Every finding on record at Tekakwitha Living Center

Based on observation, interview, documentation review, and policy review, the provider failed to ensure the staff followed standard food safety practices by one of one dietary manager (DM) D who did not sanitize the food thermometer probe before placing it in food items during food temperature checks of food served to the residents and did not perform hand hygiene (washing hands with soap and water or using alcohol-based hand sanitizer) before putting on, or after removing her gloves and regarding food items that were not safely stored in the walk-in refrigerator and freezer in one of one main kitchen. Findings include1. Observation on 7/28/26 at 11:08 a.m. of the walk-in refrigerator and walk-in freezer in the kitchen revealed there were oranges and melons stored on the bottom shelf of the walk-in refrigerator. There were three packages of wrapped meat thawing on a tray on the shelf above those fruits. There were more than nine boxes of food, including frozen vegetables and sherbet, stored on the floor inside the walk-in freezer. 2. Observation on 7/28/26 at 11:43 a.m. of the lunch meal service in the main kitchen with DM D revealed she opened a retractable food thermometer, wiped the thermometer probe with her finger, placed that probe in the meatloaf, and checked the temperature of the meatloaf. She then used an alcohol wipe to clean the probe and placed that unclean wipe on the metal counter. She used that same thermometer to check the temperature of the wax beans, and, without cleaning the probe, placed the probe into the sweet potatoes, checked the temperature of the sweet potatoes, and then set the thermometer on the counter. DM D picked up the thermometer, wiped the probe with the palm of her hand, and checked the temperature of the macaroni and cheese. She then used the same unclean wipe she placed on the counter to clean the probe, retracted the probe, and placed the thermometer in her shirt pocket under her apron. DM D took a second retractable thermometer off the microwave and, without cleaning the probe, placed it in the pork and checked the temperature of the pork.Continued observation of DM D revealed she exited the main kitchen and entered the north kitchenette. DM D touched both the main kitchen and north kitchenette's doorknobs, the handle of the cart used to transport food items to the kitchenette, and the lids of the pans of hot water on the steam table. DM D used potholders to move the pans of food from the cart into the compartments in the steam table, and placed those potholders on the transportation cart. DM D then removed the thermometer from her scrub pocket, and, without performing hand hygiene, she put on a pair of gloves. With those same gloved hands and without cleaning the thermometer probe, she checked the temperature of the meatloaf, wiped that probe on a paper towel, used a pen to document that food temperature, checked the temperature of the sweet potatoes, and then wiped the probe on that same unclean paper towel. DM D repeated this process to check the temperatures of the remaining food items. DM D wiped that same thermometer probe on that same unclean paper towel after she checked the temperature of the last food item, retracted the thermometer probe, and placed the thermometer on the transport cart.With her same gloved hands, DM D touched each resident's plate and surfaces of those plates where food would be placed with those gloved hands. She used several food serving utensils and plated food for approximately sixteen residents.With those same gloved hands, DM D used the potholders to lift the food pans with the serving utensils still inside of them and placed those pans back on the transportation cart. She removed her gloves, discarded those gloves in the garbage can, and then brought the cart with those pans of food on it to the east kitchenette.Without performing hand hygiene, DM D used the potholders to place the food pans into the steam table in the east kitchenette. DM D took the thermometer from the top of the cart, opened the thermometer and, without cleaning the thermometer probe, placed the probe into the sweet potatoes, checked the temperature of the sweet potatoes, wiped the probe on a potholder, placed the probe into the meatloaf, checked the temperature of the meatloaf, wiped the probe on that same unclean potholder, and repeated that process as she checked the temperature of each food item. Without performing hand hygiene, DM D put on a pair of gloves and touched each resident's plate and surfaces of those plates where food would be placed with those gloved hands as she plated food for the approximately fifteen residents in that dining room. 3. Interview on 7/28/26 at 6:13 p.m. with DM D revealed she started working in the kitchen about three months ago as a cook and the dietary manager in training. She recently completed the ServSafe certification course and was now the dietary manager. She stated that she needed to wash her hands when she left the kitchen and returned to the kitchen, took out the trash, or touched raw meat. She stated she did not need to wash her hands when she put on or removed her gloves. She explained that she felt wearing gloves in the kitchen and while serving resident food items made it easier for her because the gloves do not cross-contaminate, and she did not have to wash her hands as often.She stated that she knew the food thermometer probe was clean when she started checking the food temperatures because she was the last person to use it. She wiped the thermometer probe on a paper towel and potholder in the kitchenettes to clean it and then cleaned the thermometer probe again when she returned to the main kitchen. She explained that she placed the thermometer in her scrub pocket because Where else do you want me to put it? She thought she may have made small mistakes while taking the temperatures of the food items because she had worked 13-hour shifts for nine days in a row. She did not know who had placed the boxes of food on the floor or placed the fruit below the meat in the refrigerator and did not think that was of any concern. 