were marked as "not used." Review of resident 3's 8/28/14 evaluation for use of side rails revealed: *The use of the side rails had been documented for "Medical symptoms." *The medical symptoms identified had been for weakness and unable to support trunk (upper body) in an upright position. *He had been identified as "Unaware of safety needs." *The side rails were to have assisted him with: -Repositioning from side-to-side while in bed. -Avoiding rolling out of bed with a comment of "Resident does swing leg over side, turn noodle (used for repositioning) placed under mattress." -Providing a sense of security. *He was incontinent of both bowel and bladder and had been dependent upon staff to meet his toileting needs. *He was having a decline in cognitive (memory) status with a comment of "According to history dementia is progressing." *Recommendations marked were to use 1/2 partial side rails for left upper and right upper. *The side rails had been assessed for repositioning by the MDS coordinator on 3/3/14, 6/5/14, and 8/28/14. No signed consent form for the use of the side rails had been located in his active chart. Interview on 2/5/15 at 2:00 p.m. with the social services worker revealed they were unable to locate a signed consent form for the use of his side rails. She confirmed someone would have had to sign the consent form for resident 3 to use the side rails due to his mental status and [DIAGNOSES REDACTED]." Review of resident 3's 9/2/14 care plan revealed: *A problem of "Alteration in mobility R/T (related to) movement disorder and advanced dementia." *A goal of "Use of side rails daily through next 90 days." *An approach of "Side Rails: Half rails up on bed to assist resident with some movement, will also hold onto rail during cares." Observation on 2/3/15 at 4:05 p.m. with certified nursing assistants (CNA) C and D with resident 3 revealed: *They had been preparing to assist him with transferring out of bed. *He had been laying in bed and required CNA C and D to assist him with turning and sitting up on the edge of the bed. *They had not cued him to use the side rail to help assist them with turning and sitting up. *He had made no attempt to use the side rail while the CNAs assisted him with repositioning and transferring him out of the bed. Interview on 2/4/15 at 3:15 p.m. with CNA C regarding resident 3 revealed he: "Does not use the side rails for sitting up or moving in bed." She had not attempted to cue him to see if he could use the side rails. She "thought he probably could with cueing, but wasn't sure." 5. Random observations from 2/3/15 through 2/5/15 of resident 5's bed revealed: *Two Hil-Rom 1/2 side rails were attached to the head of his bed. *They were in the up position at all times. Review of resident 5's complete medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He had been currently taking psychotropic (mood altering) medications. Review of resident 5's 1/8/15 quarterly MDS assessment revealed: *He had: -Impaired vision and could read large print. -Required extensive assistance of one or two staff persons for moving in bed and transfers. -Range of motion (ability to move freely) limitations to both of his legs. -Received antianxiety and antidepressant medications. *The bed rails were marked as "not used." Review of resident 5's 10/21/14 care plan revealed no documentation to support the use of the side rails. Review of the consent for use of side rails signed by the MDS coordinator and resident 5 dated 5/20/13 revealed: *Recommendations marked were to use 1/2 partial rails for left upper and right upper sides of the bed. *They had been recommended for night use only. *The purpose for the side rail use was for repositioning. Review of resident 5's 1/8/15 Evaluation For Use of Side Rails form revealed: *The side rails had been requested by the resident for weakness, balance problem, and pain. *He was to use the side rails to help with moving in bed, transfers, avoid rolling out of bed, and for a sense of security. *The side rails had been assessed by the MDS coordinator on 5/1/14, 7/24/14, 10/16/14, and 1/8/15. Observation on 2/3/15 at 1:45 p.m. of resident 5 revealed: *He was laying in bed resting. *Both of the 1/2 side rails were in the up position. *Both of his legs were hanging over the edge of the bed. This had created a potential hazard related to the position of the upper side rails. 