Every finding on record at Sunset Manor Avera Health

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to protect the residents' right to be free from physical abuse for one of one sampled resident (1) who was straddled and restrained in his bed by one of one certified nursing assistant (CNA)G while he provided incontinence (involuntary urine and bowel leakage) care to resident 1. Findings include:1. Review of the provider's SD DOH FRI report dated 3/23/26 revealed that resident 1 had a Brief Interview for Mental Status (BIMS) assessment score of 99, which indicated his cognition was severely impaired. The report indicated that on 3/22/26 at 4:00 a.m., resident 1 became combative during incontinence care provided by CNA G. During the interaction, CNA G straddled resident 1 in his bed to manage the resident's combative behavior and applied pressure with his thumb to a pressure point behind the resident's ear to calm the resident. This action increased the resident's combative response, and CNA G provided incontinent care while the resident was restrained. 2. Review of resident 1's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His diagnoses included neurocognitive disorder with Lewy Bodies (progressive brain disorder characterized by abnormal protein deposits that cause cognitive decline, visual hallucinations, movement issues, and fluctuating alertness), dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbances and anxiety (anticipation of future changes or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). His care plan indicated he had memory problems and became confused easily, and staff were to encourage and assist him in making safe decisions regarding his care and personal relationships by giving him safe and simple choices. He wore incontinent products (briefs) for dignity and protection, and staff were to assist him with incontinent care with each incontinent episode. 3. Observation on 5/5/26 at 10:15 a.m. of resident 1 revealed he was asleep in his bed and unable to be interviewed. 4. Interview on 5/5/26 at 10:10 a.m. with director of nursing (DON) B revealed that CNA G reported the incident to licensed practical nurse (LPN) C at approximately 6:00 a.m. on 3/22/26 during the morning shift report (the communication given by the staff who are ending their shift to the incoming staff before the new shift begins. It includes essential information about each patient's current status, recent changes, important events from the previous shift, ongoing concerns, and tasks that need follow up. The purpose is to ensure continuity of care, maintain patient safety, and keep the oncoming staff fully informed). LPN C then reported the incident to nurse manager (NM) E, who subsequently notified the minimum data set (MDS) nurse F. CNA G returned for his scheduled night shift on 3/23/26 and provided direct resident care. MDS nurse F reported the incident to administrator A and DON B on 3/23/26 through the FRI reporting process and an email. DON B suspended CNA G on 3/23/26 pending the outcome of the facility's investigation. During the investigation, DON B interviewed LPN C, NM E, and MDS nurse F, who confirmed that the interaction between CNA G and resident 1was reported by CNA G. DON B ensured the resident's medical provider and representative were notified of the incident. 5. Interview on 5/5/26 at 1:41 p.m. with LPN C revealed that on 3/22/26, around 6:00 a.m. CNA G indicated that resident 1 was combative while he provided his care. CNA G used the term straddle the resident when he described how he managed the resident's behavior when he cleaned stool from the resident's perineal area (the region of the body between the thighs, including the area from the genitals to the anus). He also reported that he had placed pressure behind the resident's ear to distract him when he completed the care. LPN C assessed the resident and did not find any injuries on resident 1's body.She reported the information to her supervisors, NM E, and MDS nurse F, both of whom were in the facility after she had received the report. LPN C stated this was the first time she had heard of an incident of this nature and now understands she was required to notify the DON and complete a report to the SD DOH. 6. Interview on 5/5/26 at 3:08 p.m. with CNAs D and H revealed they each had received training on abuse and neglect, resident rights, and dementia care. CNA H indicated that she had a criminal background check completed, and she had to sign an abuse affidavit before she was allowed to work at the facility. CNA H and CNA D indicated they had no concerns regarding any staff member regarding abuse or neglect. They denied any family members sharing a concern, such as abuse to her, but indicated they would go to their DON or nurse if there was a concern. 7. Review of NM E's personnel file revealed she was placed on leave on 3/23/26, and her employment with the facility was terminated on 3/24/26. She received annual training on 9/11/25 and 9/15/25 that included abuse and neglect, resident rights, and dementia care. An abuse affidavit was completed when she was hired, and a criminal background check was completed that had no remarkable findings. 8. Review of MDS nurse F's personnel file revealed she was placed on leave on 3/23/26, and her employment with the facility was terminated on 3/25/26. She received annual training on 9/8/25 that included abuse and neglect, resident rights, and dementia care. An abuse affidavit was completed when she was hired, and a criminal background check was completed that had no remarkable findings. 9. Review of CNA G's personnel file revealed he was hired on 9/25/25 and his employment with the facility was terminated on 3/25/26. He received training on 9/25/25 that included abuse and neglect, resident rights, and dementia care. An abuse affidavit was completed when he was hired, and a criminal background check was completed that had no remarkable findings. 10. Review of the provider's January 2024 Long Term Care Abuse Prohibition Policy revealed, It is essential for facilities to prohibit and prevent abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. The facility will have systems in place to encourage and support all residents, staff, families, visitors, and resident representatives in reporting any suspected acts of abuse, neglect, or exploitation of residents, misappropriation of resident property, corporal punishment, and involuntary seclusion. The term abuse (indicates any type of abuse, i.e., sexual abuse, staff to resident, resident to resident, visitor to resident, physical, mental, verbal, deprivation of goods and services, neglect, exploitation, involuntary seclusion, misappropriation of resident property, and corporal punishment) will be used throughout this policy unless specifically indicated. An owner, licensee, administrator, manager, employee, agent, contractor, or volunteer of a nursing home shall not physically, mentally, or emotionally abuse, mistreat, or neglect a resident. All alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator. All owners, operators, employees, managers, agents, or contractors must report to the State Agency and one or more law enforcement entities any reasonable suspicion of a crime against an individual who is a resident of or is receiving care from the facility. No later than 24-hours if the event did not result in serious bodily injury. Abuse: the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Physical abuse includes, but is not limited to, hitting, slapping, pinching, and kicking. Corporal punishment, which is physical punishment, is used as a means to correct or control behavior. Corporal punishment includes, but is not limited to, pinching, spanking, slapping of hands, flicking, or hitting with an object. Convenience: is defined as the result of any action that has the effect of altering a resident's behavior such that the resident requires a lesser amount of effort or care and is not in the resident's best interest. Freedom of movement means any change in place or position for the body or any part of the body that the person is physically able to control. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria, cannot be removed easily by the resident; and restricts the resident's freedom of movement or normal access to his/her body.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, and policy review, the provider failed to report a physical abuse incident to the SD DOH within the required time frame for one of one sampled resident (1), who was straddled and restrained in his bed by one of one certified nursing assistant (CNA) (G) while he provided incontinence (involuntary urine and bowel leakage) care to resident 1. Findings include: Findings include: 1. Review of the provider's 3/23/26 SD DOH FRI (a required reporting of unexpected or adverse events) report revealed that on 3/22/26 at 4:00 a.m., resident 1 was combative during morning care rounds (changing of residents who were incontinent of stool or urine). CNA G had turned the resident so he was positioned on his side, lying in his bed. That increased the resident's combative behavior, so CNA G placed a leg over the resident to straddle him. CNA G then used his thumb and put pressure on a pressure point under the resident's ear (to lock the resident's jaw) to distract the resident. This increased resident 1's combative behavior, but allowed CNA G to complete the incontinence care for resident 1. CNA G reported this incident to licensed practical nurse (LPN) C at 6:00 a.m. on 3/22/26 during the morning shift report (report to the oncoming staff about resident care). LPN C reported the incident to nurse manager (NM) E, who then reported it to the minimum data set (MDS) nurse F. An incident report was completed by LPN C on 3/22/26 and placed under DON B's office door. The incident occurred over the weekend, and DON B was not in the facility. LPN C asked MDS nurse F if DON B should be called to notify her of the incident. She was told by MDS nurse F that an email was sent to DON B. The email was sent by MDS nurse F to DON B on 3/22/26 at 2:52 p.m., before she had left for the day. CNA G returned to work on 3/23/26 for his next scheduled night shift and provided direct contact care for the residents. 2. Interview on 5/5/26 at 10:10 a.m. with DON B revealed on 3/23/26, she became aware of the alleged abuse incident that involved resident 1 and CNA G. She indicated the incident occurred on 3/22/26 at 4:00 a.m. during the resident's morning incontinence cares, and CNA G reported it to LPN C before he left the facility after his scheduled shift. DON B had indicated that the incident had not been reported to the SD DOH in the required time frame. DON B stated resident 1 was combative when CNA G was providing resident 1's incontinence care. CNA G had stated he straddled the resident in the resident's bed to hold him down so he could clean stool from the resident's perineal area (the region of the body between the thighs, including the area from the genitals to the anus). Resident 1 remained combative with CNA G, so CNA G put pressure on a pressure point area behind the resident's ear to distract him from moving. CNA G returned to work on 3/23/26 for his scheduled night shift, since0 the incident was not reported to the DON B or administrator A as it should have been. She completed the incident reporting to the SD DOH on 3/23/26, but she did not report the incident to the Department of Human Services (DHS). She indicated that there were previous incidents involving other residents that she had reported to DHS, but she never heard back from the DHS, or if she did, they told her they were not concerned because the resident was in a safe place. 3. Interview on 5/5/26 at 1:41 p.m. with LPN C revealed on 3/23/06 at 6:00 a.m., during morning report with CNA G, he reported he had straddled resident 1 during his incontinence cares because the resident was being combative. CNA G told her he then used his thumb to put pressure on a pressure point behind the resident's ear to calm him down. CNA G indicated that the resident became more combative after he had done that, but he was able to get the job done. She assessed resident 1 after receiving the report of the incident from CNA G, and no injuries were found on resident 1's body. She reported the incident to NM E, who then reported the incident to the MDS nurse F, as she was the management nurse that day. LPN C had asked NM E and MDS nurse F if CNA G should return for his scheduled night shift on 3/23/26. She indicated that both NM E and MDS nurse F reported that they had filled out an incident report, placed it under DON B's office door, and sent her an email to inform her of the incident. 4. Interview on 5/5/26 at 1:08 p.m. with DON B revealed she expected that if an alleged violation involving resident abuse or neglect occurred, she would be notified immediately. 5. Review of the provider's 1/2024 Long Term Care Abuse Prohibition Policy revealed, It is the policy of the facility that abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion allegations are reported according to Federal and State Laws. The facility will ensure that all alleged violations involving abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion are reported immediately to the administrator. All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including the State Survey Agency and adult protective services where State law provides for jurisdiction in long-term care facilities. Immediately, but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury. Facility initial reporting of allegations: For all allegations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, the administrator or designee will notify officials in accordance with State law, to include the State Survey Agency and adult protect services where state law provides for jurisdiction in long-term care facilities immediately but not later than 2 hours if the alleged violation involves abuse or results in serious bodily injury or no later than 24 hours if the alleged violation involves neglect, exploitation, mistreatment, or misappropriation of resident property; and does not result in serious bodily injury. Department of Human Services (DHS) Notification: only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person.

Based on observation, record review, interview, and facility assessment review, the provider failed to post the required nursing staffing information in a location readily visible to residents, staff, and visitors that clearly reflected actual hours worked by the nursing staff from October 2025 through December 2025 daily:*For 46 of 92 days reviewed regarding the Traumatic Brain Injury unit (TBI).*For 24 of 92 days reviewed regarding the Challenging Behavior Unit (CBU).*For 13 of 92 days reviewed regarding the main area where residents resided (The Manor). Findings include:1. Observation on 12/29/25 at 2:34 p.m. of the provider's posted nurse staffing hours for The Manor and the CBU revealed:*The information was posted on a bulletin board near the nurses' station in the Manor.*It included the date of 12/26/25 and resident census for The Manor and the CBU.*There were no registered nurse (RN) hours documented on those postings.2. Observation on 12/29/25 at 3:45 p.m. in the TBI unit revealed there were no posted nurse staffing hours.3. Observation on 12/31/25 at 9:28 a.m. of the provider's 12/31/25 posted nurse staffing hours for The Manor and the CBU revealed there were no RN hours documented for that day.4. Review of the posted nurse staffing hours from 10/1/25 through 12/31/25 revealed there were no nurse staffing information forms for:*The Manor on 10/10/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, 12/27/25, 12/28/25, and 12/29/25.*The TBI unit on 10/1/25, 10/3/25, 10/7/25, 10/11/25, 10/12/25, 10/13/25, 10/16/25, 10/17/25, 10/21/25, 10/29/25, 11/1/25, 11/2/25, 11/3/25, 11/6/25, 11/7/25, 11/11/25, 11/14/25, 11/18/25, 11/20/25, 11/22/25, 11/23/25, 11/24/25, 11/25/25, 11/26/25, 11/27/25, 11/28/25, 11/29/25, 11/30/25, 12/1/25, 12/2/25, 12/3/25,12/8/25, 12/10/25, 12/11/25, 12/13/25, 12/14/25, 12/15/25, 12/18/25, 12/19/25, 12/23/25, 12/24/25, 12/25/25, 12/26/25, 12/27/25, 12/28/25, and 12/29/25.*The CBU on 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/27/25, 10/28/25, 10/29/25, 10/30/25, 10/31/25, 12/10/25, 12/11/25, 12/12/25, 12/13/25, 12/14/25, 12/15/25, 12/16/25, 12/17/25, 12/18/25, 12/19/25, 12/20/25, 12/21/52, 12/27/25, 12/28/25, and 12/29/25.5. Review of the posted nurse staffing hours from 10/1/25 through 12/31/25 revealed there were no documented RN coverage hours for 10/7/25, 10/23/25, 10/27/25, 11/12/25, 11/24/25, 11/25/25, 11/28/25, 12/3/25, 12/4/25, 12/8/25, 12/11/25, 12/13/25, 12/14/25, 12/17/25, 12/18/25, 12/22/25, 12/23/25, 12/26/25, 12/30/25, and 12/31/25.6. Review of the provider's nurse staff schedules from 12/13/25 through 12/31/25 revealed:*On 12/13/25 RN/Minimum Data Set (MDS) coordinator C was scheduled to work, and those hours were not represented on the posted nurse staffing hours.*On 12/14/25 RN/assistant director of nursing (ADON) FF was scheduled to work, and those hours were not represented on the posted nurse staffing hours.*On 12/18/25 RN/ADON FF was scheduled to provide resident care from 8:00 a.m. until 11:30 a.m. and director of nursing (DON) B was scheduled to provide resident care from 11:30 a.m. until 6:00 p.m. due to an LPN that was identified on the nurses' schedule to have called in sick.-The posted nurse staffing hours were not updated to reflect that change.7. Review of the posted nurse staffing forms and interview on 12/31/25 at 10:43 a.m. with LPN D on the TBI unit revealed:*The posted nurse staffing hours were posted on a bulletin board behind a desk in the unit's common area.*LPN D stated the posted nurse staffing hours were to be completed each day, but she did not know who completed them.*She did not change the information on the posted nurse staffing if there were changes in the staffing during her shift.*She verified the nurse assigned to the CBU and TBI unit shared their scheduled hours between the two units, but the TBI unit posted nurse staffing form identified the nurse was scheduled on that unit for the entire 12-hour shift, which was inaccurate.*LPN D agreed the location of the posted nurse staffing hours in the TBI unit was not readily visible for residents or visitors.8. Interview on 12/31/25 at 1:42 p.m. with administrator A revealed:*The night shift nurse was responsible for completing the daily nurse staffing hours form for the next day according to the staff schedule and resident census and was to post them in each unit.*She expected that the posted nurse staffing hours would be updated each shift if there was a staffing change by the nurse on duty in that unit.*She expected the hours on the posted staffing to be accurate. She agreed the nurse hours documented on those forms for the TBI unit and the CBU were not accurate.9. Interview on 12/31/25 at 3:09 p.m. with director of nursing (DON) B revealed:*The posted nurse staffing hour forms were to be completed by The Manor night shift nurse and posted on each unit.*The MDS coordinator and the DON hours were not included on the posted nurse staffing hours forms.*She verified that she and the MDS coordinator assisted with resident care needs.*She verified the MDS and DON hours were submitted as RN coverage hours in the Payroll Based Journal (PBJ) reporting system.*The posted nurse staffing hours were to be posted daily and were to be accurately reflect the hours worked by each staff member.*She agreed there were missing posted nurse staffing hour forms for all three units.*She agreed that the staff did not update the posted nurse staffing forms to represent an accurate number of hours worked for each shift.*She agreed the LPN and RN hours posted for the CBU and TBI units did not accurately represent that the nurses split scheduled 12-hour shifts between the two units.*She expected the posted nurse staffing hours to be completed accurately and posted in a location that was visible for residents, staff, and visitors.10. Review of the provider's 4/2/25 Facility Assessment revealed:*Staffing Plan Nursing, nutrition services and housekeeping staffing is evaluated at the beginning of each sift [shift] and adjusted as needed to meet the care needs and acuity of the resident population. See the posted nursing staffing hours for details. CBU:Charge Nurse: 5:30a [a.m.]- 6p [6:00 p.m.], 5:30p-6a (shared with TBI). TBI:Charge Nurse: 5:30a [a.m.]- 6p [6:00 p.m.], 5:30p-6a (shared with CBU).* Support Staff:Director of Nursing: Monday thru Friday 7am [7:00 a.m.] -5p. [5:00 p.m.]MDS Coordinator, RN: Monday thru Friday 8am-4:30pm.* At the minimum there is one RN/LPN in [the] facility at all times for 24h [24 hour] nursing coverage (8 hour RN coverage at minimum).