4. Interview on 7/29/26 at 11:05 a.m. with registered dietitian (RD) E revealed she visited the facility one to two times per month. During those visits, she consulted on dietary issues, provided education to staff members on dietary topics, and completed audits of the cleanliness of the kitchen and food preparation and serving processes in the kitchen. She was aware of ongoing concerns about DM D's sanitation practices in the kitchen and had discussed those concerns with administrator A when she conducted her June 2026 facility visit.RD E expected that DM D would wash her hands before putting on gloves, when she removed her gloves, and after touching a contaminated or unclean surface while preparing or serving the resident's food. She stated that gloves were only to be used for completing a single task, such as when handling ready-to-eat foods.RD E expected the staff to clean the food thermometer probe with a new thermometer probe sanitizing wipe before and after each time it was used to check the temperatures of each food item. The food thermometer should never be stored in a staff member's pocket.RD E stated that all food boxes needed to be stored off the floor and on a shelf. She expected produce and fruits to be stored above meat items in the refrigerator to prevent the liquid from the thawing meat from dripping on the ready-to-eat produce items. 5. Interview on 7/29/26 at 12:18 p.m. with director of nursing (DON) B revealed that she was also the facility's infection preventionist. She did not oversee the kitchen and expected DM D or RD E to oversee the staff's sanitation practices in the kitchen. She thought that the dietary staff members should wash their hands frequently during food preparation and meal service.She stated gloves were for single use and should not be used as a replacement for hand washing. She expected the food thermometer to be cleaned before it was used, and as often as RD E instructed the dietary staff to clean it. She did not know how often the food thermometer probe should have been cleaned. She stated that the food thermometer should not be carried in any staff member's pocket. She did not conduct staff handwashing or glove use audits in the kitchen. 6. Interview on 7/29/26 at 1:03 p.m. with administrator A and regional director C revealed that RD E visited the facility monthly, provided education, and conducted audits of the cleanliness of the kitchen and food preparation and serving processes in the kitchen. Administrator A confirmed that RD E had discussed her concerns about DM D's food service sanitation practices, including licking her fingers while she was cooking in June 2026. Administrator A stated that he provided verbal education to DM D that she needed to wash her hands more frequently, but he did not document that he provided that education. He felt that concerns brought to him regarding the kitchen by RD E were overreacting.Administrator A expected DON B to oversee the infection prevention practices of the staff who worked in the kitchen, including hand washing and glove use. 7. Review of the 5/28/26 through 7/15/26 General Foodservice Checklist audits completed by RD E revealed that food items were documented as observed on the floor in the walk-in refrigerator/freezers on 5/28/26, 6/26/26, and 7/15/26. An area on that checklist, which read Food is served at proper temperatures (Check food temps accordingly) was marked no on 5/28/26 and 6/26/28. Those audits did not include the staff's handwashing practices or glove use in the kitchen. 8. Review of the provider's 2001 Preventing Foodborne Illness policy revealed that All employees who handle, prepare or serve food will be trained in the practices of safe food handling and preventing foodborne illness. Employees must wash their hands. Whenever entering or re-entering the kitchen; Before coming in contact with any food surfaces; After handling soiled equipment or utensils; During food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks; and/or after engaging in other activities that contaminate the hands. Gloves are considered single-use items and must be discarded after completing the task for which they are used. The use of gloves does not substitute for proper hand washing. 9. Review of the provider's 2013 Food Storage policy revealed that Food items will be stored on shelves.Food is stored a minimum of 6 [six] inches above the floor. This policy did not include where or how fruit and meat items should be safely stored in the refrigerator. 10. Review of the provider's 2013 Employee Sanitary Practices policy revealed staff members were to Pick dishes up by their rims. Follow all federal, state and local requirements. 11. Review of the provider's 2013 Food Temperature policy revealed that it did not include a process for taking food temperatures or the sanitary use of the food thermometer. 12. Review of the provider's undated Dietary [NAME] job description revealed that a cook thaws meat, .and maintains high standards of following sanitary procedures. 13. Review of the provider's undated Dietary Manager job description revealed the DM was expected to conduct monthly sanitation audits, put away freight, and Inspects quantity, quality, temperature, and appearance of food before it is served. Assures that the dietary department is in compliance with all state, federal and local regulations.There was no documentation in the job description regarding hand washing or sanitation practices. regarding hand washing or sanitation practices.