6. Random observations on 2/4/15 of resident 7's bed revealed two Hil-Rom 1/2 side rails that were in the up position at the head of the bed. Review of resident 7's complete medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *The 2/3/15 physician's orders [REDACTED]." *She had been currently taking psychotropic (mood altering) medications. Review of resident 7's 1/1/15 quarterly MDS assessment revealed: *Her BIMS was a two indicating severe cognitive impairment. *She required extensive assistance of one to two staff persons for moving in bed and transfers. *Her balance was unsteady. *She had a history of [REDACTED]. *She had received antipsychotic (mood altering) and antidepressant medications. *The bed rails were marked as "not used." Review of resident 7's 7/22/14 care plan revealed an approach stating "Side rails: not used." That documentation had two lines drawn through it with D/C'd (discontinued) written beside it. The D/C'd documentation had no date located beside it to indicate when they had been discontinued. Review of the consent for use of side rails signed by the MDS coordinator and resident 7's son on 12/28/11 revealed: *Recommendations marked were to use 1/2 partial rails for left upper and right upper sides of the bed. *The frequency recommended was for at all times when the resident was in bed. *The side rails were to have been used as a mobility aid. Review of resident 7's 12/31/14 evaluation for use of side rails revealed: *The family had requested the use of the side rails for security. *She had been unaware of safety needs. *She was to use the side rails to help with bed mobility, transfers, avoid rolling out of bed, and provide a sense of security. *The cognitive status indicated she had dementia. *The side rail precautions and alternatives for side rails had been discussed with the son. *The side rails had been assessed by the MDS coordinator on 4/24/14, 7/17/14, 10/9/14, and 12/31/14. 7. Interview on 2/5/15 at 8:30 a.m. with the MDS coordinator revealed: *She had been responsible for the assessments and evaluations of the side rails on the residents. *She had not assessed the residents for the safety risk on using the side rails. *She had not been aware of any safety concerns or risks with the current side rails and mattresses they had been using. *She had not been aware of the risks or of the potential for the residents of getting their head through the Hil-Rom side rails. Review of the provider's updated 2/4/15 Policy and Procedure on Side Rails revealed: *"Each resident will be provided with a hospital type bed which if appropriate for use according to side rail assessment." *"If side rails are needed for own bed they may be ordered." *"All side rails must fit bed properly not to pose an injury to resident or staff." *"Side rails may be used to enable resident independence or when specifically requested by the resident or in an emergency." B. Based on observation, interview, and policy review, the provider failed to ensure: *The storage of cleaning chemicals for one of one housekeeping cart (southeast wing) had been locked and secured from residents access. *Exposed light bulbs had a protective cover in one of two observed soiled utility rooms (southwest wing). *One of one biohazardous (infectious waste) waste bin was secured from residents and all staff access in the southwest soiled utility room. *One of four observed exit doors (southwest wing) security alarm had activated and sounded upon opening. Findings include: 1. Random observations on 2/3/15 from 8:10 a.m. through 1:45 p.m. of a housekeeping cart located on the southeast wing revealed: *It had been observed in various locations on the southeast wing. *No housekeeping staff had been in attendance or monitoring that cart during any of the observations. *The housekeeping cart had been unlocked and contained the following chemicals: -One spray bottle of Sanicare TBX disinfectant cleaner. -One spray bottle of Sparkle acid cleaner. -One spray bottle of Quaternary disinfectant cleaner. -One spray bottle of Multi-purpose nonconductive surface cleaner. *All of the labels on the above chemicals read "Keep out of the reach of children." *Several residents were observed wandering up and down the hallway in the area of the housekeeping cart. Interview on 2/4/15 at 9:10 a.m. with the housekeeping supervisor revealed the housekeeping cart should have been locked when not in attendance. Review of the provider's undated Housekeeping and Maintenance Department Responsibilities policy revealed "Chemicals must be either in your possession or locked in the appropriate cabinet at all times." 