Based on record review, interview, and policy review, the provider failed to ensure six of six sampled residents' (2, 6, 9, 34, 39, and 40) with a severe mental health illness Minimum Data Set, a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs, (MDS) assessments were accurately coded for the area of Pre-admission Screening and Resident Review (PASRR).Findings include: 1. Review of resident 2's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His diagnoses included bipolar (mental condition causing extreme shifts in mood, energy, and activity levels), and neurocognitive disorder (a group of conditions marked by the decline in mental function like memory, thinking, and reasoning) and psychotic disorder (a loss of contact with reality characterized by symptoms like delusions (false beliefs) and hallucinations (seeing, hearing, feeling things that are not true)). *He had a level I (1) PASRR completed on 9/5/25 for a potential change in condition that stated. -Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. -The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?' *There was Level II PASRR in resident 2's EMR dated 1/18/23. *Item A1500 of his 10/9/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 2. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included depression, anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and psychotic disorder. *She had a level I PASRR completed on 9/5/25 for a potential change in condition that stated. -Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. -The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?' *There was no Level II PASRR in resident 6's EMR. *Item A1500 of his 5/8/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 3. Review of resident 9's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included depression, anxiety disorder, psychotic disorder, and schizophrenia (a severe brain disorder causing distorted reality perception, featuring hallucinations, delusions, disorganized thinking, and reduced emotional expression). *She had a level I PASRR completed on 7/24/25 for a potential change in condition that stated. -Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. -The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?' *There was a Level II PASRR in resident 9's EMR dated 11/14/18. *Item A1500 of his 2/28/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 4. Review of resident 34's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included depression, anxiety disorder, and bipolar disorder. *There was a Level II PASRR in resident 34's EMR dated 7/14/23. *Item A1500 in of his 7/6/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 5. Review of resident 40's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included depression, anxiety disorder, and psychotic disorder. *She had a level I PASRR completed on 9/5/25 for a potential change in condition that stated. -Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. -The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?' *There was a Level II PASRR in resident 40's EMR dated 3/11/25. *Item A1500 of his 3/31/25 comprehensive MDS assessment was coded No to the question Is the resident currently considered by the state level II PASRR process to have serious mental illness and/or intellectual disability or a related condition? 6. Review of resident 39's EMR revealed: *He was admitted on [DATE]. *He had diagnoses of Parkinson's disease (a brain disorder that slowly worsens over time leading to symptoms of shaking, stiffness, slow walking, balance issues, and potential problems with sleep, mood and thinking), dementia (a group of symptoms affecting memory, thinking and social abilities), major depressive disorder (a serious mood disorder where intense sadness, hopelessness, and loss of interest in life for at least two weeks, making it hard to do daily things) (MDD), and anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). *He had current physicians orders for clozapine (an antipsychotic [a medication that alters the activity of neurotransmitters in the brain to reduce symptoms of psychosis (a state of losing touch with reality) and duloxetine (an antidepressant medication). *His 3/4/25 and 6/11/25 PASRR level I screen outcomes indicated he had a positive level I, and no status change. -His PASRR conditions were serious mental illness. -His 6/11/25 PASRR outcome explanation stated: - Your Level 1 Screen was submitted for a potential status change. It shows you have evidence of a serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation. If your needs change, a new Level 1 screen should be submitted by your health care provider. Unless your needs change, your [NAME] Level II Summary of Findings remains valid during your stay at the nursing facility and should transfer with you if you move to a different nursing facility. You require no further Level 1 screening unless you experience a significant change in serious mental illness or IDD treatment needs. -Since this evaluation has determined that you have a PASRR condition, if you admit to a Medicaid-certified nursing facility .the facility will need to document your PASRR condition in important Medicaid nursing facility paperwork. The facility should mark yes for questions A1500 on the Minimum Data Set, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? Also, your specific PASRR condition(s) should be checked in question A1510, Level II 'Preadmission Screening and Resident Review (PASRR) Conditions.' -His 10/9/25 comprehensive MDS assessment, question A1500, Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or a related condition? was marked No. -Item A1500 was coded No on his 10/25/24 and11/21/24 comprehensive MDS assessments. 7. Interview on 12/31/25 at 1:18 p.m. with social service designee (SSD) H revealed she: *Had just started in the SSD position in August. *Was responsible for submitting the PASRR screens to Maximus (the state contracted agency responsible for reviewing, making determinations, and recommendations related to residents' PASRR screening results). *Submitted PASRR screens to Maximus for review on any resident with a mental health medication change or a new mental health diagnosis for evaluation. *Did not enter the PASRR information into the residents' MDS assessments. *Verified residents 2, 6, 9. 34, 39, and 40 had level II PASRRs according to the information provided by Maximus. *Agreed that if a resident's level II PASRR was not present in their EMR she would not be able to determine if the PASRR II recommended services were being provided. 8. Interview on 12/31/25 at 1:42 p.m. with administrator A revealed: *Registered nurse (RN)/MDS coordinator C was responsible for coding the PASRR information in the residents' MDS assessments. -RN/MDS coordinator C was not available for an interview during the survey. *Administrator A expected the residents' MDS assessments to be coded accurately. 9. A review of the provider's 1/2025 LTC Resident-Assessment-Instrument (RAI)-System Standard policy regarding MDS completion revealed: *All persons who have completed any portion of the MDS Resident Assessment Form must sign the document attesting to its accuracy. *The Assessment Coordinator is responsible for electronically transmitting encoded, accurate, and complete MDS data to the CMS [Center for Medicare and Medicaid Services]

Based on interview, observation, record review, and policy review the provider failed to ensure the staff followed standard food safety practices regarding:*Monitoring the food and drink temperatures prepared and served were served to residents by cook M, P and Q and dietary assistant (DA) N on one of one evening meal services and one of one lunchtime meal services.*Handwashing and glove use by DA N and O and Cooks P and Q was followed during one of one evening meal service and one of one lunch time service in the kitchen. Findings include:1. Interview on 12/29/25 at 3:17 p.m. with resident 48 in her room revealed:*She stated the food was not prepared well.*At times the food is overcooked and at times it is cold.*She stated that there were multiple residents who did not eat their meals due to how the food was prepared and served.*She had reported her concerns to staff members but they were not the staff members who had the authority to do anything about her concerns.2. Observation on 12/29/25 at 5:23 p.m. from of the residents' meal trays in the kitchen revealed the residents' drinks were pre-poured and stored on individual resident trays on an open sided cart.3. Observation and interview with DA N on 12/29/25 at 5:32 p.m. from the dining room of the residents' during the evening meal service revealed:*With only a few resident trays left to be served, DA N was requested to measure the temperature of the milk.*DA N asked cook M how to measure the temperature of the milk.*Cook M removed a thermometer out of the sink, put hand sanitizer on the thermometer, wiped the thermometer off and gave it to dietary assistant N.*DA N measured the temperature of the milk with that thermometer and stated it was 53.6 degrees Fahrenheit (F).*When asked what the temperature of the milk was supposed to be DA N stated he would have to refer to dietary manager (DM) R.*Cook M stated the milk needed to remain between 36- and 40-degrees F for safe consumption.*DM R dumped that glass of milk out and instructed cook M to dump out all the remaining poured prepared of milk on the trays to pour new glasses of milk.4. Observation on 12/29/25 at 5:40 p.m. of DA N in the kitchen and dining room revealed:*He handled dirty linens from the kitchen and dining room with his bare hands.*With those same bare hands, he handled three glasses with his fingers by the tops inside glasses, poured milk into those glasses and then placed them on the residents' meal trays to be served to the residents.5. Observation on 12/30/25 at 11:07 a.m. of cook P in the kitchen revealed:*Cook P put on gloves without washing her hands.*She then picked up the blender that contained pureed foods, used those same gloved hands and a spatula to pour the pureed food into the tray to be placed in the steamer, wiped the pureed foods from the side of the container with her gloved hands, and placed the container in the steamer.*She removed and discarded her gloves, and did not wash her hands. With her bare hands she removed a container of coleslaw, and a container of ham spread from the refrigerator, put them on the counter, and entered the pantry that was attached to the kitchen. When she returned to the kitchen, she did not wash her hand and then put on a pair of gloves.*With those hands cook P poured ice into containers for the coleslaw container to be stored on, removed her gloves, did not wash her hands, and gathered thermometers and alcohol wipes to check the holding temperatures of the prepared foods.6. Observation and interview on 12/30/25 at 11:22 a.m. of cook P as she checked the temperatures of the residents' prepared food items revealed:*She washed her hands and put on a pair of gloves.*She checked the temperatures of all of the food that were stored in the steam table.*Cook P did not take the temperature of the fries under the heat lamp or the assorted pieces of chicken in the warmer.*Cook P placed a chicken [NAME] from that on a resident's meal tray it was served to the resident.*Cook P was asked to take the temperature of the chicken pieces. The temperatures of the chicken drummies were 130 degrees F.*Cook P then placed all the chicken pieces back into the oven.*Cook P verified she should have checked the temperature of the chicken pieces prior to serving them to the residents.*Cook P verified the dietary staff were supposed to check the temperatures of the food items to be sure the food was cooked and stored at a safe temperature before serving the food to the residents.7. Observation on 12/30/25 at 11:45 of cook Q revealed:*She did not perform hand hygiene and then began placing covers over the chocolate cake with whipped topping.*One of the pieces of caked tipped over and the whipped topping handed on cook Q's hand.*Cook Q tipped the cake back up with her bare hand, put a cover on the cake, and washed her hands8. Observation on 12/30/25 at 11:52 a.m. in the kitchen during the meal service revealed:*Cook P had gloves on and retrieved a knife from the magnet on the wall.*With those same gloved hands, she held a chicken breast with one hand as she cut the chicken breast into pieces.*DM R instructed [NAME] P to use a fork to cut up the chicken breast.*Cook P covered the plate of chicken with an insulated cover, placed it on a resident's meal tray.*Cook P used those same gloved hands to grab a bowl from the shelf by the inside and the top of the bowl. She dished soup into that bowl and placed the bowl of soup on a resident's meal tray.*At 12:00 p.m. pre-poured cold drinks were removed from the refrigerator, placed on the individual resident trays, and stored on an open sided cart in the kitchen.*Cook P again plated a resident's meal that included chicken breast with the same process observed above and she prepared two more meal trays with those same gloves on.*Cook P touched the resident's plated mashed potatoes with those same gloved hands while cutting another chicken breast to serve to the resident.*With those same gloved hands [NAME] P touched and moved potato wedges to the side of to serve to the resident and [NAME] touched a chicken breast while she cut it into pieces.*With those same gloved hands cook P moved a chicken piece to the side of a resident's plate to make room other food items.*With those same gloved hands [NAME] P picked up a piece of breaded chicken pulled it into pieces and served it to the resident. She continued to touch several other food items with those same gloved hands as she plated the residents' meals.9. Observation and interview on 12/30/25 at 12:25 p.m. of lunch meal service with cook Q revealed:*Cook Q was asked to take the temperature of the last milk being served.*Cook Q stated the milk was 50 degrees F and dumped out the milk and poured new glasses of milk to serve to the residents.10. Interview on 12/31/25 at 9:33 a.m. with DA O revealed:*Gloves were to be worn when handling ready to eat foods.*Hands should be washed entering or leaving the kitchen and before putting on gloves and after taking gloves off.11. Observation on 12/31/25 at 9:51 a.m. of DA O in the kitchen revealed:*With gloved hands DA O prepared lettuce salads, handled dirty dishes, and put sandwich meat into a plastic container.*She removed those gloves, did not wash her hands, and put cheese and lettuce salads into the refrigerator.*With her unwashed bare hands, she handled dirty dishes, picked up trash off the floor, and then wiped off the counter where she had prepared food.12. Review of the provider's October 2025 through December 2025s food temperature log revealed:*There were no documented temperatures of the prepared food items that were to be plated and served to the residents.*There were no documented temperatures of hot or cold drinks to be served to the residents.13. Interview on 12/31/25 at 2:40 p.m. with DM R revealed:*She expected gloves to be worn by the staff when handling ready to eat foods.*Gloves should be removed and discarded when they were visibly soiled, and hands should be washed before putting on gloves and after removing gloves.*She expected staff to use clean gloves or clean hands to prepare and serve resident's meals.*Staff were to wash their hands when they entered the kitchen, and after using the bathroom.*The food temperatures were to be checked when it was done cooking ensure it was completely cooked and then prior to serving to ensure it was held at a safe temperature.*She verified staff only documented the cooking temperatures of food and not the holding temperatures.*She verified she could not be sure the holding food temperatures had been taken or within the safe holding temperature ranges if they were not documented.*She verified that the temperatures of the milk and chicken on 12/29/25 and 12/30/25 did not meet the safe temperature ranges.14. Review of the provider's 2023 Food Temperatures policy revealed:* The temperatures of all food items will be taken and properly recorded prior to the service of each meal.1. All hot food items must be cooked to appropriate internal temperatures, held and served at a temperature of at least 135 [degrees] F.* Hot food items may not fall below 135 [degrees] F after cooking, unless it is an item which is to be rapidly cooled to below 41 [degrees].* Temperatures should be taken periodically to assure hot foods stay above 135 [degrees] F and cold foods stay below 41 [degrees] F during the holding and plating process and until food leaves the service area.* Food preparation areas will follow these methods:a. Hold foods at or below 41 [degrees] F for cold foods and at or above 135 [degrees] F for hot food (to keep out of the temperature danger zone.Review of the provider's 2023 Bare Hand Contact with Food and Use of Plastic Gloves policy revealed:* Single use gloves or other barriers will be used when handling food directly with hands to assure that bacteria are not transferred from the food handlers' hands to the food product being served. Barehand contact with food is prohibited.* Staff will use clean barriers such as single use gloves, tongs, deli paper and spatulas when handling foods.* Gloved hands are considered a food contact surface that can become contaminated or soiled. If used, single use gloves shall be used for only on task such as working with ready-to-eat (RTE) food or with raw animal food, used for no other purpose and discarded when damaged or soiled, or when interruptions occur in the operation.* Hands are to be washed when entering the kitchen and before putting on single use gloves (before beginning work with food) and after removing single use gloves.* Clean gloves are to be used when:a. Handling ready-to-eat foods.f. Anytime hands would otherwise touch food directly.* Gloves are just like hands. They get soiled. Anytime a contaminated surface is touched, the gloves must be changed and hands must be washed:.During food preparation, as often as necessary to remove soil and contamination and prevent cross contamination when changing tasks.After engaging in other activities that may possibly contaminate the hands with bodily fluids.Any time a contaminated surface is touched.* Hands should be washed after removing gloves.