Based on South Dakota Department of Health (SD DOH) complaint report review, observation, interview, record review, and policy review, the provider failed to report an allegation of potential staff-to-resident abuse within the required time frame to the SD DOH when the staff reported to one of one administrator (A) that one of one dietary manager (DM) D kissed one of one sampled resident (1) multiple times. Findings include:1. Review of the 6/30/26 anonymous SD DOH complaint reports revealed that many facility staff members witnessed DM D kiss more than one resident. The reports indicated that resident 1 was kissed on the lips more than once. Twice on the lips and once on the forehead. There were no other residents identified by name in the report.The above complaint report indicated that the residents were vulnerable, and the staff members reported those incidents to the administrator and were brushed off by administrator A. That report also included that the complainants were concerned for the safety of the residents and felt the incidents needed to be investigated. 2. Review of the 7/2/26 SD DOH complaint report revealed that on 7/1/26, anonymous staff member F witnessed DM D kiss resident 1 in the dining room and reported it to the administrator. That it was the third time staff members had witnessed DM D kiss resident 1. Anonymous staff member H felt that administrator A brushed it off like it was nothing, and was not taking their concerns seriously. The staff members felt that as mandated reporters, the incidents needed to be investigated. 3. Review of the 7/6/26 SD DOH anonymous complaint report revealed that a facility staff member witnessed DM D kiss resident one on the mouth. The report indicated the incident was reported to the administrator and was not taken seriously. 4. Observation on 7/28/26 at 10:27 a.m. with resident 1 revealed he was resting in his room in a high-back wheelchair with a right-sided wedge between his upper body and the wheelchair. His head was down, and he did not respond to the surveyors' knocks on his door. 5. Interviews on 7/28/26 at 11:00 a.m., 2:09 p.m., 3:30 p.m., and 4:52 pm with anonymous staff members F, G, and H, and on 7/29/26 at 8:25 a.m. and 8:45 a.m. with anonymous staff members I, and J, who requested to remain anonymous for fear of retaliation, revealed there were more than three instances when those staff members witnessed DM D kiss resident 1 on the resident's lips and forehead. Anonymous staff members F, G, H, and I stated that DM D's instances of kissing resident 1 occurred in the dining room on different days in June and July 2026 when DM D was serving meals to the residents. Anonymous staff members H and I felt that resident 1 was unable to physically move away from DM D when she kissed him because he was in a wheelchair and unable to move his wheelchair without staff assistance. Anonymous staff member H reported those concerns to anonymous staff member J, who told anonymous staff member H that she felt that she would be fired if she got involved in issues involving dietary staff members, and that she did not witness DM D kiss resident 1 or any other resident. Anonymous staff member J told anonymous staff member H to report the concern to the administrator, the ombudsman, or the state. Those incidents were reported to administrator A by anonymous staff member F and H. Anonymous staff member F and H stated that administrator A did not take their concerns seriously, that they were told by administrator A to stop tattling, and they were afraid that they would lose their jobs if they reported their concerns to any other management staff. Anonymous staff members F, G, H, and I chose to report their concerns to the SD DOH. 6. Review of resident 1's electronic medical record (EMR) revealed resident 1 admitted to the facility on [DATE]. His 6/28/26 Brief Interview for Mental Status (BIMS) assessment score was 7, which indicated his cognition was severely impaired. His diagnoses included major depressive disorder (a mental health condition defined by a persistent low mood, loss of interest in activities, and lasting changes in sleep and energy), and a stroke. 