2. Observation on 2/3/15 at 8:20 a.m. of the soiled utility room located on the southwest wing revealed: *The entrance door into the soiled utility room had been unlocked. *A light fixture attached to the ceiling had no protective cover over the light bulbs. Interview on 2/5/15 at 9:05 a.m. with the administrator, maintenance supervisor, and DON revealed they had not been aware the light fixture did not have a protective cover. They agreed the light fixture should have had a protective cover over the light bulbs to ensure safety from the potential of the bulb breaking resulting in injury. 3. Observation on 2/10/15 at 8:15 a.m. of the soiled utility room located on the southwest wing revealed: *The entrance door into the soiled utility room had been unlocked. *Inside that room there had been a large red biohazardous (infectious materials) waste garbage bin. The lid was unlocked and easily opened. *Inside that bin were two small red biohazardous waste containers. Those waste containers had been: -Covered with white plastic lids to enclose the contents inside the containers. -Filled with used syringes, needles, and small glass vials. -Small enough to pick-up and take out of the room. Interview on 2/10/15 at the time of the above observation with the maintenance supervisor revealed: *The soiled utility room had always been unlocked. *Any staff member or any resident could have entered the soiled utility room at any time. *He had not considered the biohazardous waste garbage bin or containers a safety risk for the residents or a drug diversion issue with staff. *He agreed the garbage bin and containers should have been secured from resident and staff access. The provider had been unable to provide this surveyor with a policy and procedure for the security of biohazardous materials during the survey or upon request. 4. Observation on 2/3/15 at 8:10 a.m. on the southwest wing revealed: *Two closed wooden doors at the end of the hallway. *A Wanderguard (wireless monitoring system for residents at risk of wandering) sounding device was attached to them. *The doors were unlocked and when they were opened the sounding device would make a loud noise. *The doors opened to a small enclosed area revealing a steel door. That door had been labeled as an exit door. *An alarm did not sound when that exit door had been opened by this surveyor. *The exit door opened to a snow-covered flight of steps leading to the back of the building. *The back of the building had not been secured and was located by a garage and an apartment complex. Interview on 2/3/15 at the time of the above observation with CNA F and the laundry supervisor confirmed: *The exit door had not alarmed upon opening. *The exit door should have alarmed at the nurses station when opened. *There had been an unidentified and confused resident who resided in a room next to the exit door. His wife shared a room with him and watched over him. Interview on 2/10/15 at 9:10 a.m. with the administrator and maintenance supervisor confirmed the above interview. The checking of the exit doors had been on the maintenance supervisor's check list to monitor for security and alarming. They would have expected the exit door to alarm upon opening to ensure the safety of the residents. Review of the provider's undated Door Alarm System policy revealed: *"All exit doors to the facility also have a separate buzzer system which is regulated on a panel by the nurses station." *"The southwest and southeast alarms are on 24 hours a day." *"The health care team at (provider name) is committed to the safety of the residents while maintaining their level of function."

Based on observation, interview, record review, and policy review, the provider failed to ensure effective pain management for: *One of one sampled resident (3) who was cognitively (memory) impaired with communication deficits and on comfort care (end-of-life). *One of one sampled resident (1) during a dressing change by one of one licensed practical nurses (LPN) (A). Findings include: 1. Review of resident 3's complete medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *He was not interviewable. *The staff had to anticipate his needs due to his communication deficit. *He had been dependent upon staff to meet all of his activities of daily living needs. *On 1/15/15 he had acquired a respiratory (lung) infection with the following physician's orders [REDACTED]. -[MEDICATION NAME] (antibiotic) 750 milligrams (mg) daily by intravenous (IV) for seven days. -[MEDICATION NAME] (antibiotic) 300 mg to be administered every 12 hours by IV for five days. -[MEDICATION NAME] (increases airflow in the lungs) solution to be administered four times a day and as needed (PRN). -Oxygen 1 to 3 liters per nasal cannula PRN to keep oxygen levels in the blood greater than or equal to 90% (percent). -Oral suctioning (removes increased secretions from the mouth) PRN. *On 