Based on observation, interview, record review, and policy review, the provider failed to ensure infection control practices were followed regarding: *Cleaning of mechanical lifts and slings by three of three certified nursing assistants (CNA) (W, Z, and AA) observed while transferring three of three sampled residents (9, 24, and 25).*Hand hygiene completed by five of five CNAs (W, X, Z, BB, and CC) observed when assisting three of three sampled resident (17, 24, and 50) with cares.*Hand hygiene completed by two of two CNAs (W and Y) observed assisting five of five sampled resident (1, 9, 16, 25, and 40) to eat. *Use of personal protective equipment by two of two CNAs (X and AA) while providing resident care to one of one sampled resident (24) who was on enhanced barrier precautions (EBP). Findings include: 1. Observation on 12/29/25 at 2:24 p.m. in the common area of the Challenging Behavior Unit (CBU) revealed: *There was a sling made of cloth material draped over the sit-to-stand mechanical lift (a mechanical lift used to assist from a seated to a standing position) in the hallway. *There were no disinfectant wipes available for use on the mechanical lift. *Certified nursing assistants (CNAs) W and Z pushed the sit-to-stand lift in front resident 9's recliner, put the sling that was draped over the lift behind resident 9, and assisted her to a standing position. -While resident 9 was raised to a standing position with the sit-to-stand lift her shirt lifted and the strap of the sling came in direct contact with her skin. *CNAs W and Z did not clean the lift or perform hand hygiene (handwashing) after using the sit-to stand lift to assist resident 9. *CNAs W brought the sling that was used for resident 9 to resident 25's recliner. As she was bringing the sling to resident 25's recliner she dragged the strap of the sling on the floor. *CNAs W and Z placed that sling behind resident 25 and assisted him into his wheelchair while using the sit-to-stand lift. *CNA Z draped the sling back over the sit-to-stand lift and placed the lift in the hallway and did not clean the lift. *Without having performed hand hygiene CNA W assisted resident 9 to a dining table. *Without performing hand hygiene CNA W put on gloves and gave resident 25 Oreo cookies. *CNA W removed her cloves, did not perform hand hygiene, and gave resident 16 a can of pop from the refrigerator and a cookie. *CNA W wiped her nose with the back of her bare hand, did not perform hand hygiene. She then put on a pair of gloves, and assisted resident 9 with eating a donut. *CNA W removed her left glove, rolled the glove into the palm of her hand, and with her right gloved hand continued to assist resident 9 with eating a donut. *While holding the soiled glove in her left hand, CNA W used her left hand to assisted resident 40 to drink pop. *CNA W used her ungloved left hand with the soiled glove in it to lift the lid on the garbage can for a resident, did not perform hand hygiene, and then assisted resident 9 to drink pop. *CNA W then removed the glove from her right hand discarded both gloves and did not perform hand hygiene. *While CNA Y was assisting resident 1 with eating yogurt, she removed her gloves, and did not perform hand hygiene, and continued assisting residents eat their snacks. 2. Observation on 12/29/25 at 3:07 p.m. outside resident 25's room revealed: *There was a sign on the outside of his door that indicated he was on enhanced barrier precautions (EBP) which required glove and gown use when providing contact care. *The EBP sign from the Centers for Disease Control and Prevention (CDC), which hung outside of resident 25's door revealed: -It stated, 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 resident care activities. -dressing -bathing/showering -Transferring -changing Linens -providing hygiene -changing briefs or assisting with toileting -device care or use. -wound care: any skin opening requiring a dressing. *There were gowns and gloves hanging on his door and available for use. Review of resident 25's electronic medical record revealed he was on EBP due to a recurring infection to his elbow and a history of Methicillin-resistant Staphylococcus aureus, a bacteria that is resistant to several common antibiotics that spreads from direct contact or contact with contaminated surfaces (MRSA). 3. Observation on 12/29/25 at 4:32 p.m. in The Manor common area of CNA X revealed: *CNA X did not wash his hands and then put on a pair of gloves. *He put foot pedals on resident 17's wheelchair, removed his gloves, did not perform hand hygiene, and then went into resident 24's room to prepare resident 24 to transfer out of his bed. 4. Observation on 12/29/25 at 4:50 p.m. of CNA s X and AA in resident 24's room revealed: *There was a sign on the outside of his door that indicated he was on EBP. *There were gowns and gloves hanging on the outside of resident 24's door. *CNAs X and AA entered resident 24's room, did not apply gowns, used the manual full body lift (a lift and sling used to lift a person's full body), and transfer resident 24 from his bed to his wheelchair. *CNA AA did not clean the full body lift and pushed it into an unoccupied resident room used for storage and left it in that room. 5. Observation and interview on 12/30/25 at 10:58 a.m. with CNAs BB and CC, in resident 50's room revealed: *Resident 50 was sitting in his wheelchair with a urinary catheter (flexible tubing placed in the bladder to drain urine) bag that hung on the side of his wheelchair. *CNAs BB and CC stated they were going to transfer the resident to his bed and then to his recliner. *CNA CC did not wash her hands, and put on a gown and gloves. *CNA BB washed her hands and put on a gown and gloves. *CNAs BB and CC transferred Resident 50 to his bed using a total body lift. *CNAs BB and CC lowered resident 50's pants. CNA CC removed his incontinence brief, wiped his perineal area and buttocks with a wet cleaning wipe, and put barrier cream on resident 50's perineal (genital area) and buttocks. *With those same gloved hands, CNA CC assisted CNA BB to pull up resident 50's pants. *With those same gloved hands, CNA CC then adjusted his urinary catheter (flexible tubing placed in the bladder to drain urine) tubing and bag, transferred him to his recliner, held his hands during the transfer, placed his urinary catheter bag on the side of the recliner, covered him up with a blanket, moved a folding chair, and then took off her gown and gloves, discarded them, and washed her hands. *CNA BB left the residents room while wearing the same gown and gloves on, walked over to the laundry room door, took off her gloves, did not wash her hands, grabbed keys to open the laundry room door, took off her gown, entered the laundry room, exited the laundry room, and then walked over to a sink in the kitchenette and washed her hands. Interview with CNA's BB and CC immediately after the observations above revealed resident 50 was on EBP because he had a catheter and an open skin wound. CNAs were to wash their hands before and after assisting residents with their care and when changing. CNA BB should have taken off her gown and gloves and washed her hands before leaving the resident's room. CNA CC should have removed her gloves, washed her hands, and put on a new pair of gloves after she put the barrier cream on the resident. Review of Resident 50's EMR (electronic medical record) revealed: *He was admitted on [DATE]. *He had a pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) to his right ankle. *He had a urinary catheter. *His 12/25/25 care plan indicated he was on EBP because he had a feeding tube (a flexible tube that delivers liquid food and medicine directly to the stomach when unable to eat or drink by mouth). 6. Interview on 12/31/25 at 10:26 a.m. with CNA T revealed: *Each resident who used the sit-to-stand lift had their own sling. *If a sling became soiled it was to be sent to laundry to be cleaned. *The mechanical lifts were to be cleaned with disinfectant wipes between each resident use. *The disinfectant wipes were stored in a locked closet in the kitchenette. *She said when a resident was on EBP staff were to wear a gown and gloves when they assisted the resident to the toilet, changed their brief, or changed the resident's clothes. *She said gown did not need to be worn when transferring a resident on EBP. 7. Interview on 12/31/25 at 10:43 a.m. with licensed practical nurse (LPN) D revealed: *Hand hygiene was to be performed after using the toilet, after eating, before and after and resident cares, and before and after the use of gloves. *Residents on EBP were identified by the signage and the personal protective equipment on their door. *Residents would be on EBP if they had an infection or a urinary catheter. 8. Interview on 12/31/25 at 3:09 p.m. with director of nursing (DON) B revealed: *She expected hand hygiene to be completed anytime a staff member entered or exited a resident room, before and after providing resident contact care, and after assisting one resident, and before assisting another. *She expected staff to wear a gown and gloves when they provided direct care for residents on EBP, which included transferring residents in their rooms. *Each resident had their individual lift slings. *She expected the lifts to be cleaned between each use. *She verified not cleaning the lifts between resident and sharing lift slings could risk infections and allow for cross contamination between residents. *She stated when the sling strap was dragged on the floor, it was soiled and should have been sent to laundry, not used on another resident. 9. Review of the provider's 11/2025 LTC (long term care)- Hand Hygiene policy revealed: *Hand hygiene (HH) continues to be the primary means of preventing the transmission of infection. *HH, either with soap and water or with alcohol based hand rub (ABHR): 1. immediately before touching a resident 2. before a clean procedure or handling an invasive medical device 3. after contact with potential for body fluid or contaminated surfaces 4. after touching a resident or the resident's immediate environment 5. after removing gloves 10. Review of the provider's undated LTC - Transmission Based Precautions and Enhanced Barrier Precautions policy revealed: *Purpose: -To provide infection prevention and control recommendations for long-term-care. -Transmission of infectious organisms within a healthcare setting requires three elements to be linked: -A source (or reservoir) of infectious organisms -A susceptible host -A means of transmission for the organism. -Interruptions of this link in the chair of infection is achieved primarily by separating an individual physically (Transmission Based Precautions) or using a barrier (Enhanced Barrier Precautions). *[Provider] will incorporate the use of Standard Precautions, Enhanced Barrier Precautions, and additional Transmission Based Precautions as indicated for known, suspected or incubating infections or communicable diseases, and for the protection of residents, visitors, and staff from potential exposure to communicable and transmissible diseases. *Enhanced Barrier Precautions are used during high contact resident care activities for the following residents: Infection or colonization with an MDRO when contract precautions do not otherwise apply Wound requiring a dressing, regardless of MDRO status (e.g. central line, urinary catheter, feeding tube, trach) If a, b, or c: gown and gloves to be worn during high contact resident care activities, including (but not limited to) i. dressing ii. Bathing or showering iii. Transferring iv. Providing hygiene v. changing linen vi. Device care or use (Central lines, urinary catheter, feeding tube, trach adjustment/care) viii. Wound care (any wound requiring a dressing) *Staff is responsible for complying with precautions and for tactfully calling observed infractions to the attention of offenders. *In addition to what is posted on precautions signage, follow Standard Precautions by type of exposure anticipated and with additional tasks: a. Work from 'clean to dirty' b. Limit opportunities for 'touch contamination'-protect yourself, others, and the environment. If contamination occurs, remove PPE [personal protective equipment], complete hand hygiene and don clean PPE c. Do not touch your face or adjust PPE with contaminated gloves d. Do not touch environmental surfaces (including privacy curtains) except as necessary during resident care *Remove PPE appropriately and complete hand hygiene before leaving the room

Based on South Dakota Department of Health (SD DOH) facility-reported incidents (FRI), record review, interview, and policy review, the provider failed to ensure staff followed a resident's documented do not resuscitate (DNR) code status wishes for one of one closed record sampled resident (52) when discovered with no pulse or respirations by staff and was then provided cardiopulmonary resuscitation (CPR) without first verifying the resident's code status. Findings include: 1. Review of the provider's [DATE] SD DOH FRI revealed:*On [DATE] at 5:20 a.m. a nurse obtained resident 52's vitals which were stable, and her blood sugar was reading high both times it was checked and then assisted resident 52 (who had agreed to go to the hospital) to the restroom.*The nurse called the on-call provider to report on resident 52's condition and to receive orders to administer insulin and Zofran (medication for nausea).*A second nurse went to resident 52's room and found her slumped over on the toilet and heard a gurgling noise. The resident's vitals were not able to be obtained. Resident 52 was transferred to the floor where staff started CPR, and applied an AED (automated external defibrillator).*Three nurses performed chest compressions on resident 52. *The director of nursing (DON) B arrived during resuscitation efforts in resident 52's room and informed staff to stop CPR due to the resident having no breath sounds or an apical pulse. The resident's time of death was reported as 7:05 a.m. on [DATE] at the facility. 2. Review of resident 52's closed electronic medical record (EMR) revealed:*She was admitted to the facility on [DATE].*She had an advance directive (a document that expresses a person's health care wishes if they become unable to speak for themselves) signed by her legal representative and physician on [DATE] indicating her resuscitation code status was a DNR/DNI.*There was an active physician's order on [DATE] indicating she was a DNR/DNI. 3. Interview on [DATE] at 8:35 a.m. with DON B and administrator A about the FRI regarding resident 52 revealed:*There were three nurses (licensed practical nurse (LPN) F, registered nurse (RN) K, and LPN DD) involved in the above incident on [DATE].*The nurses had started CPR on resident 52, checked the code status which was a DNR/DNI, but continued performing CPR.*The nurses involved explained to DON B that they thought since they had already started CPR they were to continue until EMS had arrived.*By the time DON B had arrived and verified that resident 52 was a DNR/DNI the nurses had been performing CPR on resident 52 for about 20 minutes.*DON B and administrator A spoke with the medical director who reported that the staff should have stopped CPR once they confirmed the code status of a resident was a DNR.*On [DATE] DON B conducted a nurses meeting after resident 52's incident where she educated the staff on advance directives and code statuses.*She expected her staff to call for help, grab the crash cart, call a supervisor and the provider, and check the code status in the event a resident was unresponsive.*DON B did not expect the staff to recall a resident's code status and expected the staff to start CPR until they could verify the code status of the resident.*The code statuses of residents were identified in their EMR and on the hall sheets (lists residents' care needs and interventions) that the staff members were to carry with them while they worked.*They stated they had not performed any auditing or monitoring to ensure the residents' code statuses were identified or that the staff were aware of the expectations regarding their processes for providing life sustaining measures according to a resident's code status after resident 52's incident. 4. Interview on [DATE] at 9:45 a.m. with LPN L revealed:*She had started working at the facility in [DATE].*She had received general education regarding advance directives and code status.*She explained she would not start CPR on a resident with a DNR code status if the resident was unresponsive with no pulse or respirations.*Resident code statuses were identified in the EMR and the hall sheets. 5. Interview on [DATE] at 9:57 a.m. with LPN D revealed:*She started working at the facility in [DATE].*Resident code statuses were identified in the EMR and the hall sheets.*In an emergency, she would check a resident's code status before beginning CPR.*She received mandatory education about advance directives and code statuses. 6. Interview on [DATE] at 10:09 a.m. with certified nursing assistant (CNA) J revealed:*She had worked at the facility for about a week.*She was CPR certified.*She watched orientation training videos, but they did not provide education specifically regarding a resident's code status.*Resident's code statuses were identified in the EMR and the hall sheets. 7. DON B was unable to provide signed education documentation of the nursing staff to verify who attended the nurses meeting on [DATE] after resident 52's [DATE] incident. 8. Review of the provider's new hire orientation and annual education for staff revealed they provided education on advance directives and resident code statuses. 9. Review of the provider's reviewed 10/2025 LTC Code Status/Resuscitation policy revealed:* To provide staff with accurate information in the event of cardiac and/ or respiratory arrest.* e. A 'Medical Emergency' [a health condition or situation that needs immediate medical attention] is initiated on any resident needing emergency resuscitation due to a cardiac and/ or respiratory arrest unless there is a 'Do Not Resuscitate' order documented in the resident's electronic medical record. 10. Review of the provider's [DATE] Advance Directive policy revealed:* It is the policy of this facility will provide basic life support, including CPR - Cardiopulmonary Resuscitation, when a resident requires such emergency care, prior to the arrival of emergency medical services, subject to physician order and resident choice indicated in the resident's advance directives. Nurses are educated to initiate CPR, as recommended by the American Heart Association (AHA) unless: A valid Do Not Resuscitate order is in place.