7. Observation and interview on 7/28/26 at 4:27 p.m. with resident 1 revealed he was resting in his room in a high-back wheelchair. His eyes were open; he did not verbally respond to questions the surveyor asked. 8. Interview on 7/28/26 at 5:16 p.m. with administrator A and director of nursing (DON) B revealed that administrator A acknowledged that a dietary staff member reported to him their concerns that DM D allegedly kissed resident 1 in the dining room. He could not recall which staff member reported that allegation to him. He did not document when that allegation was reported to him but thought that it was reported to him about a month ago. He did not tell DON B about that allegation or report it to the SD DOH. Administrator A stated that he considered the source of the allegation and considered the allegation as tattling. He could not recall if the staff member who reported the allegation to him had stated that they were worried that DM D's actions were considered abuse. DON B was unaware that staff members had reported concerns of DM D kissing resident 1 to administrator A. No staff members had reported those concerns about DM D kissing resident 1 to her.Administrator A and DON B indicated that it would be inappropriate for a staff member to kiss a resident if they did not want to be kissed, and that a staff member kissing a resident could be considered abuse in some situations. DON B completed the incident reports that were required to be submitted to the SD DOH. She expected administrator A to have notified her of the abuse allegation regarding DM D kissing resident 1 because all allegations of potential resident abuse were to be reported to the SD DOH immediately. The facility should have conducted an investigation to determine if abuse to resident 1 had occurred. 9. Observation and interview on 7/29/26 at 9:08 a.m. with resident 1 revealed that he was hard of hearing, had difficulty finding words, answered questions out of context, and appeared unable to understand direct questions when he shrugged his shoulders and smiled rather than responding to the questions asked. 10. Interview on 7/29/26 at 9:15 a.m. with licensed social worker (LSW) K and social services director (SSD) L revealed that an allegation that a staff member kissed a resident could be considered potential resident abuse and should be reported to the SD DOH immediately and investigated to eliminate the potential harm for residents. They were unaware that an allegation of potential resident abuse regarding resident 1 was made to administrator A. 11. Interview on 7/29/26 at 1:03 p.m. with administrator A and regional director C revealed that administrator A expected that all allegations of potential resident abuse to be reported to a member of facility leadership. He did not report the allegation that DM D kissed resident 1 to DON B because he felt that the staff member who reported it was complaining. Regional director C stated that a staff member kissing a resident should not happen, and expected that all allegations of abuse to be reported to the SD DOH immediately. 12. Review of the provider's January 2025 Employee Handbook revealed Any employee. shall immediately report all cases of physical or verbal abuse or neglect to a supervisor or department head. The supervisor or department head will then notify the designated person within the building who will make any necessary report to an appropriate state agency. Any person making such a report in good faith will be free from retaliation and disciplinary action for making the report. 13. Review of the provider's 1/30/26 Vulnerable Adult Abuse, Neglect, Exploitation, and Misappropriation Prevention Policy revealed Staff must immediately report any observed, suspected, or alleged abuse . Upon learning of an allegation or suspicion, staff must immediately ensure resident safety and notify the charge nurse, administrator, director of nursing, or designee. Any staff member who knows or has reasonable cause to suspect abuse, neglect, exploitation, mistreatment. must report the concern immediately according to facility procedure. Reasonable suspicion of a crime occurring in a federally funded long-term care facility must be reported to law enforcement and the State Survey Agency, consistent with federal requirements.