1/19/15 the physician had written an order placing the resident on comfort care. *His January 2015 Medication Administration Record [REDACTED]. *He had been taking the scheduled Tylenol since 1/4/12. *On 1/19/15 he had been placed on comfort care with all of his oral medications discontinued including the Tylenol. *The physician had ordered [MEDICATION NAME] (antianxiety) 0.5 to 1.0 mg intramuscular (an injection into the muscle) every four hours PRN. *No medications had been ordered for pain or discomfort. Review of resident 3's 11/20/14 Minimum Data Set (MDS) assessment revealed: *He was hard of hearing and rarely understood others. *His vision was highly impaired. *He had not been able to be interviewed to establish his current memory recall. *He was unable to ambulate and required extensive assistance of two staff members for transfers and moving in bed. Review of resident 3's progress notes revealed: *On 1/15/15 he had a fever (elevated body temperature) ranging between 99.4 to 101.4 degrees Fahrenheit (F). He had not been swallowing effectively and required suctioning. The physician had been notified and the above orders were received. *On 1/16/15 he continued to have an elevated temperature. The nursing staff had provided PRN Tylenol to help reduce his fever. The physicians' assistant (PA) had been updated on his continued deteriorating condition. The PA had requested the staff visit with resident 3's spouse regarding comfort care. The wife was notified. *On 1/17/15 at 3:15 p.m. "No s/s (signs or symptoms) of pain noted. Remained in bed. Repositioned and hygiene care routine. Has accepted most care but does push staff away when not wanting to eat or accept neb (nebulizer) treatment. Increased restlessness at supper time." No documentation to support anything had been administered for his restlessness. *On 1/17/15 at 10:50 p.m. "Resident became extremely agitated when this nurse attempted to give neb treatment this evening. Began to holler loudly while pulling on nebulizer mask. Also striking out at staff with his fist. Respiratory congestion noted with occasional harsh cough. Restless at times." *On 1/18/15 with no time charted. The staff had discussed comfort care with his wife. She was going to consult with family at that time. "Resident remained in bed with repositioning and hygiene care." "Is easily agitated with cares - grabs out at staff, eyes become wide open with starring look." Temperature to 99.9 degrees F with Tylenol suppository (given rectally) given for the elevated temperature. *On 1/18/15 at 11:40 p.m. "Resident becomes agitated when staff attempt cares. Yells out, swings his fists and attempts to strike out." *On 1/19/15 with no time charted. He had pulled out his IV during the night. PAC ordered the IV to be discontinued and to follow-up with the wife regarding comfort care. *On 1/19/15 at 7:30 p.m. The wife had been contacted, and the family had been agreeable with the orders for comfort care. "(Wife's name) also asked if we were going to initiate Hospice (support program for end-of-life)." "Shared that staff (supervisory) would evaluate and talk with her about opportunities." *On 1/19/15 and on 1/20/15 resident 3 had continually removed his O2 tubing. *There had been no documentation to support the: -[MEDICATION NAME] had been administered for his restlessness. -Nursing staff had administered the Tylenol as a pain reliever. Observation on 2/3/15 at 10:45 a.m. with certified nursing assistants (CNA) (F and J) assisting resident 3 with personal care revealed: *He was in his room. *He had been quietly sitting in his wheelchair (w/c). *He had required the use of a hanger mechanical lift (device to assist with transfers) to assist him with standing. *The CNAs: -Placed a Hoyer sling around him and fastened it to the mechanical lift. -Assisted him to stand-up. -Pulled his slacks down to replace his urine soiled incontinent brief with a dry one. -Pulled his slacks back up and assisted him with sitting back down in his w/c. *During the entire process resident 3 continually grimaced, moaned, and cried out loudly. *While he was standing in the mechanical lift he stiffened his body several times and pulled himself forward into the lift. *After the CNAs had finished his personal care and sat him in the w/c he became quiet. Observation on 2/3/15 at 3:40 p.m. of resident 3 revealed he: *Was resting in his bed. *Had been awake and moaning out loudly. *Would have frequently stiffened his arms, raised them up in the air, and clenched his hands into a fist. Observation on 2/3/15 at 4:05 p.m. with CNAs C and D assisting resident 3 with personal care revealed the same