Based on South Dakota Department of Health (SD OH) facility-reported incident (FRI), record review, observation, interview, and policy review, the provider failed to protect the resident's right to be free from sexual abuse by one of one sampled resident (3) who made unsolicited sexual advances towards one of one sampled resident (2). Resident 3 had a history of sexually inappropriate behavior and required close supervision while in common areas around peers. Findings include: 1. Review of the SD FRI report dated 6/9/25 revealed: *The incident occurred on 6/7/25. *Residents 2 and 3 ambulated via wheelchairs independently. *Residents 2 and 3 were in a hallway unmonitored by staff. *Resident 3 propelled himself in his wheelchair up to resident 2 and rubbed her right leg then rolled away from her. *Certified nursing assistant (CNA) J talked to residents 2 and 3 in the hallway but had not separated the residents. *Resident 3 put hand sanitizer on his hands, rolled over to resident 2 and put some of the sanitizer on her hands, started to rub her lap, and touched her private area. *CNA J realized they were next to each other and removed resident 3 from the area and moved resident 2 into the dining room near the table. *CNA J notified the nurse of the situation. *Resident 2's vital signs (measurement of the body's basic functions) were as follows: blood pressure (BP) 153/78, pulse 68, oxygen saturation (level of oxygen in blood) 95 percent on room air. *Resident 2's doctor and family were notified of the incident. *Staff were reminded of the need for resident 3 to be monitored in the commons area at all times. 2. Observation and interview on 6/18/25 at 7:46 a.m. of camera footage from 6/7/25 with director of nursing (DON) B revealed: *On 6/7/25 at 10:43 a.m. residents 2 and 3 were in their wheelchairs in the challenging behavior unit (CBU) dayroom. *Resident 2 moved from the hall toward resident 3. *Resident 3 backed up toward resident 2, and rubbed his right hand on her right leg. *There were no staff in view at that time. *Resident 2 wheeled herself away from resident 3. *Resident 3 followed her and pushed on the right wheel of resident 2's wheelchair as he continued to follow her down the hallway. *At 10:45 a.m. CNA J came into view from the dining room, she went back into the dining room but did not enter or look down the hall where residents 2 and 3 were. -CNA J did not attempt to intervene or stop the interaction between the two residents. *Resident 2 wheeled herself back up the hall toward resident 3 who was getting hand sanitizer from the wall dispenser. -They had moved toward each other in the hall, but resident 2 then turned and went away away from resident 3. *No staff were seen in that area, resident 2 was seen seated in her wheelchair with her right side toward resident 3 who had moved toward her. *Resident 2 then turned and began to move. *CNA J was in the doorway but did not face them and turned back away from them. -CNA J went back into the dining room without attempting to stop the interaction between resident 2 and resident 3. *Resident 3 wiped his hands on his shirt. *Resident 2 turned back towards him and stopped herself by resident 3. *Resident 3 rubbed resident 2's hands, turned toward her, patted and rubbed her hand, and then moved his hand to her private area between her legs. *At 10:52 a.m. resident 3 turned away and the two residents separated from each other. -Resident 3 rolled back up the hallway. *Resident 2 attempted to go into a room identified as hers by DON B. *Resident 3 went back toward resident 2 but CNA J took him back toward the day room and dining room area. *Licensed practical nurse (LPN) E did not come in to view on the footage during the interactions between residents 2 and 3. *DON B agreed resident 3 had touched resident 2's private area between her legs, without her consent. *DON B stated LPN E should have completed an assessment on resident 2 for the physical and emotional well-being and contacted her. *DON B would have expected LPN E to have known to do those things as a nurse. *DON B explained that the 1:1 within arm reach at all times regarding residents 2 and 3 that was indicated on the hall sheets was to ensure residents had close monitoring. -Resident 3 was easily agitated if staff had gotten too close to him. -The staff had been instructed to remain in close vicinity of him so they could have intervened quickly when he exhibited inappropriate behaviors. *DON B was out of the facility on 6/12/25 and there had been no further internal investigation completed from the 6/7/25 incident between resident 2 and 3 until today, 6/18/25. -She had become aware of the incident on 6/9/25 but no internal investigation was initiated to rule out abuse and neglect at the time of the incident or at the time of her awareness. *DON B thought the staff may have been in the bathroom when not in view on the footage. 3. Interview on 6/17/25 at 9:25 a.m. with housekeeper D regarding the above 6/7/25 incident revealed: *She had worked the day of 6/7/25 and had been cleaning the nurse's station in the manor unit which adjoined the CBU with double doors with windows when the incident occurred but could not remember the time. *She stated she looked into the CBU and saw resident 2 and 3 sitting by each other in their wheelchairs in the hallway. *Resident 3 was using hand sanitizer on his hands. *Resident 3 then put his right hand on resident 2's left leg, rubbed her leg, and moved his hand up to her private area between her legs, and then he stopped. -She though resident 3 stopped because he had seen her through the window. *She could not see any staff in the area and went into the CBU and found LPN E at the nurse's station. *She stated a contracted travel CNA was in the dining room when she and LPN E had come back out of the nurses' station. She reported to them what she had seen. *She stated she reported the incident between residents 2 and 3 to DON B on Monday, 6/9/25, when she saw her. 4. Interview on 6/17/25 at 10:30 a.m. with LPN E regarding the above incident revealed: *She had been finishing up things in the CBU nurses' station when housekeeper D reported to her that she thought she saw resident 3 put his hands down resident 2's pants. *She stated she came out of the nurse's station and CNA J was in the hallway near the dining room. *CNA J had reported that resident 3 had put hand sanitizer on resident 2's hands and she moved resident 2 up to the dayroom. -Resident 3 was down at the end of the hall and then came up the to sit next to resident 2 in the day room. *LPN E stated: -She had been at the nurse's station and had not realized resident 3 was that close to resident 2. -She had documented a progress note of what she was told had occurred from the staff. -When DON B came back to the facility on 6/9/25, she called LPN E in to her office to ask her what had happened on 6/7/25 . -Resident 3 had put sanitizer on resident 2 and the camera footage showed he had put his hand on her knee. -That is all I saw. -She did not think the 6/7/25 incident was substantial and had not completed an assessment on resident 2 after the incident. She had not completed an incident report, but she documented about it in a progress note. -Stated she had checked resident 2's vital signs the following Monday on 6/9/25 after she had discussed the incident with DON B. 5. Review of resident 3's progress note dated 6/7/25 revealed: *LPN E was the author of that note. *The note indicated, Housekeeping reported to nurse that she thought she had seen resident put his hands down a females [female's] pants. Writer asked CNA and she stated that what she [had] seen was resident putting hand sanitizer on the females [female's] hands. CNA did intervene and moved resident away from the female resident. Will continue to monitor for behaviors. *There were no further follow up notes or assessment related to the resident's well-being after that time. 6. Review of resident 3's EMR revealed: *He admitted to the facility on [DATE], *His diagnosis included dementia (forgetfulness), altered mental status (confusion), and anxiety. *His quarterly cognitive status dated 6/6/25 indicated: -Makes Self Understood, Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. -Ability To Understand Others, Understands-clear comprehension. *His care plan interventions indicated: - I need close supervision when I am in common areas around my peers to ensure that I do not harm others or interfere with their with their daily living, which was initiated on 1/28/25. -Staff to monitor me closely due to my history of being sexually inappropriate with female peers and making socially inappropriate comments to/about female staff, which was initiated on 9/2/25. -I need staff to monitor me with the females on the unit due to having a history of being inappropriate with them. Examples: Undressing them and getting them into my room, which was initiated on 9/2/24. 7. Review of resident 2's electronic medical record revealed (EMR) revealed: *She was admitted to the facility on [DATE]. *Her diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), anxiety, Psychotic disturbance (hallucinations, delusions, and disorganized thinking), mood disturbance. *Her quarterly cognitive status dated 5/5/25 indicated: - Makes Self Understood, Rarely/never understood. -Ability To Understand Others, Sometime understands-responds adequately to simple, direct communication only. 8. The facility did not have a policy regarding incident reports. Their documentation for Incident Reporting for residents was a part of their electronic medical record system referred to as point click care (PCC). The nurses had the option to choose from a drop down menu to complete their documentation which included: -Med error; Med error Wrong Med. -Physical Aggression Initiated. -Physical Aggression Received. -Alleged Abuse. -Alleged Neglect. -Choking. -Elopement. -Self-Inflected Injury. -Pressure Ulcer. -Injury. -Fall-Witnessed; Unwitnessed' During staff assist. 9. Review of the CNA & Nurses Meeting (February 18th, 2025) revealed: * We met with CNA staff and Nursing Staff to cover this topic. -Incident/Falls: [resident 3] in CBU is on 1:1. 1 [One] staff member should be within arms length, or in the vicinity of him at all times. He can still visit with and be near his peers, but staff should be able to easily intervene and prevent him from harming others. This does not mean that every time he opens his mouth or goes to visit with someone, we immediately move his wheelchair. When it is time for breaks-as long as there is 1 CNA on the floor for pt care and 1 on the floor for the 1:1 you are ok to [take] breaks. If there are several behaviors going on then you [your] nurse needs to be on the floor with you or you need to have [medical records [(MR)]/[CNA]/medication aide [(MA)]/infection control [(IC)] [K], myself (DON) [B], someone come cover also or you need to wait to take break. We have had 14 state reports in January, 12 of those in the CBU. Nurses should be coming out of the office and assisting in the monitoring halls/dayroom etc. 10. Review of the daily hall sheet used by the staff indicated both resident 2 and 3 were 1:1 within arm length at all times as explained above. 11. Review of the provider's Abuse Prohibition policy dated 3/2024 revealed: * The purpose is to establish guidelines to identify and report suspected abuse, neglect or exploitation of disabled adult residents or a resident's inability to care for self. Residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation, and involuntary seclusion. It is the policy of this facility to protect residents from abuse, regardless of the source, and to have an effective system in place for reporting and investigating incidents. Staff will be available in adequate numbers to insure [ensure] that each shift has sufficient staff to provide care that meets the resident's needs. Staff is responsible to know the resident's care plan they are providing care for. *Definitions of Adult Abuse: .Sexual abuse is non-consensual contact of any type with a resident. *It was the policy of the provider to institute a zero tolerance for any form of abuse to any and all residents. *Procedure. *2. Report the incident verbally or in writing to a Charge Nurse or Department Manager. This will initiate investigation of the incident. Clear concise documentation of indisputable evidence is critical for protection of the resident. Document in the resident chart specifics of the investigation, including both the resident and the caregivers' explanation of what occurred. The charge nurse will assess, if immediate medical attention is needed and a preliminary investigation will be completed. *3. The Administration will complete a thorough investigation of the incident, including interviews with staff, residents and family as appropriate and complete a written report of these findings.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review, the provider failed to complete a resident assessment for the physical and emotional well-being of one of one resident (2) who experienced unsolicited touching of her body by one of one resident (3) following alleged abuse for one of one sampled resident (2). Findings include: 1. Review of the SD FRI report dated 6/9/25 revealed: *The incident occurred on 6/7/25. *Residents 2 and 3 ambulated via wheelchairs independently. *Residents 2 and 3 were in a hallway unmonitored by staff. *Resident 3 propelled himself in his wheelchair up to resident 2 and rubbed her right leg then rolled away from her. *Certified nursing assistant (CNA) J talked to residents 2 and 3 in the hallway but had not separated the residents. *Resident 3 put hand sanitizer on his hands, rolled over to resident 2 and put some of the sanitizer on her hands, started to rub her lap, and touched her private area. *CNA J realized they were next to each other and removed resident 3 from the area and moved resident 2 into the dining room near the table. *The nurse was notified of the situation. *Resident 2's vital signs (measurement of the body's basic functions) were as follows: blood pressure (BP) 153/78, pulse 68, oxygen saturation (level of oxygen in blood) 95 percent on room air. *Resident 2's doctor and family were notified of that incident. *Staff were reminded of the need for resident 3 to be monitored in common areas at all times. 2. Observation and interview on 6/18/25 at 7:46 a.m. of camera footage from 6/7/25 with director of nursing (DON) B revealed: *On 6/7/25 at 10:43 a.m. residents 2 and 3 were in their wheelchairs in the challenging behavior unit (CBU) dayroom. *Resident 2 moved from the hall toward resident 3. *Resident 3 backed up toward resident 2, and rubbed his right hand on her right leg. *There were no staff in the area. *Resident 2 wheeled herself away from resident. *Resident 3 followed her and pushed on the right wheel of resident 2's wheelchair as he continued to follow her down the hallway. *At 10:45 a.m. CNA J came into view from the dining room and then went back into the dining room. -She was not observed intervening or stopping the inappropriate actions between residents 2 and 3. *Resident 2 wheeled herself back up the hall toward resident 3 who was getting hand sanitizer from the wall dispenser. -They had moved toward each other in the hall, but resident 2 then turned and went away away from resident 3. *No staff were seen in that area at that time. *Resident 2 was seen seated in her wheelchair with her right side toward resident 3 who had moved toward her. *Resident 2 then turned and began to move. *CNA J was in the doorway but had not faced them. -CNA J turned back away from the residents and went back into the dining room. *Resident 3 wiped his hands on his shirt. *Resident 2 turned back toward him and stopped herself by resident 3. *Resident 3 rubbed resident 2's hands, turned toward her, patted and rubbed her hand, and then moved his hand to her private area between her legs. *At 10:52 a.m. he turned back away and resident 2 and 3 separated as he rolled back up the hallway. *Resident 2 attempted to go into a room identified as hers by DON B. *Resident 3 went back toward resident 2 but CNA J took him back toward the dayroom and dining room area. *Licensed practical nurse (LPN) E did not come in to view on the footage when the above interactions occurred. *DON B agreed resident 3 had touched resident 2's private area between her legs, without her consent. *DON B stated LPN E should have completed an assessment on resident 2 for the physical and emotional well-being of her and contacted her. -She would have expected LPN E to have known to do those things as a nurse. *DON B explained that the 1:1 within arm reach at all times regarding residents 2 and 3 that was indicated on the hall sheets was to ensure resident needed close monitoring. Resident 3 would get agitated if staff would get too close to him at times, so staff were to be in close vicinity to intervene. *DON B was out of the facility on 6/12/25. There had been no further internal investigations completed from Monday 6/9/25 when she had initially become aware of the incident until today 6/18/25. *DON B thought the staff may have been in the bathroom when not in view on the footage. 3. Interview on 6/17/25 at 9:25 a.m. with housekeeper D regarding the above 6/7/25 incident revealed: *She had worked the day of 6/7/25 and had been cleaning the nurse's station in the manor unit which adjoined the CBU with double doors with windows when the incident occurred but could not remember the time. *She stated she looked into the CBU and saw resident 2 and 3 sitting by each other in their wheelchairs in the hallway. *Resident 3 was using hand sanitizer on his hands. *Resident 3 then put his right hand on resident 2's left leg, rubbed her leg, and moved his hand up to her private area between her legs, and then he stopped. She though resident 3 stopped because he had seen her through the window. *She could not see any staff and went into the CBU and found LPN E in the nurse's station area. *She stated a contracted travel CNA was in the dining room when she and LPN E had come back out of the nurses' station. She reported to them what she had seen. *She stated she reported the incident between residents 2 and 3 to DON B on Monday, 6/9/25, when she saw her. 4. Interview on 6/17/25 at 10:30 a.m. with LPN E regarding the above incident revealed: *She had been finishing up things in the CBU nurses' station when housekeeper D reported to her that she thought she saw resident 3 put his hands down resident 2's pants. *She stated she came out of the nurse's station and CNA J was in the hallway near the dining room. *CNA J had reported that resident 3 had put hand sanitizer on resident 2's hands and she moved resident 2 up to the dayroom. -Resident 3 was down at the end of the hall and came up the hall and was sitting next to resident 2 in the day room. *LPN E stated she had been in the nurse's station and had not realized resident 3 was that close to resident 2. *LPN E stated she had documented a progress note of what she was told had occurred from the staff. *She stated when DON B came back to the facility on 6/9/25, she had asked her what happened on 6/7/25. *She saw resident 3 had put sanitizer on resident 2 and the camera footage showed he had put his hand on her knee. -She stated, That is all I saw. *She stated she did not think the 6/7/25 incident was substantial and had not completed an assessment on resident 2 after the incident. *She had not completed an incident report, but she documented about it in a progress note. *She stated she had checked resident 2's vital signs the following Monday 6/9/25 after she had discussed the incident with DON B. 5. Review of resident 3's progress note dated 6/7/25 revealed: *LPN E was the author of that note. *The note indicated, Housekeeping reported to nurse that she thought she had seen resident put his hands down a females [female's] pants. Writer asked CNA and she stated that what she [had] seen was resident putting hand sanitizer on the females [female's] hands. CNA did intervene and moved resident away from the female resident. Will continue to monitor for behaviors. *There were no further follow up notes or assessment related to the resident's well-being after that time. 6. Review of resident 2's electronic medical record revealed (EMR) revealed: *She was admitted to the facility on [DATE]. *Her diagnosis included dementia (a group of symptoms affecting memory, thinking and social abilities), anxiety, Psychotic disturbance (hallucinations, delusions, and disorganized thinking), mood disturbance. *Her quarterly cognitive status dated 5/5/25 indicated: - Makes Self Understood, Rarely/never understood. -Ability To Understand Others, Sometime understands-responds adequately to simple, direct communication only. 7. Review of resident 3's EMR revealed: *He admitted to the facility on [DATE]. *His diagnosis included dementia, altered mental status, and anxiety. *His quarterly cognitive status dated 6/6/25 indicated: -Makes Self Understood, Usually understood-difficulty communicating some words or finishing thoughts but is able if prompted or given time. -Ability To Understand Others, Understands-clear comprehension. *His care plan indicated the staff were to monitor him closely due to his history of being sexually inappropriate with female peers and making socially inappropriate comments to and about female staff, which was initiated on 9/2/24. -He needed close supervision when he was in common areas around peers to ensure that he did not harm others or interfere with their daily living and which was initiated on 1/28/25. 8. The facility did not have a policy regarding incident reports. Their documentation for Incident Reporting for residents was a part of their electronic medical record system referred to as point click care (PCC). The nurses had the option to choose from a drop down menu to complete their documentation which included: -Med error; Med error Wrong Med. -Physical Aggression Initiated. -Physical Aggression Received. -Alleged Abuse. -Alleged Neglect. -Choking. -Elopement. -Self-Inflected Injury. -Pressure Ulcer. -Injury. -Fall-Witnessed; Unwitnessed' During staff assist. 9. Review of the CNA & Nurses Meeting (February 18th, 2025) revealed: * We met with CNA staff and Nursing Staff to cover this topic. -Incident/Falls: [resident 3] in CBU is on 1:1. 1 staff member should be within arms length, or in the vicinity of him at all times. He can still visit with and be near his peers, but staff should be able to easily intervene and prevent him from harming others. This does not mean that every time he opens his mouth or goes to visit with someone, we immediately move his wheelchair. When it is time for breaks-as long as there is 1 CNA on the floor for pt care and 1 on the floor for the 1:1 you are ok to [take] breaks. If there are several behaviors going on then you [your] nurse needs to be on the floor with you or you need to have [medical records [(MR)]/[CAN]/medication aide [(MA)]/infection control [(IC)] [K], myself (DON) [B], someone come cover also or you need to wait to take break. We have had 14 state reports in January, 12 of those in the CBU. Nurses should be coming out of the office and assisting in the monitoring halls/dayroom etc. 10. Review of the daily hall sheet used by the staff indicated both resident 2 and 3 were 1:1 within arm length at all times. 11. Review of the provider's Abuse Prohibition policy dated 3/2024 revealed: *The purpose is to establish guidelines to identify and report suspected abuse, neglect or exploitation of disabled adult residents or a resident's inability to care for self. Residents have the right to be free from verbal, sexual, physical and mental abuse, corporal punishment, exploitation, and involuntary seclusion. It is the policy of this facility to protect residents from abuse, regardless of the source, and to have an effective system in place for reporting and investigating incidents. Staff will be available in adequate numbers to insure [ensure] that each shift has sufficient staff to provide care that meets the resident's needs. Staff is responsible to know the resident's care plan they are providing care for. *Procedure. *2. Report the incident verbally or in writing to a Charge Nurse or Department Manager. This will initiate investigation of the incident. Clear concise documentation of indisputable evidence is critical for protection of the resident. Document in the resident chart specifics of the investigation, including both the resident and the caregivers' explanation of what occurred. The charge nurse will assess, if immediate medical attention is needed and a preliminary investigation will be completed. *3. The Administration will complete a thorough investigation of the incident, including interviews with staff, residents and family as appropriate and complete a written report of these findings.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interviews, record review, and lift manufacturer's instructions, the provider failed to ensure that one of one sampled resident (1) was free from accident hazards during a transfer using a sit-to-stand lift when the manufacturer's operator's instructions for the safe use of the lift had not been followed. Findings include: 1. Review of the provider's FRI submitted to SD DOH on 4/16/25 at 3:42 p.m. revealed: *Resident 1 had a fall from the sit-to-stand lift (a mechanical lift used to assist from a seated to a standing position) on 4/9/25 at 5:00 a.m., when his right arm gave out and went above his head during the transfer while using the sit-to-stand and he was lowered to the floor. *The safety straps on the sit-to-stand were not used on his waist or legs during the transfer. *After the fall, he initially complained of feeling sore in both shoulders, which had been baseline for him, but no injury was visualized and he refused medical treatment. *After several days of soreness and refusal of treatment, he agreed to have an x-ray and to see the physician when his pain had not subsided. *The physician found no shoulder dislocation or injury. 2. Interview on 6/17/25 at 9:00 a.m. with resident 1 revealed: *He was well-spoken and easy to understand. *He did not consider the incident on 4/9/25 a fall as he stated his waist belt popped off, and his right arm went above his head, and the staff lowered him to the ground. *He said that both of his arms then went up because his left arm does not work, and it was painful when his left shoulder had pushed into his head. *He denied having refused to wear to the waist or leg straps on the lift, and again stated that the waist belt popped open that day. *He said that the nurse aide, a former employee, always rushed and did not listen to his directions that day. Interview on 6/16/25 at 11:00 a.m. with certified nursing assistant (CNA) F revealed: *Resident 1 would stand and pivot to transfer to and from the toilet during the day. *He only transferred resident 1 with equipment on his bath day, and used a full body lift (a mechanical lift and sling used to lift a person's full body). *Resident 1 required the use of the Hoyer (full body lift) for a period of time in April 2025 after he fell, but he had been cleared to return to stand and pivot transfers and to use the EZ stand (sit-to-stand) lift. *He had not had issues with resident 1 refusing to use safety straps on equipment during transfers. Interview on 6/17/25 at 1:30 p.m. with CNA G revealed: *Resident 1 was a stand and pivot transfer to and from the toilet. *She did not use a mechanical lift for him as she did not put him to bed or get him up as the night staff did that. Interview on 6/17/25 at 2:00 p.m. with CNA H revealed: *She assisted resident 1 to and from bed regularly. *Resident 1 used the sit-to-stand lift. *He had never refused to use the safety straps when she helped him. *She would get the nurse rather than try to use the equipment without safety straps. *She had not been aware of him refusing to use the safety straps with other staff. Interview on 6/17/25 at 2:00 p.m. with licensed practical nurse (LPN) E revealed: *She had recently been out on leave and did not know how resident 1 was transferred now. *She had been aware that resident 1 had refused to use the safety straps on the mechanical lift prior to her leave. *She asked a CNA how he was to be transferred. 3. Review of resident 1's electronic medical record (EMR) revealed: *He had a brief interview for mental status assessment (BIMS) score of of 15, which indicated his cognition was intact. *He had no use of his left arm and leg due to a stroke but wore a brace on his left leg that allowed him to bear weight while standing. *A nursing note on 3/28/25 stated that resident transfers with [the use of an] EZ stand and refused to use chest strap or leg straps. Resident was educated for safety and remains to refuse. *A nursing note on 4/1/25 stated that resident assisted to bed, transfers with EZ stand. Resident refuses to use chest strap or leg strap. Resident educated on need for straps for safety. Resident transferred per request without safety straps. *Review of the working care plan revealed that resident 1 had been cleared to transfer with a stand and pivot transfer and an EZ stand on 6/10/25. *Review of the hall sheet for daily care revealed that he was to transfer using the Hoyer (full body lift) only. *Review of resident 1's EMR care plan revealed no information about his fall risk, any history of falls, or how he was to be transferred. 4. Interview on 6/17/25 at 2:15 p.m. with Minimum Data Set (MDS) coordinator C revealed: *She agreed that the EMR care plan did not include any information about how resident 1 transferred. *She would not normally put that information in the resident's EMR care plan. *Nursing staff used the working care plan and a hall sheet, which was a pocket care plan, to know how to care for residents. Interview on 6/17/25 at 3:00 p.m. with administrator A revealed: *After refusing medical treatment for several days after the fall from the lift on 4/9/25, resident 1 agreed to an x-ray and a physician visit, which did not show that he had an injury. *Their internal investigation verified that resident 1 had refused to use the waist belt and knee strap and had only been using the sling at the time of his fall. *She described resident 1 as being very particular with his cares and stated he was known to give staff a very hard time when he felt they were not providing his cares the way he wanted them to. Interview on 6/18/25 at 9:00 a.m. with director of nursing (DON) B revealed: *Resident 1 could be very difficult and demanding, particular about his cares, and had a history of being verbally abusive with staff. *She felt the staff were frustrated with resident 1's refusals to allow the use of the safety straps on his waist and legs when using the mechanical lift, and said they could not force him to use them. *They attempted to limit him to transferring by using the Hoyer lift only, but he refused to use it and said he would stay in bed. *He was cleared by physical therapy to return to stand and pivot transfers and use of the sit-to-stand lift. Review of the EZ Way Smart Stand operator's instructions revealed: 1. Position the harness around the upper body of the patient so the sides of the harness are between the patient's torso and arm, resting 2-3 (two to three) inches below the underarm. 2. For the safety of the patient, securely fasten the safety strap around the patient's torso. Use of shin pad strap: If a caregiver deems it necessary to keep a patient's shins or feet on the foot plate, secure the shin strap around the patient's legs.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review the provider failed to ensure the safety of one of one sampled resident (2) with cognitive impairment who ingested an improperly stored and secured Santimine (sanitizing chemical) tablet. Findings include: 1. Review of the provider's 2/6/25 SD DOH FRI regarding resident 2 revealed: *His Brief Interview for Mental Status (BIMS) assessment score was 1 which indicated he had severe cognitive impairment. *On 2/6/25 at 1:50 p.m. he was observed raising his hand to his mouth and a blue coloration was noted in his mouth. *A unnamed certified nursing assistant (CNA) asked him to spit it out which he. *Unnamed CNAs approached him and noted they were Santimine (sanitizer tablets). *He went to put another tablet in his mouth, and registered nurse RN C swatted it out of his hand causing it to fall to the floor. *Material safety data sheets (MSDS) were pulled. *Poison control was called. *Medical director (MD) J was notified. -Due to increased behaviors and agitation, he was given Haldol 5 mg intramuscularly (IM). -Immediate medical intervention was to push fluids, not to induce vomiting, and to monitor. -He was given diluted orange juice. *His vital signs were taken. -Blood pressure 121/74: -Temperature 98.1. -Pulse 105. -Respirations 18. -Oxygen saturation on room air was 94%. 2. Review of resident 2's electronic medical record (EMR) revealed: *He had diagnoses of: -Chronic obstructive pulmonary disease (a disease that blocks airflow making it difficult to breathe). -Dementia (memory loss) with behavioral disturbances and agitation. -Epilepsy (seizure disorder). -Age-related bilateral cataract (clouding of the eye lens). -Presbyopia (far-sightedness). *His care plan indicated: -Offer me 1:1 (staff monitoring), redirect me back to my room to watch tv, or to play checkers. -Staff to monitor me (resident 2) closely . -Staff will monitor me for going into other resident rooms . *It was documented in his medication administration record for 2/6/25 that he had refused all of his morning medications that day. 3. Interview on 2/11/25 at 1:40 p.m. with RN C revealed: *There were two CNAs working in the Challenging Behaviors Unit (CBU) at the time of the above incident. Resident 2 was yelling at CNA H, while CNA K was helping another resident in the bathroom. *Resident 2 had a Santimine tablet in his mouth. *They asked him to spit it out, which he did. *Resident 2 tried to place another Santimine tablet in his mouth and she moved his hand away from his mouth. *Santimine tablets were supposed to be locked up. *Resident 2 found them in an unlocked drawer behind resident clothing protectors. 4. Interview on 2/11/25 at 2:15 p.m. with CNA H regarding the above incident revealed: *Resident 2 was on close, 1:1 monitoring. *CNA K had taken another resident to the bathroom. *CNA H had her back to resident 2. *Resident 2 was observed by CNA K near the kitchenette in the CBU after exiting the bathroom. -She asked resident 2 what he had in his hand. *RN C entered the CBU and noticed resident 2 had something in his mouth. -RN C asked him to spit it out, which he did. It was a Santimine tablet. -He then tried to put another tablet in his mouth and RN C swatted it out of his hand. *CNA H thought CNA F had put a bottle of the tablets in a drawer that was not locked. *Santimine tablets were supposed to be locked up. 5. Interview on 2/11/25 at 3:05 p.m. with CNA K regarding the above incident revealed: * She observed resident 2 was leaving the kitchenette area and had something in his mouth. *RN C entered the CBU and asked him to spit it out and he did. *He then tried to put another Santimine tablet in his mouth before it was taken away. *They gave him extra fluids after that incident. *Santimine tablets were supposed to be locked up. 6. Interview on 2/11/25 at 3:10 p.m. with RN C revealed: *She pulled the MSDS information on Santimine tablets. *DON B called poison control she believed and notified MD J of the incident with resident 2. 7. Interview on 2/11/25 at 3:35 p.m. with CNA F revealed: *He had worked the 2/5/25 night shift and left on 2/6/25 at 6:00 a.m. *Before leaving he had used the Santimine tablets to make a bucket of cleaner. *He had placed the Santimine tablet bottle in an unlocked drawer by the sink before he left. *That drawer lock had been broken for some time. *The locks had been fixed on 2/11/25. *He was aware that Santimine tablets should have been locked up. *Santimine tablets had been pulled from the CBU and were not being used. 8. Interview on 2/12/25 at 11:15 a.m. with DON B revealed: *She was alerted by RN C about the above incident. *RN C had pulled and referred to the sanitizer's MSDS. *RN/Unit Coordinator (UC) L had contacted the poison control center. *DON B had notified MD J of the above incident. - An order was received for resident 2 to be given Haldol (An antipsychotic) 5 mg IM for behaviors and it was given. *Administrator A was notified of the above. *An investigation was started. *An incident report was completed. *The SD DOH FRI report was completed. *She explained 1:1 monitoring for resident 2 meant staff were: -To be within arm's length of him between 6:00 a.m. and 10:00 p.m. -That 1:1 monitoring had increased his behaviors, so they would give him a little space and intervene when needed. -She expected staff to not turn their back on resident 2. *There was a notice dated 2/3/25 in the CBU: -We will be adding a third staff for CBU from 6:00 a.m. to 10:00 p.m. -You should remain in the common area within reach of resident 2 at all times to prevent any assaults from occurring. -There must be two staff present on the unit, at all times. One staff member must be monitoring resident 2/common areas at all times. If this means your nurse needs to come out call them, If this means you need [RN/UC L], or [DON B], call us. *Locks have been replaced. *Verbal education was provided to staff working in the CBU. *Santimine tablets were removed, from the CBU temporarily, until the locks have been replaced. Review of the providers revised 4/2023 Hazardous Materials and Waste Management Plan policy revealed: *To recognize the potential threat that hazardous materials present to human health and the environment. To establish, implement, monitor and document evidence of an ongoing program for the management of hazardous materials and waste to ensure that there is minimal risk to patients, personnel, visitors and the community environment within the confines of the ASHH campus. The processes include education, procedures for safe use, storage and disposal, and the management of spills and exposure. *Providing adequate and appropriate space and equipment for safe handling and storage of hazardous materials and wastes: All storage areas have spaces appropriate for storage regarding space requirements and are under lock and key to provide safe segregation from other work areas.