Based on South Dakota Department of Health (SD DOH) complaint report review, observation, interview, record review, and policy review, the provider failed to investigate a staff-reported allegation of potential resident abuse when the staff reported to one of one administrator (A) that one of one dietary manager (DM) (D) kissed one of one resident (1) multiple times to determine if abuse occurred and to mitigate the risk of future abuse to the residents who resided at the facility. Findings include:1. Review of the 6/30/26 anonymous SD DOH complaint reports revealed that many facility staff members witnessed DM D kiss more than one resident. The reports indicated that resident 1 was kissed on the lips more than once. Twice on the lips and once on the forehead. There were no other residents identified by name in the report.The above complaint report indicated that the residents were vulnerable, and the staff members reported those incidents to the administrator and were brushed off by administrator A. That report also included that the complainants were concerned for the safety of the residents and felt the incidents needed to be investigated. 2. Review of the 7/2/26 SD DOH complaint report revealed that on 7/1/26, anonymous staff member F witnessed DM D kiss resident 1 in the dining room and reported it to the administrator. That it was the third time staff members had witnessed DM D kiss resident 1. Anonymous staff member H felt that administrator A brushed it off like it was nothing, and was not taking their concerns seriously. The staff members felt that as mandated reporters, the incidents needed to be investigated. 3. Review of the 7/6/26 SD DOH anonymous complaint report revealed that a facility staff member witnessed DM D kiss resident one on the mouth. The report indicated the incident was reported to the administrator and was not taken seriously. 4. Refer to F609, findings 5 and 6. 5. Interview on 7/28/26 at 5:16 p.m. with administrator A and director of nursing (DON) B revealed that administrator A acknowledged that a dietary staff member reported to him their concerns that DM D allegedly kissed resident 1 in the dining room. He could not recall which staff member reported that allegation to him. He did not document when that allegation was reported to him but thought that it was reported to him about a month ago. He did not tell DON B about that allegation, speak with resident 1 or DM D regarding the allegations, report it to the SD DOH, or conduct an investigation. Administrator A stated that he considered the source of the allegation and considered the allegation as tattling. He could not recall if the staff member who reported the allegation to him had stated that they were worried that DM D's actions were considered abuse.DON B was unaware that staff members had reported concerns of DM D kissing resident 1 to administrator A. No staff members had reported those concerns about DM D kissing resident 1 to her. Administrator A and DON B indicated that it would be inappropriate for a staff member to kiss a resident if they did not want to be kissed, and that a staff member kissing a resident could be considered abuse in some situations.DON B completed the incident reports that were required to be submitted to the SD DOH. She expected administrator A to have notified her of the abuse allegation regarding DM D kissing resident 1 because all allegations of potential resident abuse were to be reported to the SD DOH immediately. The facility should have conducted an investigation to determine if abuse to resident 1 had occurred. 6. Interview on 7/29/26 at 9:15 a.m. with licensed social worker (LSW) K and social services director (SSD) L revealed that an allegation that a staff member kissed a resident could be considered potential resident abuse and should be reported to the SD DOH immediately and investigated to eliminate the potential harm for residents. They were unaware that an allegation of potential resident abuse regarding resident 1 was made to administrator A. 7. Interview on 7/29/26 at 1:03 p.m. with administrator A and regional director C revealed that administrator A expected that all allegations of potential resident abuse would be reported to a member of leadership. He had not reported the allegation that DM D kissed resident 1 to DON B to complete a report to the SD DOH or to complete an investigation because he felt that the staff member who reported it was complaining. Regional director C stated that a staff member kissing a resident should not happen, and expected that all allegations would be reported to the SD DOH and investigated to determine if abuse had occurred and to determine any actions that would need to be taken to prevent further abuse, with a final report submitted within five days. 8. Review of the provider's 1/30/26 Vulnerable Adult Abuse, Neglect, Exploitation, and Misappropriation Prevention Policy revealed Upon learning of an allegation or suspicion, staff must immediately ensure resident safety and notify the charge nurse, administrator, director of nursing, or designee. The facility will promptly investigate all allegations or suspicions, regardless of the source of the report. The administrator, director of nursing, or designee will assign an appropriate investigator and ensure the investigation is objective, timely, and thorough.