observations as documented above. Interview on 2/3/15 at the time of the above observation with CNA C regarding resident 3 revealed: *He always had those behaviors during personal care or at rest. *She had not considered those behaviors to be a sign of pain. *She had considered his behaviors to be a sign of anxiety "He did not like to be touched." *She could not confirm how she knew he did not like to be touched. *She had not received any education on "specific" signs and symptoms of pain. Interview on 2/4/15 at 11:00 a.m. with the MDS assessment coordinator revealed: *She had been responsible for the resident's pain assessments. *She had not used any formal type of form to complete a pain assessment. The nurses had a pain management assessment form to be used as a tool for them to determine a resident's pain level. *She would have only performed her required pain interview from the MDS section J. *She agreed that moaning, grimacing, stiffening, and clenching of fists were all signs of pain. She also considered those signs of anxiety. *Resident 3 had always exhibited those behaviors since he had been admitted in 2011. They had increased when he had a respiratory infection. *She knew his scheduled Tylenol had been discontinued on 1/19/15 with no further pain medications recommended. *She could not confirm the Tylenol twice a day had helped control any of those behaviors he had exhibited. *She could not provide documentation to support how they had determined those behaviors resident 3 exhibited were anxiety versus pain. *She further confirmed the provider had not administered any of the above ordered [MEDICATION NAME] to resident 3 to determine if his behaviors were anxiety induced. *After his respiratory infection had resolved she had considered those behaviors normal for him. Interview on 2/4/15 at 11:30 a.m. with the director of nursing revealed she: *Supported the above interview with the MDS coordinator. *Had considered the staff to be proficient (doing a good job) providing pain management. *Could not provide this surveyor with any documentation to support the supervisory staff had a follow-up conversation with resident 3's wife regarding hospice support and care. *Stated "It was just a phone call. The wife was comfortable with the care we are providing." Review of resident 3's 9/2/14 care plan revealed: *The following approaches: -"Assist resident with all decisions. Resident will indicate stress/pain by looking anxious, and moaning more. He does not communicate so all needs need to be anticipated." -"History of grabbing staff and other residents prior to admission." -"Need to anticipate his needs. Speak directly and close to him to get his attention. Only moans, if increase in moaning or restlessness, could be pain, try and figure out what he needs." -"Pain: Noted to have increase in restlessness and moaning in the morning and afternoon. Started [MEDICATION NAME] (Tylenol) 650 BID (twice a day) and this has improved. Will need to anticipate his needs and be mindful of possible pain if resident is restless or moaning more than usually." *A line had been drawn through the [MEDICATION NAME] sentence with no discontinued date provided. Review of resident 3's monthly pharmacy consultation reports from April 2014 through January 2015 revealed: *No documentation to support: -The discontinuation of a pain medication that the resident had been taking for some time. -Or encourage another type of pain medication for comfort during the resident's end-of-life. *Under the comment section the word "none" had been written. *No further documentation was found to support the pharmacist had completed a thorough review of the resident's current health and medical condition. Interview on 2/10/15 at 12:45 p.m. with the consulting pharmacist revealed he: *Would not have reviewed a resident's chart for adequate pain management. *Stated "I feel doctors prescribe too many pain medications and the residents get addicted to them." Review of the provider's undated Pain Assessment and Management policy revealed: *Policy "It is the policy of (provider name) to help the staff identify pain in the resident, and to develop interventions that are consistent with the resident's goals and needs and that address the underlying causes of pain." *General Guidelines "Conduct a comprehensive pain assessment upon admission to the facility, at the quarterly review, whenever there is a significant change in condition, and when there is onset of new pain or worsening of existing pain." *"The staff and physician will identify the nature and severity of pain." *"The nursing staff will identify any situations or