Based on South Dakota Department of Health (SD DOH) complaint, interview, interview, record review, and policy review, the provider failed to ensure dining assistance and nutritional needs were adequately care planned and implemented for one of one resident (1) with traumatic brain injury (TBI) when he refused to leave his room for meals or refused to eat. Findings include: 1. Review of the SD DOH complaint that was filed anonymously about resident 1 on 1/6/25 revealed: *Resident resided in the traumatic brain injury (TBI) unit. *He had behavioral problems, such as: refusing cares, refusing to take his medications, refusing to come out of his room for meals, refusing to eat. *When residents who required assistance would not come out of their rooms, they were not allowed to have a meal tray in their room. *Two to three weeks prior to filing the complaint, resident 1 had gone without his evening meal for three consecutive nights due to him not coming out of his room. *Resident 1 required assistance with eating. 2. Observation on 2/11/25 at 11:45 a.m. of resident 1 while eating his noon meal revealed: *Resident 1 was in the dining area with his spouse and other residents who were sitting in the area. *Resident 1's spouse was assisting him in eating his meal. *Resident 1 was dependent on his spouse to help him eat his meal. 3. Interview on 2/11/25 at 1:30 p.m. with resident 1's spouse revealed: *He has been here for over a year. *She felt there was a lot of staff turnover and a lack of staff on duty during the nighttime. *She was concerned about him not receiving meals at night. -She reported that a certified nursing assistant (CNA) (she was unable to recall the CNA's name) told her if resident 1 did not come out of his room for meals, he would not eat because there were no extra staff to help him eat. *She reported some of the CNAs were not trained to care for residents with traumatic brain injuries. *She felt some of the CNAs did not understand that it took resident 1 more time to process what was said to him, and the CNAs would get frustrated with him. 4. Interview on 2/12/25 at 9:10 a.m. with CNA G revealed: *She was a traveling CNA and had worked at the facility for about three years. *There was no specific or extra training required to work in the challenging behavior unit (CBU) or TBI units. *She confirmed that resident 1 required assistance with eating. *CNAs are oriented in all three units because they can be assigned to work anywhere in the facility. *If residents who required assistance with eating did not come out of their rooms for a meal, there was no one available to assist them with eating in their rooms. 5. Interview on 2/12/25 at 11:57 a.m. with director of nursing (DON) B revealed: *There was no specific training provided for CNAs that worked on the CBU or TBI units. -We want our CNAs to be able to work on any unit at any time. *Resident 1 would sometimes eat in his room with assistance by his spouse. *Resident 1's spouse visited him nearly every day during the noon meal and would assist him with eating. *Resident 1 was not allowed to eat alone in his room due to his difficulty with swallowing. *She reported if resident 1 did not want to come out of his room at the time of the evening meal, staff should attempt to have him come out to the dining area later to eat, offer him snacks later, and document that. *It was her expectation resident 1 would be assisted with eating in his room. *It was her expectation that if resident 1 refused to eat his meals in the dining room several nights consecutively, it would be noted in the progress notes. *Documentation of meals was to be recorded three times per day and as needed (PRN). *She reported the PRN documentation would be for afternoon or evening snacks. 6. Review of the resident's care plan revealed there was no specific instruction on the amount of eating assistance he needed from staff during meals. *His care plan did not indicate if he could or could not eat in his room. 7. Review of resident 1's electronic medical record (EMR) revealed: *Documentation of his meals and snacks from 1/14/25 through the morning of 2/12/25 indicated: -On two of 30 days, meals and/or snacks intakes were documented four times each day. -On 22 of 30 days, meals and/or snacks intakes were documented three times each day. -On five of 30 days, meals and/or snacks intakes were documented two times each day. -On seven of 30 days, it was documented resident 1 refused his evening meal (1/14, 1/19, 1/28, 1/29, 1/30, 2/1, and 2/8/25). *His progress notes did not indicate why resident 1 had not received meals and/or snacks, or if meals or snacks had been offered between scheduled meals. 8. Review of the provider's 11/2020 Resident Right-Nursing Home booklet given to residents on admission revealed: *Page 3: All nursing homes are required to provide services and activities to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident in accordance with a written plan of care. *Page 5: Right to dignity, respect, and freedom: Be treated with consideration, respect, and dignity.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, video review, and policy review, the provider failed to protect six of eight sampled residents (1, 2, 3, 5, 7, and 8) from neglect by licensed practical nurse (E) who did not offer or provide repositioning or toileting assistance as directed in their plans of care. Findings include: 1. Review of the 9/12/24 SD DOH complaint revealed: *The complainant wanted to remain anonymous. *There was concern regarding neglect for all residents in the Traumatic Brain Injury (TBI) unit. *From 9/7/24 at 10:00 p.m. to 9/8/24 at 6:00 a.m. -Resident 5 was left in the same clothes he was dressed in on 9/7/24. -He was curled up in a ball on the floor with no blanket. -He was cold to the touch. -He was covered in feces. -His bed was still made from the previous day. *Residents (1, 2, 3, 7, and 8) were identified as being incontinent of both bowel and bladder in the complaint. *Complainant requested a review of the video footage of the unit. 2. Review of resident 1's electronic medical record (EMR) revealed: *His diagnoses included: -Traumatic subdural hemorrhage with loss of consciousness. (blood pooling between the brain and the outer layer of the brain-protective membrane). -Urinary incontinence. -Major depressive disorder. -Cognitive communication deficit. -Restlessness and agitation. -Impulse disorder. *His Brief Interview for Mental Status (BIMS) score was 4 which indicated he had severe cognitive impairment. *He required the assistance of one to two staff with all mobility, toileting, personal hygiene, and dressing. *He was to be checked (for incontinence needs) and changed every 2 hours. 3. Review of resident 2's EMR revealed: *His diagnoses included: -Traumatic subdural hemorrhage with loss of consciousness. -Fracture of base of skull. -Mental disorder due to known physiological condition. -Psychotic disorder. -Anxiety disorder. -Cerebral infarction due to thrombosis (stroke due to a blood clot). -Hemiplegia and hemiparesis (paralysis) following a cerebral vascular disease (conditions that affect blood flow to the brain). *His BIMS score was 99 which indicated he chose or could not participate. *He had incontinence and was to be checked and changed every 2 hours. *He was dependent on two staff to assist him with all activities of daily living (ADLs). *He was dependent on staff for assistance with all his toileting, hygiene, dressing and personal hygiene needs. *He required the use of a total body mechanical lift for all transfers. *He was known to hit staff. *He had a gastrostomy tube (G-tube) for nutrition and medication administration and is nothing by mouth. 4. Review of resident 3's EMR revealed: *His diagnoses included: -Vascular dementia. -Major depressive disorder. -Hemiplegia (paralysis) following nontraumatic intracerebral hemorrhage (bleeding in brain). -Psychosis (disconnection from reality). *His BIMS score was 7 indicated he had severe cognitive impairment. *He had incontinence and was to be checked and changed every 2 hours. *He requires one to two staff to assist him with his bed mobility, bathing, toileting, and personal hygiene needs. *He required the use of a sit-to-stand lift for transfers. 5. Review of resident 5's EMR revealed: *His diagnoses included : -Dementia with behavioral disturbances. -Nontraumatic intracranial hemorrhage (stroke that occurs from a blood pooling in brain). -Anoxic brain damage (lack of oxygen to the brain). -Sleep disorder. *His BIMS score is 99 and he had inattention that would fluctuate. *He had incontinence of his bowel and bladder. -He used incontinence products. -He needed the assistance of one staff with his toileting needs every 2 hours. 6. Review of resident 7's EMR revealed: *His diagnoses included: -Traumatic subarachnoid hemorrhage with loss of consciousness. -Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side. -Dementia, severe with behavioral disturbances. -Major depressive disorder, recurrent, severe with psychotic symptoms. *His BIMS score was 1 which indicated he had severe cognitive impairment. *He had incontinence of his bowel and bladder. -He required substantial/maximal staff assistance for his transfers and ADLs. -He required the use of a total mechanical lift at times with the assistance of two staff. *He had a history of physical outbursts, verbal aggression, resistance with care, and social and sexually inappropriateness. 7. Review of resident 8's EMR revealed: *Her diagnoses included: -Dementia without behavioral disturbances. -Nontraumatic intracerebral hemorrhage (stroke that occurs from a blood pooling in brain). -Hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis following a stroke). -Neuromuscular dysfunction of the bladder (muscles in the bladder do not work properly) with stress incontinence. *BIMS score of 99, and indicated she was unable to participate. *She required substantial to maximal assistance of two staff with all of her ADLs and mobility. *She had incontinence of her bowel and bladder. -She required to be checked and changed every two hours, and staff were to assist her with her incontinent care needs at each episode. 8. Interview on 9/24/24 at 4:45 p.m. with certified nursing assistant (CNA) F revealed: *She had worked on the TBI unit 9/8/24 and at 6:00 a.m. that day: *Resident 1 was incontinent of both bowel and bladder and his bedding was soaked through. *Resident 2 was soaked in urine from head to toe and bedding was soaked through. *She found resident 5 lying on the floor, in the living room area of his room. -His body was curled up in a ball, and his skin was cold to the touch. -He had feces on him and was incontinent of urine. *She stated he should have been assisted with toileting every two hours and that he would at times lay on the floor, but would stay in bed if staff placed him in his bed. -He had on the same clothes she had dressed him in on the 9/7/24 morning shift. *Resident 6 was incontinent, and his bed was soaked with urine. *Resident 8 was incontinent of bladder and bedding was soaked through. *She stated all of those residents required staff assistance with their toileting needs every two hours. 9. Interview on 9/25/24 at 8:02 a.m. with licensed practical nurse (LPN) E revealed: *He had worked on 9/7/24 from 6:00 p.m. to 9/8/24 at 6:00 a.m. and was assigned to be the nurse in the TBI and CBU (challenging behaviors unit) from 6:00 p.m. to 10:00 p.m. that night. *He said he went to the TBI unit on 9/7/24 at 10:00 p.m. to work only on TBI unit till 9/8/24 at 6:00 a.m. *He was unsure why a CNA was not assigned to the TBI unit. *He completed toileting and personal cares for the TBI unit residents from 10:00 p.m. on 9/7/24 until 6:00 a.m. on 9/8/24. *He did not know which residents needed to get up in the morning. *He completed all point click care (PCC) EMR charting. *He stated resident 5 would lie on the floor at times. *He said typically, there were three CNAs and two nurses in the building from 10:00 pm to 6:00 a.m. *He had not been trained to perform the CNA tasks. 10. Interview on 9/25/24 at 9:20 a.m. with LPN D revealed: *She was the nurse for the TBI and CBU on 9/8/24 at 6:00 a.m. *She had been told resident 5 had been up all night and had not slept from a report with LPN E. *Resident 2 had been spitting and kicking at LPN E and he needed assistance to change him. *CNA F had told her resident 2 was soaked. *She stated the CNAs working that morning never contacted her regarding complaints about residents' care. *On 9/8/24 at 6:30 a.m. she had washed up resident 2 and changed his bedding, because he had soaked through the incontinence soaker pad and all of his bedding. *She stated, resident 7 did not like male staff. 11. Interview on 9/25/24 at 9:50 a.m. with director of nursing (DON) B revealed: *Tasks are automated in the PCC EMR system with assessments when completed. *Tasks can be added independently. *Registered nurse (RN)/Minimum Data Set (MDS) H was in charge of reviewing tasks and updating them when needed. *Social worker (SW) C was in charge of updating resident care plans. 12. Interview on 9/25/24 at 10:42 a.m. with RN/MDS H revealed: *She did not enter the tasks for residents in PCC. *She thought DON B or medical records (MR) I entered the tasks. *She did not know who updated the resident pocket care plans for staff. 13. Interview on 9/25/24 at 10:50 a.m. with MR I revealed: *She did not enter tasks in PCC. *She did not update the pocket care plans. 14. Interview on 9/25/24 at 10:52 a.m. with DON B revealed: *Everyone in management had access to update the pocket care plans. *Pocket care plans were kept at the front desk for staff. *DON B would update the pocket care plans for the main floor residents. *MR I printed them off and placed them at the front desk for staff. 15. Interview on 9/25/24 at 12:05 p.m. with Administrator A and DON B revealed: *LPN E had training completed on 9/6/24 with LPN M. *All nurses would have received CNA training in nursing school. *The standard nursing care for incontinent residents was to check and change or toilet them every two hours. *They had checked with other facilities and they did not put toileting tasks in PCC for every two hours. *There had been no communication to management that there was a problem on the 9/7/24 and 9/8/24 weekend from the TBI nursing staff. *DON B had contacted LPN E employment agency in regards to him needing to improve on his required tasks while working in the facility before she had learned of the complaint. 16. Interview on 9/25/24 at 1:20 p.m. with DON B revealed: *She completed the schedule for nursing staff. *Usual staffing for a 10:00 p.m. to 6:00 a.m. shift included is two nurses and three CNAs in the building. *She stated one of the CNAs scheduled to work had called in on 9/7/24. *Her expectation for residents who needed two staff for assistance with their care needs was that staff would be assisted by staff from another unit. 17. Interview on 9/25/24 at 1:41 p.m. with CNA G revealed: *She worked 9/7/24 at 6:00 p.m. until 9/8/24 at 6:00 a.m. *Pocket care plans are available at the front desk where report was given. *She was on the CBU for her shift that day. *She did not know who called in. *She had given LPN E a list of what needed to be completed for the residents on the TBI unit that included: -Who was to be checked and changed every two hours. -Who needed to have morning cares completed on 9/8/24. She stated that included residents 1, 5, and 8. *When she needed help she would call for assistance. 18. Review of the provider's video footage of TBI unit for 9/7/24 10:00 p.m. through 9/8/24 at 6:00 a.m. revealed: *Resident 2 was in a wheelchair in the dining area. *LPN E arrived at 10:05 p.m. on the TBI unit. *LPN E attempted to give resident 2's medications to him through his G-tube at 10:23 p.m. *LPN E called for assistance, at 10:25 p.m. Medication aide J and LPN K arrived and assist with that medication administration then they exited the TBI unit. *LPN E entered resident 3's room at 10:38 p.m. and exited that room at 10:49 p.m. *LPN E and CNA L entered TBI unit and entered to resident 1's room at 11:02 p.m. *LPN E and CNA L remained in resident 1's room till 11:22 p.m. *CNA L and LPN E repositioned resident 2 from his wheelchair with a total mechanical lift to his room at 11:26 p.m. and exited his room at 11:31 p.m. *CNA L and LPN E entered resident 7's room till 11:36 p.m. then CNA L exited the TBI unit. *LPN E was at a desk in the TBI unit from 11:38 p.m. until 12:40 a.m. when he got up, went and goes to the laundry room and then returned to the desk. *CNA L entered the TBI unit at 1:00 a.m. and entered resident 1's room, he exited that room at 1:08 a.m. with a garbage bag and left the TBI unit. *LPN E sat at a desk from 1:10 a.m. until 2:01 a.m. *CNA G entered the TBI unit checked on resident 1 in his room and then exited the TBI unit. *LPN E returns to a desk from 2:03 a.m. to 2:41 a.m. he then stood, peeks into resident 1 room and returned to a desk. *CNA L entered TBI unit at 2:45 a.m. LPN E exited TBI unit at 2:48 a.m. CNA L walked up and down both hallways and entered resident 5 room at 2:56 a.m. and then exited the room a minute later. *LPN E returned to the TBI unit at 3:08 a.m. and CNA L exited the TBI unit LPN E remained at a desk until 4:25 a.m *LPN E entered resident 6's room and exited at 4:28 a.m. with no garbage bag in hand, LPN E entered laundry room. *LPN E sat at a desk from 4:29 a.m. until 5:34 a.m. when LPN D entered the TBI unit. -LPN E gives report to LPN D. -Observed LPN E and LPN D counting narcotics in the medication cart. *CNA F and CNA L entered TBI unit at 5:51 a.m. CNA L leaves the TBI unit after one minute. *CNA F entered resident 3's room at 6:01 a.m. and then returned to the dining room area. *CNA N entered the TBI unit at 6:04 a.m. for her shift. *CNA N and CNA F entered resident 5's room at 6:10 a.m. *LPN E exited the TBI unit at 6:12 a.m. *CNA N and CNA F are observed talking with LPN D at the desk at 6:23 a.m. 19. Follow-up interview on 9/25/24 at 2:47 p.m. with DON B revealed: *Last rounds were to be completed before 10:00 p.m. *Check and change for incontinence needs would then start approximately at midnight and every two hours after that. *She confirmed residents 1, 2, 3, 5, 7 and 8 had incontinence and needed to be checked and changed every two hours. 20. Follow-up interview on 9/25/24 at 3:43 p.m. regarding the above observations of the video recording with administrator A and DON B revealed: *LPN E was not in resident rooms when he was expected to be. *Cares for residents were not completed as required by staff on the night of 9/7/24 at 10:00 p.m. to 9/8/24 at 6:00 a.m. and according to the residents' care plans. 21. Review of the provider's 1/20/24 LTC Abuse Prohibition Policy revealed: *Neglect the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *Neglect occurs when the facility is aware of or should have been aware of, goods or services that a resident(s) requires but the facility fails to provide them to the resident(s) . *Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, results in or may result in physical harm, pain, mental anguish, or emotional distress. *Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person.

Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and video review, the provider failed to ensure eight of eight sampled residents (1, 2, 3, 4, 5, 6, 7, and 8) who were dependent on staff for their care needs, received those cares as directed on their care plans. Findings include: 1. Review of the 9/12/24 SD DOH complaint revealed: *The complainant wanted to remain anonymous. *There was concern regarding neglect for all residents in the Traumatic Brain Injury (TBI) unit. *From 9/7/24 at 10:00 p.m. to 9/8/24 at 6:00 a.m. -Resident 5 was left in the same clothes he was dressed in on 9/7/24. -He was curled up in a ball on the floor with no blanket. -He was cold to the touch. -He was covered in feces. -His bed was still made from the previous day. *Residents (1, 2, 3, 7, and 8) were identified as being incontinent of both bowel and bladder in the complaint. *Complainant requested a review of the video footage of the unit. 2. Review of resident 4's electronic medical record (EMR) and pocket care plan revealed: *His diagnoses included: -Cerebral Infarction (stroke) affecting right dominant side. -Aphasia (language disorder). -Atherosclerotic heart disease. *His Brief Interview for Mental Status (BIMS) score was 00 which indicated he had severe cognitive impairment. *He needed 24-hour supervision. *He was at risk for elopement. *He lacked safety awareness. *He could not express his needs at times due to his speech. *Staff were to anticipate his needs. *He was independent with emotional, intellectual, physical and social needs. *He was continent of bowel and bladder. *He was a full code. 3. Review of resident 6's EMR and pocket care plan revealed: *His diagnoses included: -Cerebral infarction (stroke). -Incontinent of bowel. -Aphasia (language disorder). -Heart disease. *He required the assistance of one staff for most of his activities of daily living (ADLs). *His BIMS score was 9 which indicated he had moderate cognitive impairment. *Staff were to anticipate his needs, due to him rarely expressing his needs, even though he was able to. *He required partial/moderate assistance of one staff with bed mobility, toileting needs, and ADLs. *He was a full code. 4. Interview on 9/25/24 at 8:45 a.m. with administrator A revealed: *Tasks are used for ADL charting. *Provider does not have an ADL Policy. 5. Review of the provider's video footage of TBI unit for 9/7/24 10:00 p.m. through 9/8/24 at 6:00 a.m. revealed: *Resident 2 was in a wheelchair in the dining area. *LPN E arrived at 10:05 p.m. on the TBI unit. *LPN E attempted to give resident 2's medications to him through his G-tube at 10:23 p.m. *LPN E called for assistance, at 10:25 p.m. Medication aide J and LPN K arrived and assist with that medication administration then they exited the TBI unit. *LPN E entered resident 3's room at 10:38 p.m. and exited that room at 10:49 p.m. *LPN E and CNA L entered TBI unit and entered to resident 1's room at 11:02 p.m. *LPN E and CNA L remained in resident 1's room till 11:22 p.m. *CNA L and LPN E repositioned resident 2 from his wheelchair with a total mechanical lift to his room at 11:26 p.m. and exited his room at 11:31 p.m. *CNA L and LPN E entered resident 7's room till 11:36 p.m. then CNA L exited the TBI unit. *LPN E was at a desk in the TBI unit from 11:38 p.m. until 12:40 a.m. when he got up, went into the laundry room and then returned to the desk. *CNA L entered the TBI unit at 1:00 a.m. and entered resident 1's room, he exited that room at 1:08 a.m. with a garbage bag and left the TBI unit. *LPN E sat at a desk from 1:10 a.m. until 2:01 a.m. *CNA G entered the TBI unit checked on resident 1 in his room and then exited the TBI unit. *LPN E returns to a desk from 2:03 a.m. to 2:41 a.m. he then stood, peeks into resident 1 room and returned to a desk. *CNA L entered TBI unit at 2:45 a.m. LPN E exited TBI unit at 2:48 a.m. CNA L walked up and down both hallways and entered resident 5 room at 2:56 a.m. and then exited the room a minute later. *LPN E returned to the TBI unit at 3:08 a.m. and CNA L exited the TBI unit LPN E remained at a desk until 4:25 a.m *LPN E entered resident 6's room and exited at 4:28 a.m. with no garbage bag in hand, LPN E entered laundry room. *LPN E sat at a desk from 4:29 a.m. until 5:34 a.m. when LPN D entered the TBI unit. -LPN E gives report to LPN D. -Observed LPN E and LPN D counting narcotics in the medication cart. *CNA F and CNA L entered TBI unit at 5:51 a.m. CNA L leaves the TBI unit after one minute. *CNA F entered resident 3's room at 6:01 a.m. and then returned to the dining room area. *CNA N entered the TBI unit at 6:04 a.m. for her shift. *CNA N and CNA F entered resident 5's room at 6:10 a.m. *LPN E exited the TBI unit at 6:12 a.m. *CNA N and CNA F are observed talking with LPN D at the desk at 6:23 a.m. *Residents 1, 2, 3, 4, 5, 6, 7, and 8 were not provided care according to their individual care needs. Refer to F600 findings 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, and 20.

Based on South Dakota Department of Health (SDDOH) complaint report review, record review, policy review and interview the provider failed to ensure 15 of 22 (2, 3, 7, 8, 14, 16, 20, 23, 25, 26, 29, 33, 35, 41, 43) Elopement risk evaluations were completed accurately to ensure resident safety. Findings include: 1. Review of SDDOH complaint report revealed: *Resident 43 had eloped from the building on 7/17/24 out a door that had an alarm. *The alarm did not sound and alert staff to a resident exiting the building. *Staff observed resident 43 walking with a walker across the front lawn of the building. *They assisted him back into the building. *Nurse completed vitals and assessed him to make sure he was okay. *Staff checked all other doors in the building, making sure all other alarms were working. 2. Review of resident 43's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had diagnoses of: -Macular degeneration. -Dementia with other behavioral disturbances. *Brief interview for mental status (BIMS) score is 9 meaning moderate impairment. *Elopement risk evaluations that were completed revealed: *On admitted d 4/10/23 he was not at risk for elopement with a score of three. *On 7/8/23 following an elopement he was not at risk for elopement with a score of 4. *Elopement risk evaluation scoring/summary of risk indicated Three or more Resident Status/Potential Risk Factors and/or one or more Definitive Risk Factors indicate a resident AT RISK for elopement. *No elopement risk evaluation was completed after 7/8/24 elopement. *The working care plan had a written elopement documented risk dated 7/18/24. 3. Review of residents (2, 3, 7, 8, 14,16, 20, 23, 25, 26, 29, 33, 41) elopement risk evaluations revealed: *They all scored three or more. *They were marked as not being at risk for elopement. 4. Review of provider's Elopement policy dated 8/2024 revealed: *It is the policy of Sunset Manor to investigate and report all cases of missing residents off facility grounds. *The elopement of a resident occurs when a resident has left the premises without the knowledge of a staff member. *Charge nurse will complete Incident report in Risk Management, complete detailed progress note, and complete an Elopement risk evaluation. 5. Interview on 8/7/24 at 2:40 p.m. with registered nurse (RN) F revealed: *Social service designee D would have updated the care plan for the resident in 7/2024. *A new elopement risk evaluation should have been completed by the nurse working on 7/17/24. *The stop sign on the door had been there for around six years. 6. Interview on 8/7/24 at 3:03 p.m. with minimum data set (MDS) coordinator C revealed: *The elopement should have been added to the working care plan signature sheet where changes were added, and updated. *The nurse working on 7/17/24 should have added it to the signature sheet. *Resident 43 is due for annual elopement risk evaluation in 3/2025. *She agreed resident 43 was marked wrong on the elopement risk evaluation as not being at risk for elopement. *He did not have a new elopement risk evaluation completed after he eloped on 7/17/24. 7. Interview on 8/7/24 at 3:20 p.m. and 8/8/24 at 8:16 a.m. with SS designee D revealed: *She added the elopement risk to resident 43's working care plan following his elopement on 7/17/24. *Licensed practical nurse (LPN) G should have added it after the event. -She had not though it was an elopement. -She had not though it was a reportable incident. *Resident 43 had eloped from the building once before. 8. Interview on 8/8/24 at 8:22 a.m. with director of nursing (DON) B revealed: *Elopement risk evaluations were completed on admission and if an elopement occurred. 9. Interview on 8/8/24 at 9:50 a.m. with administrator A and DON B revealed: *They agreed resident 43's elopement risk evaluation was marked incorrectly as not at risk. *They expected an elopement would have been addressed in the resident's care plan. *They confirmed there was nothing in resident 43's current care plan or the EMR about being at risk for elopement. *They agreed that anyone with a score of three or more on the elopement risk evaluation should have been marked as at risk for elopement. *They were in the process of changing from American Health Tech to Point Click Care for their EMR system.