Based on interview, observation, document review, and policy review, the provider failed to ensure the staff followed proper sanitation and food handling practices regarding:*Handwashing and glove use standards were followed by dietary aide/cook I, dietary aide J, cook O, restorative supervisor N, and certified nursing assistant (CNA) H during one of one evening meal service and one of one lunch time service.*The steam tables in the north kitchenette were clean.*Dishwasher temperatures and sanitization levels were monitored and documented after each meal. Findings include:1. Interview on 1/20/26 at 2:40 p.m. with dietary aide/cook I in the kitchen revealed:*They had a dispenser of multi-range sanitizer that was premixed with water.*They used that sanitizer solution to clean the counters in the kitchen and the tables.*They did not test and did not have sanitizer testing strips to test the sanitation level of the sanitation solution. 2. Observation on 1/20/26 at 5:07 p.m. with dietary aide J in the north kitchenette revealed:*Dietary aide J was in the kitchenette, put on gloves, opened the door to the dining area, and pushed a cart that contained a big bowl of lettuce, styrofoam bowls, and salad dressing to the dining area. She then served the salad to the residents at their tables.*With those same gloved hands, dietary aide J grabbed a handful of lettuce with those dirty gloves and put it in a styrofoam bowl, put the salad dressing on it, and served it to a resident. *With those same dirty gloves hands, dietary aide J touched a resident's arm, the handle on the resident's wheelchair, the handle on the cart, and two more residents' arms, and then used those same gloves to grab a handful of lettuce, put it in the styrofoam bowl, put salad dressing on it, and served it to those residents.*She continued to serve the lettuce in the same manner throughout the dining service with those same gloves.*Restorative supervisor N removed the soups from the steam table, food particles were floating in the water in the steam table, and the water appeared dirty and hazy. 3. Interview on 1/20/26 with restorative supervisor N and dietary aide J revealed:*They were not sure how often the steam table needed to be cleaned.*Dietary aide J stated she thought it was done weekly, and the water was changed at that time. 4. Continued observation on 1/20/26 at 5:34 p.m. of dietary aide J in the east dining room revealed: *Dietary aide J put on gloves and pushed the cart that contained the big bowl of lettuce, styrofoam bowls, and salad dressing.*With those same gloved hands, she touched the resident's table, then grabbed a handful of lettuce, applied the salad dressing, and served it to the residents.*With those same gloved hands, she touched the handle on the cart when she pushed it to another table, touched a resident's arm, the handle on a resident's wheelchair, grabbed a handful of lettuce, put it in the styrofoam bowl, put the salad dressing on it, and served it to the residents. She continued in that fashion until all the residents were served the lettuce. 5. Observation on 1/20/26 at 5:36 p.m. of restorative supervisor N in the east kitchenette revealed:*She did not wash her hands before putting on a clean pair of gloves. She checked the temperature of the soup with a digital thermometer.*With those same gloved hands, she grabbed a wrap or a sandwich and put it on the resident's plate for them to eat, and then touched the ladle to put soup into a bowl. She did this throughout the dining and servicing process. 6. Observation on 1/20/26 at 5:43 p.m. of dietary aide/cook I in the east kitchenette revealed:*She had gloves on her hands. She pushed a cart with drinks on it, and served the drinks to the residents.*She removed her gloves, did not wash her hands, and put on a new pair of gloves, took out a slice of bread from the bread bag, and served it to a resident. 7. Interview on 1/21/26 at 8:30 a.m. with cook O in the kitchen revealed:*They used the sanitizer from the premixed dispenser to wipe off the counters in the kitchen, and they did not have testing strips to test the sanitation level of that solution.*She confirmed that, without the testing strips, she was unsure if the solution was at the appropriate sanitation level to sanitize the counters.*She stated, The manager before said it was fine [not to test the sanitation level].*Dietary staff were to wash their hands with soap and water when coming into the kitchen, before handling food, between handling certain foods, before putting gloves on, and after taking gloves off. 8. Observation on 1/21/26 at 12:03 p.m. of the north kitchenette steam table revealed there was dirty water and food floating in it. 9. Observation on 1/21/26 12:10 p.m. of the dining service in the north dining room revealed:*Dietary aide J and dietary aide/cook I had gloves on.*While getting a resident's order, dietary aide J touched the resident's arm with her gloved hand, she obtained the plate of food, and with those same gloved hands, she used the resident's silverware to cut up her food.