interventions where an increase in the resident's pain may be anticipated; for example - wound care, ambulation, or repositioning." Review of the provider's undated Comfort Care policy revealed: *Policy "The goal of comfort care is to promote dignity of the resident and to minimize pain and/or discomfort." *Some of the provisions for comfort care had been: -"Pain management." -"No medications unless resident is willing and able to ingest." -"Medications will be discontinued at the physician's discretion." Preceptor: 2. Observation on 2/3/15 from 4:10 p.m. through 4:20 p.m. revealed licensed practical nurse (LPN) A completed a dressing change to resident 1's right heel. At no time had LPN A asked resident 1 about her pain level. Interview with resident 1 immediately following LPN A's completing her dressing change revealed her pain level was 3 to 4 (on pain scale of 0 through 10 with 0 being no pain and 10 being the worst possible pain) while the dressing change was being completed. Further interview on 2/4/15 at 1:45 p.m. with resident 1 revealed staff never asked her if she wanted pain medicine before her dressing changes. Record review of resident 1's nurses notes dated 2/3/15 revealed LPN A documented resident 1 had "no complaints of pain."

Preceptor: Based on observation, interview, record review, and policy review, the provider failed to assess, identify, and implement interventions for residents at risk of developing pressure ulcers (injury to skin and underlying tissue resulting from prolonged pressure on the skin) for two of two sampled residents (1 and 6) resulting in two facility acquired pressure ulcers. Findings include: 1. Review of resident 1's 1/10/15 Minimum Data Set (MDS) assessment revealed she: *Had been readmitted on [DATE] after hip surgery. *Had a Brief Interview for Mental Status (BIMS) (memory test) score of five which indicated severe cognitive impairment (a deterioration or loss of mental functioning). *Needed extensive assistance of two or more staff members for help with: -Bed mobility (moving/changing positions). -Transfers (moving from one spot to another). -Walking. -Dressing. -Toilet use. -Bathing. *Was frequently incontinent (unable to control bladder) of urine. *Had occasional pain. *Had a fall since her last assessment dated [DATE]. *Had one unstageable (tissue loss/damage where the depth is unable to be seen) pressure ulcer. *Had a pressure reducing device for her chair and received pressure ulcer care. Review of resident 1's 7/10/14 care plan revealed she: *Was able to dress her upper body but needed extensive assistance from staff with dressing her lower body. *Was able to assist with her upper body personal care after set-up and needed limited assistance with her perineal care (cleaning of her private area). *Needed assistance of one staff member for bathing. *Toileted herself during the day. *Needed extensive assistance of one staff member for moving in bed. *Could transfer herself but needed reminders to use her walker. *Walked to all destinations with the use of her walker. *Was at risk for falls. *Was at risk for skin breakdown due to not cleaning herself well after using the restroom and obesity (overweight) with decreased mobility. *Had no interventions in place to prevent her from developing a pressure ulcer. Review of resident 1's medical record revealed: *She had surgery on 11/10/14 for a [MEDICAL CONDITION]. *On 12/22/14 the provider discovered bloody drainage from her right heel when her TED hose (compression stockings) had been removed. *She had a 1.8 centimeter (cm) by 3.0 cm black area on her right heel. *Her skin condition documentation sheet started on 12/22/14 revealed: -The pressure ulcer was unstageable. -She was to have an anti-pressure boot on when not walking. Interview on 2/3/15 at 10:15 a.m. with resident 1 revealed she did not wear anything special on her feet for her pressure ulcer. She wore her blue slippers all day. Observation during the interview showed resident 1 had been wearing her blue slippers at that time. Interview on 2/4/15 at 3:42 p.m. with the director of nursing (DON) revealed: *Resident 1's pressure ulcer was discovered on 12/22/14 by the bath aide. *She believed the resident acquired the pressure ulcer when she was in the hospital. *Her care plan should have been updated to reflect the change in her condition. 