Based on a facility-reported incident (FRI) review, observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (37) who was cognitively impaired received adequate care and monitoring to ensure she was free of physical restraints imposed for discipline or convenience and not required to treat the resident's medical symptoms that resulted in an incident of resident abuse by one of one agency staff member (H). Findings include: 1. Review of the South Dakota Department of Health (SD DOH) event report for resident 37 on 6/28/24 revealed: *She returned from the hospital on 6/28/24 at 6:35 p.m., was restless, and had tried multiple times to stand up from her chair. -She was unsteady when walking. -She was redirected to sit in her wheelchair by agency certified nursing assistant (CNA) H. -For nearly an hour and half resident [resident 37] continues to try to stand up or get out of the wheelchair and resists against [first name of agency CNA H] but is physically restrained against and to the wheelchair by [first name of agency CNA H]. --During this time [first name of agency CNA H] is physically holding [resident 37's first name]'s arms down to the wheelchair, what appears to be digging her chin into [resident 37's first name]'s scalp, towers over resident and appears to have several verbal exchanges with resident. -At 8:51 p.m. nurse [agency registered nurse (RN) I] comes back to unit and rubs [resident 37's first name]'s back and talks with her which calms her down. -2nd nurse [LPN J] comes back to unit at 8:54 p.m. and also talked to [resident 37's first name] and they [agency RN I and LPN J] take her to recliner on unit and she does not want to sit there . -They [agency RN I and LPN J] then take her down to her room and she is calm. 2. Observation on 8/6/24 at 2:07 p.m. of resident 37 revealed she was in the activity room involved with a resident group activity led by a local pastor. She was sitting in a chair and actively singing a hymn with the pastor and other residents. 3. Interview on 8/6/24 at 4:00 p.m. with resident 37 in her room revealed: *She enjoyed pastor visits, watching movies, and loved to read. *She could not remember any staff member being upset with her, raising their voice to her, or holding her down, stating They [the staff] are very good to me. *She had no recollection of the 6/28/24 incident or having been to the hospital that day. 4. Review of Resident 37's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. *After her admission, she was moved to a room in the provider's challenging behavior unit (CBU). *She was sent to the [another community] hospital's emergency roiagnom on the afternoon of 6/28/24 after the resident was exhibiting slurred speech, left-sided weakness, and facial droop. -She had been given IV [intravenous] fluids and IV Ativan [medication given to relieve anxiety] for her CT [computed tomography] scan while at the hospital. -She returned from the hospital on 6/28/24 at 6:30 p.m. to her room in the CBU. *Her diagnoses included: -Unspecified dementia, with other behavioral disturbances. -Bipolar disorder. -Alzheimer's disease. -Paroxysmal atrial fibrillation. *Her 6/17/24 annual minimum data set (MDS) assessment revealed: -Her brief interview for mental status (BIMS) was scored at 12, which indicated she was moderately impaired cognitively. -She had exhibited no behavioral symptoms in the past week. -She was independent with dressing, eating, and walking with a walker. -She was independent with toileting but had some occasional urinary incontinence. Review of Resident 37's EMR progress notes revealed: *On 6/28/24 a progress note was entered by director of nursing (DON) B at 2:56 p.m. which stated, CNA came to recorder [DON B]'s office around 1415 [2:15 p.m.] and reported that resident has had a significant decline this afternoon . was very lethargic, required 2 [staff members] extensive assist to get to bed. Staff assisted her to bed . she was leaning to the right, weak with garbled speech . This recorder [DON B] notified Dr [last name of physician] and went immediately to room to examine resident. Performed stroke screen, able to shrug shoulders, stick out tongue, squeeze fingers with grip weakness on the left, was not able to sit up unsupported with leaning to both sides, more-so to the left noted. Resident had very garbled speech . Dr [last name of physician] . requests her to be sent out via EMS [emergency medical services]. [First name of guardian] notified of condition and that resident will be sent out via ambulance. *On 6/28/24 a progress note was entered at 3:06 p.m. by LPN K updating the resident's guardian on her status. *On 6/28/24 a progress note was entered at 9:35 p.m. by RN I which stated Patient returned from ED [emergency department] at 1830 [6:30 p.m.]. Report received from discharging nurse. CT [computed tomography] scans negative. CBC [complete blood count], CMP [comprehensive metabolic panel], UA [urinalysis] all WNL [within normal limits]. Given IV [intravenous] fluids and IV [intravenous] Ativan [medication given to relieve anxiety]. No discharge diagnosis . Patient is agitated and looking for her nephew to pick her up. Combative with staff. Took HS medications with no problems, went to bed at 2130 [9:30 p.m.] . *There was no progress note related to the physical restraint of the resident by agency CNA H 5. Review on 8/6/24 of resident 37's current care plan revealed: *A focus area I have memory problems, have poor safety awareness, and make poor decisions. I have clear speech. I can usually express my needs. I can usually understand others. *A focus area I take psychotropic medications. I have physical outbursts. I have mood problems . -Interventions included: --I admitted to [name of provider's nursing unit] on 06-26-2023 from [the provider's trade name] behavioral health center in [another community], SD. I need 24 hour supervision . I was approved for challenging behavior [unit] . on 6/26/2023 . --I am followed by [provider's trade name] behavioral health for medication management. 6. Interview on 8/7/24 at 3:07 p.m. with DON B regarding the 6/28/24 incident revealed: *Agency CNA H had been scheduled to work at 3:00 p.m. on 7/3/24 but did not show up for her shift. *She reached out to CNA H by cell phone with no response. *Another unidentified agency CNA had informed her that agency CNA H had left her assignment at the nursing home for her home state of Louisiana due to her being left in the behavior unit by herself. *On 7/3/24 she emailed the agency that employed CNA H and asked regarding CNA H. *The reply she received informed her that CNA H was leaving her contract with the provider due to being alone in the behavioral unit for a couple of hours last Friday night, 6/28/24. *She was unaware of the 6/28/24 incident until Wednesday, 7/3/24. *On 7/3/24, after the emailed reply, she and administrator A reviewed the video footage from the CBU unit from Friday, 6/28/24. -Agency CNA H was seen physically in front of resident 37, who was seated in a wheelchair, holding the resident's forearms down on the wheelchair's armrests and agency CNA H's chin resting on the resident's forehead. *After reviewing the video footage, DON B asked the CBU unit coordinator about the 6/28/24 incident and agency CNA H. -CBU unit coordinator stated CNA H had worked Friday evening, 6/28/24 and then the following Sunday, Monday, and Tuesday. -Two CNAs that were scheduled on the CBU at 7:00 p.m. on 6/28/24. -The CBU unit coordinator had stated that no one had reported anything to her regarding the incident on 6/28/24. *DON B stated the CBU unit coordinator had resigned from her position with the provider two weeks ago and no longer worked at the facility. 7. Interview on 8/7/24 at 3:48 p.m. with administrator A and DON B regarding the 6/28/24 incident revealed: *Both agreed that the abuse of resident 37 had occurred with agency CNA H physically restraining the resident for a combined time of 20 minutes that occurred periodically throughout the ninety minutes she was attending to the resident on the CBU unit. -Other staff were seen coming in and out of the CBU unit during this time, but none of the staff had witnessed CNA H physically restraining the resident. --Agency RN I had passed medications on the CBU unit and another nursing unit. --CNA M and LPN J were also seen on the CBU unit that evening. --Agency CNA L had been scheduled to be on the CBU unit that evening, but was not seen on the video footage during that time as she may have been pulled to another nursing unit. *DON B stated resident 37's assessment after the incident revealed no harm was evident, but based on the video footage, she verified the physical restraint of the resident had occurred. *Both agreed the video footage was limited to the hallway by the nursing station. 8. Review of the provider's January 2024 LTC (long term care) Abuse Prohibition policy revealed: *It is essential for facilities to prohibit and prevent abuse, neglect, exploitation of residents . including freedom from physical . restraints not required to treat a resident's medical symptoms. The facility will have systems in place to encourage and support all residents, staff, . in reporting any suspected acts of abuse . *Physical restraint is defined as any manual method, .that meets all of the following criteria: -i. Is attached or adjacent to the resident's body; -ii. Cannot be removed easily by the resident; and -iii. Restricts the resident's freedom of movement .

Based on record review, policy review, and interview the provider failed to ensure Minimum Data Set (MDS) assessments were completed in a timely manner for five of twenty-four sampled residents (3, 7, 19, 23, and 37). Findings include: 1. Review of the (MDS) schedule for the facility provided by MDS coordinator C on 7/12/23 revealed quarterly assessments for residents 3, 7, 19, 23, and 37 were to have been completed on 6/12/23. Review of the MDS transmission results summary report provided by MDS coordinator C on 7/12/2023 revealed no quarterly assessments had been submitted in June or July for residents 3, 7, 19, 23, and 37. Review of the providers 3/2022 LTC-Assessment (MDS Policy) revealed assessments would be .completed within 14 days of the resident's admission, quarterly, annually, and within any significant change in condition. Interview on 7/12/23 at 9:47 a.m. with MDS coordinator C regarding quarterly assessments for residents 3, 7, 19, 23, and 37 revealed: *Completed MDS assessments were transmitted via Internet Quality Improvement and Evaluation System at least weekly. *Her normal practice for transmitting MDS assessments was to do them in batches as she completes them. *She has been the MDS coordinator for ten years. *She was behind on completing quarterly assessments. *Her goal was to have them completed by the end of the week. Interview on 7/12/23 at 3:14 p.m. with Administrator A regarding MDS quarterly assessments for residents 3, 7, 19, 23 and 37 revealed: *The expectation was to complete the MDS assessments by the due date. *When asked if she was aware that MDS assessments were overdue she sated yes. *She stated no one else in the facility was trained on completing MDS assessments. *She stated a new registered nurse was hired the end of May, was completing facility orientation, and would be trained on MDS assessments and would assist as needed for timely submission.

Based on record review, interview, and policy review, the provider failed to ensure a comprehensive care plan for two of nineteen sampled residents (30 and 40) with frequent urinary tract infections from an indwelling catheter and recurrent pneumonia. Findings include: 1. Record review of resident 30 electronic medical record revealed: *She had been discharged from the hospital on 11/4/21 with diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] *an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *Received nebulizer treatments three times per day. *On 12/5/21 she developed nausea, vomiting, and difficulty breathing. *She received nebulizer treatments three times per day. *She received IV fluids and antinausea medication from the provider 12/6/21. *She was re-hospitalized on [DATE] through 12/13/21 for recurrent pneumonia. *Had received an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . *She had continued to receive nebulizers three times per day. The care plan with an onset date of 7/18/17 had not mentioned any respiratory infection or treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] Interview on 1/13/22 at 9:15 a.m. with director of nursing (DON) B regarding resident 30's care plan revealed: *Agreed her care plan did not state anything about having pneumonia, or treatment related to it. *The resident had completed a swallow study during her last hospitalization and was diagnosed with aspiration. *She agreed that being at risk for aspiration was not documented on the care plan. *Her diet was changed to pureed with nectar thick fluids after the diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Record review of resident 40's electronic medical record revealed: *He was admitted on [DATE] with a suprapubic catheter (a tube inserted into the bladder through a small hole in the stomach that drains urine into the external bag). *While he used a leg bag during the day, he used a regular catheter bag at night. *He needed assistance at times with changing bags. *He preferred to perform own catheter cares. *His suprapubic catheter was changed every 4 weeks. *He had been diagnosed with a urinary tract infection ([CONDITION(S)]) on 9/29/21 and again on 11/11/21. *Care plan had not indicated resident was at risk for frequent [CONDITION(S)]'s nor interventions to help prevent infection. Interview on 1/12/22 1:21 p.m. with DON B regarding resident 40's care plan revealed: *Resident 40 wanted to be independent with catheter care. *Didn't like to hearing instructions from staff. *Agreed that the care plan had not indicated that the resident was at risk for frequent [CONDITION(S)]'s nor interventions used to treat recurrent infections. Policy review of providers baseline care plan revised on 3/19 revealed: *The baseline care plan will include conditions and risks affecting the resident's health and safety. Examples included: *infections.

Based on observation, interview, and policy review, the provider failed to ensure proper hand hygiene and glove use by one of one certified nursing assistant (CNA) while performing cares for one of nineteen sampled residents (15). Findings include: Observation on 1/12/22 at 8:14 a.m. of cares for resident 15 with CNA C and CNA D revealed: *Both staff were wearing gloves. *Resident was incontinent of urine. *CNA C performed peri care using disposable wipes. *CNA D helped with positioning resident. *With the same gloves performed the following: -Placed a clean brief on the resident. *Helped resident dress for the day. *Returned wipes to dresser drawer. *Removed gloves and washed hands. *Put clean gloves on then washed resident's face. *Removed gloves and exited the room with garbage bag. *No hand hygiene after removing gloves. Interview with CNA C following the observation revealed she: *Had worked at the facility for 2 months. *Received hand hygiene training through staffing agency. *Had not realized she was supposed to change gloves after performing peri care. Interview on 1/12/22 at 1:11 p.m. with director of nursing B regarding the observation of the CNA's revealed: *Agreed hand hygiene had been missed. *Stated that agency staff should have had all of their training. *She expected staff to perform hand hygiene appropriately. Review of the provider's undated nursing policy and procedure for male resident perineal care revealed: *After the perineal area was cleansed staff were to remove their gloves and perform hand hygiene.

Based on observation, interview, job description review, and policy review, the provider failed to: *Maintain cleanliness in one of one kitchen. *Ensure appropriate hand hygiene and glove usage during one of one observed meals by one of one dietary aide (A). Findings include: 1. Observation on 8/6/19 at 8:10 a.m. in the kitchen during the initial tour revealed: *The shelving above the microwave had a layer of food crumbs on it. *The outside of the large:-Flour bin had been sticky. -Sugar bin had been sticky with particles of sugar on top of it. *A large ladle in a bottom cupboard drawer had a small amount of water in it. 2. Observation on 8/6/19 at 11:35 a.m. during the noon meal revealed: *Dietary aide A dropped a tongs on the floor, picked it up, placed it on the serving cart, took her gloves off, and without performing hand hygiene put on a new pair. 3. Observation on 8/7/19 in the kitchen revealed: *The outside of stainless steel cabinets were streaked, spotted, and grimy, *The outside of the convection oven and the stove had a build up of grime and was streaked with old food particles. *There were crumbs on top of the convection oven where several large baking pans had been turned upside down. *The knobs on the oven had a build up of grime and dust on them. *The caulking around the hand sink had been dark in color. *The outside of the large stainless steel refrigerator had been streaked with dirty spots. -There were several areas of dried liquid on the inside bottom shelf. -The inside left bottom drawer had spilled crusty food on it. *The door leading into the kitchen had: -Several areas of gouged wood. -The right lower corner of the door had areas of chipped and missing wood. *The wall air conditioner unit was dirty with dust build up in the vents. -It had been blowing out cold air into the food preparation area. *There were several electrical plug ins with grime and dust build up on them. *The serving counter top where the food had been placed prior to being served had multiple missing pieces of Formica making it an uncleanable surface. *The stainless steel cart that had the large commercial mixer on it had grime, dried spills, and food crumbs on it. *The kitchen walls were discolored, sticky, dirty, and had numerous areas of chipped paint. *There were two plates on the floor under the three compartment sink. *The two stainless steel shelves in an open cupboard across from the dishwashing machine that housed clean dishes had built up grime on them. *The twelve tiered cart that was used to transport the meal trays to the challenging behavior unit and the [MEDICAL CONDITION] unit was: -Dirty with multiple dried stains on it. -The area above the four wheels had a significant amount of a black tarry build-up on it. *The fire extinguisher by the door leading into the dining room had large, dried, crusty areas on it. *The inside of the refrigerator in the dining room had:-A plastic drawer on the side shelf with a piece of masking tape running three-fourth of the way across it. -The bottom left drawer had dried on food and spills in it. *The stainless steel wall covering behind the stove had a large amount of grime build up on it. 3. Review of the weekly dietary cleaning schedule from 5/6/19 through 8/5/19 revealed the above areas had not been documented as having been cleaned weekly. Observation and interview on 8/7/19 at 10:41 a.m. with the certified dietary manager (CDM) regarding the cleanliness of the kitchen revealed: *There were two large handled cleaning devices in front of the soap dispenser that had to be moved by the CDM. -They had blocked the soap dispenser by the hand sink. *There was one plate on the floor under the three compartment sink. *There was a cutting knife in a cupboard drawer that had a small amount of water on it. *There were four white cutting boards with multiple areas of slits, scratches, and scars making it an uncleanable surface. *The masking tape in the dining room refrigerator was used to hold the drawer in place. *She agreed a few things looked dirty. *She would go behind the dietary staff and tried to check-up on their cleaning. *She would go by the dates on the weekly cleaning sheet that were signed off by the staff indicating it had been done. *The dietary cooks and the dietary aides were expected to complete the cleaning within their work time. -The evening staff were to do a majority of the cleaning. *After the tongs had fallen on the floor on 8/6/19 at 11:35 a.m. dietary aide A: -Picked up the tongs. -Threw the tongs on the bottom shelf of the food cart. -Removed her gloves and she was not sure what the dietary aide had done with those gloves. -Put on a new pair of gloves without doing hand hygiene. *Her expectations would have been for dietary aide A to have placed the tongs into the sink, washed her hands, and then put on new gloves. Review of the undated Dietary Manager job description revealed: *Job Summary: -A. Is directly responsible to the Administrator and shall assure the provision for optimal nutritional care and quality food service to the residents of the nursing facility. *Responsibility For: -Management, supervision, and in-service education of dietary personnel. *Provides safe, sanitary and timely provision of food services to meet nutritional needs of residents adhering to sanitation and safety laws and regulations. Review of the undated Cook job description revealed: *Essential Functions: -3. Maintain and use equipment and supplies, sanitize after each use. -15. Wash and sanitize pots, pans, and other equipment used. -19. Perform related duties as assigned or as the situation dictates. Review of the undated Dietary Assistant job description revealed: *Functions: -3. Clean and maintain kitchen and food preparation equipment. -6. Wash, sanitize and store dishes and utensils. -7. Perform related duties as assigned or as the situation dictates. Review of the provider's 2013 Cleaning and Sanitation of Dining and Food Service Areas policy revealed: *Policy: -The food service staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. *Procedure: -1. The food service manager will record all cleaning and sanitation tasks needed for the department. -2. Tasks shall be designated to be the responsibility of specific positions in the department. -3. All staff will be trained on the frequency of cleaning necessary. -4. The method and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. -5. A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. -6. Staff will be held accountable for cleaning assignments.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure one of two sampled residents (3) in the challenging behavior unit (CBU) received necessary services to meet his activity, psychosocial, and restorative needs. Findings include: 1. Review of resident 3's entire medical record revealed: *He had been admitted on [DATE] from Human Services Center. *His [DIAGNOSES REDACTED]. *He received the following medications to address his behaviors: -Quetiapine [MEDICATION NAME] (antipsychotic) 25 milligram (mg) tablet (tablet) every morning and a 50 mg tab at bedtime. --He could also receive a 25 mg tab every six hours as needed for agitation and anxiety. -[MEDICATION NAME] (antipsychotic) 2.5 mg tab one tab every morning and a 5 mg tab at noon. -Trazadone HCL 50 mg tab every evening for sleep. Review of resident 3's 3/8/17 care plan revealed it included: *Problem 1: He had altered thought process related to cognitive impairment and behaviors as evidenced by exit seeking, physically aggressive, and wandering. *Goals: To accept all medications as ordered. -To have fewer episodes of being physically aggressive. -To have fewer episodes of exit seeking. *Approaches: Staff would work to build a trusting relationship with resident. -Staff would monitor any behavior and notifying nurse of any changes. -Staff would work to establish a consistent routine. -Provide a calm therapeutic environment and structured routine. *Problem 2: -Restorative. *Goal: Tasks complete. *Approaches: Active Range of Motion: Would participate in recommended exercises. *Problem 3: [MEDICAL CONDITION] medications. *Goal: Will be free of any adverse side effects from medications. *Approaches: Will be followed by (mental health agency name) services. -Gradual dose reduction as recommended by pharmacist. *Problem: Due to his low cognitive level it was hard for him to engage in activities. *Goal: Would participate in 1 to 2 independent or group activities daily. *Approaches: Provide with a monthly activity calendar. -Enjoyed taking about being in the Navy. -He used to enjoy playing pool. -Enjoyed sitting outside when the weather is nice. *Problem: Does not accept his dementia diagnosis. -Contact his son/guardian as needed. -Mental health referrals as appropriate. -Pride in his serving in the Navy. -Do not rush. Review of resident 3's random nursing progress notes from 4/16/17 through 5/8/17 revealed: *4/16/17: Resident exit seeking and pacing, rummaging throughout the day. He did grab another resident's wrist and twisted it, staff was there and was able to get him to let go. Resident also got out the south door and was located by staff south of the nursing home, no apparent injury. *4/21/17: Has been pacing et exit seeing et has caused alarms to go off several times today. *4/27/17: (Resident name) was at the patio door et (and) was trying to get out and he pushed the door open et stepped out on the patio. (Resident name) was resistive to (name of CNA) who was attempting to redirect him inside this nurse came to assist along with (two additional staff names). (Resident's name) was threatening to hit this nurse on the left lateral mandible with his fist. *4/28/17: Resident was pacing and rummaging into everything after breakfast, was asking to to to Rapid City, exit seeking, asking staff if they had a car to take him to Rapid City. Quetiapine 25 mg 1 tablet PRN (as needed) was given at 8:45 a.m. resident continued to pace for another hour. Staff was able to get him to sit down in a chair and he feel asleep. *5/4/17: (Resident name) pulled his plaque off of his wall et was walking toward the nurses station on the unit et was swinging his plaque around close to another peers head. This nurse asked resident to please hand over the plaque and (resident) refused. Then (CNA name) attempted to take the plaque out of (resident's) hand when she was told not to do that action as it would escalate resident's behavior. (Resident's name) took the plaque et hit the CNA in the right side of her abdominal area. (Resident's name) tore uniform of CNA et did not leave any visible puncture marks. --SS was made aware of the situation and did ask this nurse to give a PRN medication, 1703 p.m. (5:03 p.m.) This nurse did give a PRN Quetiapine 25 mg PRN orally for combative behavior. Continues to be agitated and did go out of unit around supper et was escorted back to unit. *5/5/17: Resident pacing and rummaging throughout the day, resident was found resting on a spare bed in the units empty bedroom. Review of resident 3's 4/20/17 Restorative program referral revealed his plan included: *Patient (resident) will complete 2# (pound) weight exercises x 25 x 2 (twenty-five times twice). -Patient will participate in sensory tasks, including rice bucket, use of yoga ball to push on/sit participate in deep pressure through shoulders. -Patient will complete nuts/bolts tasks while wearing a 2# wrist weights and transferring items to designated box. -Will follow 1 step directions for re-direction and arrow down (decrease) exit seeking. -Will complete object identification by name during sensory tasks recommended by OT (occupational therapy). Interview on 5/10/17 at 2:00 p.m. with restorative aides D and E regarding resident 3 revealed: *They had not been doing any restorative program with him. *He refused to do anything they were going to do with him. -They had not revised his plan when he refused. *They were not following the plan set-up by the therapists because of his behaviors. *They were still getting to know him and did not feel it was safe to take him outside or out of the CBU. -They had not documented his refusals, because they had been told to document Activity did not occur rather than his refusal. -They did not feel that was a correct picture of him, so they had not documented anything. Review of resident 3's 5/9/17 social services notes revealed (Resident's name) had exited the CBU into the courtyard without letting staff know. (Name) stated that he was headed to the cars at the apartment complex. Recorder asked if he wanted to call his son and he agreed. He entered the CBU without issue. Recorder took him into the nurses station to call his son. Son talked with him. He was still appearing to be upset and is pacing the unit checking doors at a brisk pace. Asked (name) to watch TV and he refused. Asked (name) to look at some magazines and he refused. Nurse notified and is going to give (name) a PRN to help with his agitation that he is having. Interview on 5/10/17 at 4:50 p.m. with the social services director regarding resident 3 revealed: *The residents on the CBU were placed there because no other nursing home would take them. *Most of them had come from a psychiatric facility/hospitalization . *They all exhibited challenging behaviors. *They had an agreement with the Department of Social Services (DSS) to provide that placement extension to the Human Services Center. *The residents' goals were to return to their community or to a nursing home closer to their family. *They were still getting to know resident 3, because he had only been there two months. *He spent most of his time walking up and down the halls and exit seeking. *They could not take him to group activities out of the unit because of his exit seeking, and he was at risk for elopement. -They could not take him outside, because he would crawl over the fence; he had already done that. -She confirmed he had worked outside during his working years and would probably like that. -She did not know if reading a magazine or watching TV was an appropriate intervention to distract him in the above incident. *Because of his behaviors they did one-to-ones with him three times per week. *They were unable to provide documentation that had occurred and what was done during the one-to-one activities. Interview on 5/11/17 at 9:45 a.m. with LPN A regarding resident 3 revealed: *The resident received mental health services. *The caseworker from the mental health agency always came during the day when behaviors were less likely to occur. -She needed to come later in the day or evening to see what the resident was really like. *When the resident was seen by the psychiatrist they were seen at the clinic and relied only on the mental health case worker visit notes, and they did not have an accurate picture of the resident and the behavior they exhibited. 2. Random observations on 5/9/17 from 10:00 a.m. until 6:00 p.m. and on 5/10/17 from 8:30 a.m. until 5:30 p.m. on the CBU revealed: *There were ten residents in the unit. *It was staffed with one licensed nurse and two certified nursing assistants (CNA). -During the time noted one of the CNAs B worked for a temporary agency. -On 5/10/17 at 9:30 a.m. the second CNA C acknowledged she had only begun working there on 5/3/17. *Some residents walked up and down the hall going from one exit door to another attempting to leave the unit or get outside. *One resident was noted to be taken out of the CBU on occasions, and staff would walk with her. *An activity calendar was posted on the wall and was later verified it was the schedule of activities that occurred in the main part of the facility. -Residents in the CBU could go out to those activities if they were not an elopement risk. *There was not a schedule of activities or programs in the CBU. *Throughout the day, the residents in the CBU were observed: -Lying on their beds. -Pacing up and down the hall and some attempted to leave the unit. -Staff intervened to prevent the residents from leaving the unit. -Residents were visibly upset when they could not leave the unit. *The CBU doors were secured and could not be voluntarily exited by the residents without staff supervision. *No group activities were offered in the unit. *A large screen television was continuously on in the day room with various older television shows playing. -Occasionally one or two residents sat down and watched the television, but it was done randomly, not for a specific program. *Restorative staff came into the unit to take certain residents out of the unit for restorative care/services. Interview on 5/9/17 at 10:30 a.m. with LPN A revealed: *All of the residents had some type of challenging behaviors, and many of them had dementia. -Some of the residents had mental health illnesses such as [MEDICAL CONDITION]. *Most of the residents had come from the Human Services Hospital. *They were staffed with one nurse and two CNAs. *They had one CNA B who worked for a temporary staffing agency but had come back repeatedly for some time. Interview on 5/9/17 at 10:30 a.m. with CNA B revealed: *She had been assigned to work in the CBU for awhile. *She did not receive any specific behavior training when she came to fill in at the facility on how to deal with the residents in the CBU. *She did not have a care plan to follow that told her how to deal with some of the specific behaviors of the residents. -She had just gotten to know them by working there, and the nurse helped her too. Interview on 5/10/17 with CNA C revealed: *She had just started her employment there on 5/3/17. *She had four years of experience working at various nursing homes prior to this, but her most recent job was in a sandwich shop. *Her orientation here was review of the various resident care needs like toileting a resident and feeding them. *She had not received any specific training on behavior management to prepare her to work in the CBU. -She stated That would have been nice. Interview on 5/9/17 at 10:30 a.m. with the director of nursing revealed they did not have any policies and procedures for the CBU. Interview on 5/11/17 at 1:30 p.m. with the staff development coordinator revealed she confirmed CNA C had not received any specific behavior training before being assigned to the BCU. The CNA had several years of experience and she assumed she had worked with people with behaviors. Interview on 5/11/17 at 10:15 a.m. with the administrator revealed: *They did not have any specific policies for the CBU. *Their expectation was that residents in the CBU get the same care as the rest of the residents throughout the facility. Review of the provider's undated Mood and Behavior Policy revealed: (Name of facility) has a Mood and Behavior Policy to provide a plan of care that is individualized to the residents needs based upon the comprehensive assessment by the interdisciplinary team. This plan of care will include medically related social services to address mood and behavioral health services to attain or maintain the highest practicable well being. B. Based on observation, record review, interview, and policy review, the provider failed to ensure an effective pain management program was in place for one of ten sampled residents (7). Findings include: 1. Review of resident 7's medical record revealed: *A 12/1/16 admitted . *Diagnoses: [REDACTED]. *She had been discharged from hospice care on 4/14/17. Observation on 5/9/17 at 12:30 p.m. of resident 7 revealed she: *Was transferred into her recliner chair from her wheelchair by two random certified nursing assistants. *Transferred poorly with the standing transfer, her legs buckled. *Did not verbalize when spoken to. *Moaned during the transfer. *Stopped moaning when she was in her recliner with her legs elevated. Review of resident 7's 1/17/17 through 5/9/17 nursing progress notes revealed: *1/17/17 at 1:57 p.m.: Is noted to yell out when staff are giving her cares or transferring her. *1/19/17 at 1:44 p.m.: Resident was hollering out this morning when staff were assisting resident with morning cares. This is not unusual for this resident. Was calm and quiet after staff transferred resident to her wheelchair. Will continue to monitor. *1/21/17 at 3:51 p.m.: Resident will yell out when staff are assisting her with activities of daily living and transfers. Not in pain but almost as if she is trying to tell staff to stop. *1/23/17 at 1:33 p.m.: Resident hollers out frequently when staff assist her with cares. This is not unusual behavior for this resident. Will continue to monitor. *1/29/17 at 3:14 p.m.: Resident hollers out often when staff assist her with cares. This is not an unusual behavior for this resident as she does not fully understand what staff are trying to do. Step-by-step instructions are given with cares. will continue to monitor. *2/1/17 at 11:55 a.m.: Resident was hollering out during cares this morning even when staff gave instructions as to what they were doing. This is not unusual for resident. Will continue to monitor. *2/6/17 at 1:53 p.m.: Is noted to yell out when staff are assisting her with cares. *2/8/17 at 11:39 a.m.: Continues to holler out at staff during cares. Staff did report this morning was worse than usual but not unusual for this resident. Will continue to monitor. *2/9/17 at 5:16 a.m.: Resident yells and screams with all transfers and also when changing her at night. It is increased when her roommate is yelling. *2/13/17 at 3:45 p.m.: Noted to be hollering out during cares this shift. This is not unusual for this resident. Will continue to monitor and address as needed. *2/24/17 at 2:42 a.m.: Resident screams and hollers with cares and during rounds. Doesn't seem to be in pain. Just seems nervous and hollers out when transferring or rolling her. Will continue to monitor. *3/2/17 at 1:28 p.m.: Resident was hollering out during cares this morning. Was calm once cares were complained and resident was in wheelchair. *3/3/17 at 2:53 p.m.: Resident continues to holler with morning cares which could possibly be related to pain or maybe cognition. [MEDICATION NAME] was being used as needed (PRN) prior to cares to see if it would help resident remain calm and did work for a short period of time, but then resident returned to hollering with cares. Resident is calm when cares are completed and staff have assisted her to her wheelchair. *3/12/17 at 10:13 a.m.: Residents PRN [MEDICATION NAME] was discontinued on 3/8/17 per family request. Resident has not utilized PRN [MEDICATION NAME] since 2/24/17. She does not seem anxious but does holler at times with cares and unknown as to why, but is not usual behavior. *3/13/17 at 9:30 a.m.: Staff reported that resident was hollering with cares this morning. Resident also seemed startled and hollered when recorder approached her to take her vital signs. She is given step-by-step instructions of what staff are doing but does not help resident due to cognition. Staff stated resident immediately calmed down once cares were completed and she was sitting in her wheelchair. *3/21/17 at 4:12 p.m.: Noted to be yelling when staff got her up. More behavior-like than pain. *3/24/17 at 9:47 a.m.; Was noted to be hollering out during cares this morning. This is not unusual behavior for this resident especially with morning cares and transfers. Calm and quiet once in wheelchair. *3/27/17 at 10:29 a.m.: Was hollering out during cares this morning. Staff were assisting with changing, peri care, and dressing when resident began to holler out. This is not unusual behavior and happens often during cares. Giving resident step-by-step instructions during cares does not always deter the behavior. *4/3/17 at 12:15 p.m.: Was hollering out this morning during cares. This occurs almost every morning despite staff explaining cares to resident. Resident is calm once in her wheelchair. *4/10/17 at 2:31 p.m.: Continues to yell out when staff transfer her or give any kind of cares, almost as if she is yelling out of behavior and not pain. *4/27/17 at 4:37 p.m.: CNA informed writer that resident continues to holler out with cares in the morning but seems to be increasing. Questioning if it is pain related or dues to resident's dementia. Have tried PRN [MEDICATION NAME] in the past when resident was on hospice which seemed to be effective at times but not others. Will continue to monitor and notify physician as needed. *5/1/17 at 3:33 p.m.: Yelling is more related to behavior than her having pain. She yells out as if to yell out no don't do that when staff try to perform cares. *5/2/17 at 1:32 p.m.: CNA reports resident was yelling and did some cursing this morning when she went to get her up. Not yelling out in pain. *5/3/17 at 3:34 p.m.: Per staff resident hollering out once again with cares this morning. Staff do give resident step-by-step instructions but this does not seem to decrease resident's hollering out. Resident does calm down once cares are completed and she is in wheelchair. *5/5/17 at 11:50 a.m.: [MEDICATION NAME] sulfate was discontinued due to non-use. Resident is no longer on hospice status and has not required or utilized since change in status. *5/7/17 at 2:18 p.m.: Was yelling at the girls this morning while getting her up. More behavior than pain. Review of resident 7's January 2017 through May 2017 medication administration records revealed she received: *Aspirin 325 milligrams daily for the [DIAGNOSES REDACTED]. *[MEDICATION NAME] sulfate one time on 2/24/17. *No doses of PRN [MEDICATION NAME] for anxiety. *No other [MEDICATION NAME] for pain. Review of resident 7's undated care plan revealed: *Altered thought process related to cognitive loss/dementia and behaviors evidenced by being resistive with cares, cursing, hollering, and screaming. *She will accept all medications as ordered. *Shifts of being resistive with cares will decrease. *Will have fewer shifts of cursing, hollering, and screaming. *Pain management was not addressed. Phone interview with the resident's spouse on 5/11/17 at 10:00 a.m. revealed he: *Usually visited the resident every day. *Thought her hollering out with care and transfers might be related to anxiety. The staff had told him they thought she was fearful, because she did not know what was being done due to her dementia. *Wanted her to be comfortable and thought that maybe using [MEDICATION NAME] might help. *Did not want to use narcotics as another facility in the past had, and they had made her so sleepy. Interview on 5/11/17 at 11:00 a.m. with the director of nursing regarding resident 7 revealed she: *Agreed the above documentation did not support that her pain was controlled. *Felt it was difficult to determine if her hollering out was related to pain or fear due to her dementia. *Felt it was reasonable the staff should have contacted the physician regarding her daily hollering out and if an [MEDICATION NAME] could have been tried. Review of the provider's revised April 2017 Pain Management policy revealed: *The management of pain must be a priority for nurses and other personnel who provide care to residents in pain. *Persons who are experiencing pain have the right to have their pain relieved to the greatest extent possible. *Nurses are responsible for maintaining knowledge and skills necessary to coordinate optimal pain management. *Nurses educate staff members about pain assessment, treatment, and the common barriers to adequate pain management. *Nurses administer medications and treatments as prescribed, using knowledge to maintain both safety and pain relief. *The nurse recognizes that pain medications may be used around-the-clock. *Nurses initiate non-pharmacological nursing interventions as indicated. *Nurses communicate side effects or any reports of unrelieved pain to the prescriber and appropriate team members. *Nurses document pain assessment, intervention, evaluation, and changes to the plan of care in a clear and concise manner. *There shall be ongoing monitoring and documentation of the effectiveness of the pain management program. If pain management is not successful, other referrals to pain centers or hospice organizations may be necessary. *Direct care staff assignments should be consistent whenever possible to allow staff to become familiar with the resident and their responses to pain management.