2. Review of resident 6's medical record revealed: *An admission date of [DATE]. *[DIAGNOSES REDACTED]. *A 11/19/14 admission nursing assessment: -Identified two staples to the right hip surgical sight three staples to the surgical sight, 3.0 cm by 5.0 cm to the middle of the spine, and an area to the right posterior (behind) upper thigh. -She required two staff assistance with transfers. *An 11/27/14 nursing summary flow sheet revealed: -She was frequently incontinent of bladder and bowel. -There were pressure reducing devices for her chair and bed. -The open [MEDICAL CONDITION] section was marked "No." -The ulcers section was marked "No." -The ability to make decisions section was marked moderately impaired. -The 11/26/14 Braden scale (used to identify at risk for skin problems (with a score of 12 or lower representing high risk) score of 17. Review of resident 6's nurses notes revealed on: *11/19/14 "When giving cares found open area on R (right) upper inner thigh. Measures proxy (approximately) 3 cm by 2 cm also 3 small open areas on back of thigh." *11/19/14 "She also has a skin tear in the middle of her back." *11/24/14 "Has 2 small healing areas on bone prominence (spine) of back. Was charted as an abrasion (scraped area) but may have been a very small pressure ulcer as alluded too on transfer but now looks like a pinpoint dimple." *12/3/14 "Coccyx (tail bone) area red as is bony prominence of spine." *12/17/14 "Bony prominence of spine red, coccyx red." *12/2414 "Along spine area reddish purple." *12/26/14 "Open area to coccyx bony prominence see skin condition doc (documentation) form." *12/30/14 "Continuing care to coccyx opening." *12/31/14 "Coccyx area tx (treatment) continues et (and) shows improvement - tissue granulating (new skin tissue) et (and) redness decreasing. Foam placed on bony prominence of spine D/T (due to) redness." Review of resident 6's 12/30/14 physician's orders [REDACTED]." Review of resident 6's 1/6/15 physician's progress notes had no documentation regarding skin breakdown. Review of resident 6's 11/19/14 Temporary Care Plan revealed documentation for: Skin problems? "Yes-spine, coccyx and Right hip incision." There had not been any further care plan for her regarding those issues. Review of resident 6's MDS assessments and Care Area Assessment (CAA) summary revealed: *11/26/14 - admission MDS: -She required extensive assistance of two staff with bed mobility, dressing, transfer, toilet use, and personal cares. -She was frequently incontinent of bowel and bladder. -She was at risk for developing a pressure ulcer. -The section for resident "has stage 1 (reddened area) or higher pressure ulcer" was marked "No." -The section for skin problem was marked "skin tear." -The section for skin/ulcer treatment: turn and reposition was marked "not checked." *11/28/14 - CAA summary triggered for activities of daily living, urinary incontinence, nutritional status, and pressure ulcer. *Documentation on the CAA revealed: -Urinary incontinence - "Currently shows no s/s (signs or symptoms) of a pressure ulcer. She does have a surgical incision on her right hip and skin tear on her back." -Pressure ulcer - "At risk for pressure ulcers d/t (due to) extensive assistance with bed mobility. Does not currently have a pressure ulcer." *12/17/14 - Thirty day MDS revealed: -She required extensive assistance of one staff person with bed mobility, toilet use, bathing, and personal hygiene. -She was frequently incontinent of bowel and bladder. -She was at risk for developing a pressure ulcer. -No had been marked for pressure ulcers. 3. Interview on 2/4/15 at 10:40 a.m. with the DON regarding resident 6 revealed: *She confirmed the nursing summary had stated a pressure relieving device had been on resident 6's bed. *12/30/14 was the first time the physician had been notified of the pressure ulcer and had made recommendations. *The nursing staff had taken orders from the Standing Orders for skin treatment prior to notifying the physician on 12/30/14. *They had not used the skin documentation for stage one pressure ulcer, but had for unstageable and other pressure ulcers. *She agreed the reddened area over bony prominences could have been a stage one pressure ulcer. *She agreed there had been no documentation for a stage one pressure ulcer. *She confirmed there was no policy for use of the skin condition documentation form. Review of the provider's undated Pressure Ulcer Treatment policy revealed: *"The purpose of this procedure is to provide guidelines for the care of existing pressure ulcers and the prevention of additional pressure ulcer. *Review the resident's care plan to assess for any special needs of the resident. *The pressure ulcer treatment program should focus on the following strategies: -Assessing the resident and the pressure ulcers. -Managing tissue loads. -Pressure ulcer care. -Managing infection. -Education and quality improvement."