*With those same gloved hands, dietary aid J received another plate of food, touched a resident's wheelchair handle, touched the top of the resident's glass, and cut up the resident's food. *While getting a resident's order, dietary aide/cook I touched a resident's chair with her gloved hands, received a plate of food, and served that to a resident.*Dietary aide I put a clothing protector on a resident and, with those same gloved hands, poured drinks for residents. *Cook O took off her gloves, did not wash her hands, used utensils to plate a resident's food, touched her hand to her pants, and then touched the plate. She stated, I do not have gloves, and received a pair of gloves from the nurse, did not wash her hands, put on those gloves, and used utensils to plate food. 10. Observation on 1/21/26 at 12:30 p.m. of the east dining room service revealed:*CNA H was standing at the steam table waiting to serve residents, she touched her hair, went over and got a resident's order, touched that resident's arm, obtained a plate of food, served it to the resident, and cut up the resident's food.*CNA H served a resident a plate of food, touched the table top, served another plate of food, did not wash her hands, put on a pair of gloves, and used her gloved hands to take chicken off the bone for a resident.*Cook O put on a pair of gloves, opened a cupboard door with those gloves, removed those gloves to get an apron, did not wash her hands, put on a pair of gloves, and plated food using utensils.*While plating food, cook O served a couple of residents their food, and without changing her gloves or performing hand hygiene, continued to plate other residents' food. *Dietary aide J came into the dining room, did not wash her hands, served residents their drinks and fruit cups, and touched a resident's arm, and continued to serve fruit cups and drinks to other residents. 11. Interview on 1/21/26 at 12:46 p.m. with cook O and dietary aide T in the east dining room revealed:*The steam table in the east kitchenette did not take water.*The CNAs were to clean and change the water in the steam table in the north kitchenette every two weeks, and it has just been done.*They did not have documentation that it had been cleaned. 12. Review of the provider's Chemical Sanitizing Dishmachine Temperature and PPM Log revealed:* INSTRUCTIONS: Please log WASH (140-160 degrees F [Fahrenheit]) and PPM [parts per million] test result when washing dishes after each meal, to ensure that the water temperature and sanitizer solution are properly controlled and monitored. The log should be filled in and. by those who are directly involved in the dishwashing process.*In October 2025, the wash temperature and the sanitization level were not documented 42 times.*In November 2025, the wash temperature and the sanitization level were not documented 41 times, and on 11/24/25, the wash temperature was 118 degrees.*In December 2025, the wash temperature and the sanitization level were not documented 20 times, and on 12/20/25, the wash temperature was 115 degrees, and on 12/28/25, the wash temperature was 118 degrees.*In January 2026, the wash temperature and the sanitization level were not documented 26 times. 13. Interview on 1/22/26 at 2:08 p.m. with administrator A revealed:*He expected the dishwasher temperature and sanitation level and the bucket sanitizer solution to be documented to ensure appropriate sanitation levels were reached when cleaning dishes and counters in the kitchen, and he agreed that with no documentation, it could not be ensured that the dishes or counters were being sanitized appropriately, which could cause foodborne illness. 14. Review of the providers' undated Handwashing for Food Safety policy revealed:* Inadequate handwashing has been identified as a contributing factor to foodborne illness, especially when preparing raw meat and poultry. Hands can move germs that can cause illness found in raw meat and poultry, around the area you are preparing food, which can lead to foodborne illness. Washing our hands often is one of the best ways to stop the spread of harmful germs that can cause illness, including foodborne illness. 15. Review of the provider's undated dishwasher 2.0 Operator Procedures guide revealed:* Fill the machine with water using Fill Switch. If water temperature gauge has not reached 120 degrees F (49 degrees C [Celsius]) when the water level is just below overflow, drain water from the machine and continue to fill until proper temperature is attained.*Free chlorine rinse should be 50 ppm or more. 16. Review of the provider's 4/24/24 Dishwasher for ADS (American Dish Service) AF-C policy revealed:* Operating Procedure:-[dishwasher service company] inspects Dishwasher machine monthly. They verify a minimum of 120 degrees F that gets cycled into the machine. If temperature drop below, notify maintenance.-Sanitizer levels are at a minimum of 100 PPM.-Refer to Manufacturer guidelines for daily start-up. 17. A sanitization bucket and steam table cleaning policies were requested and not received before exiting the facility.

Based on Certification and Survey Provider Enhanced Reports (CASPER) data review, staff schedule review, timecard review, and interview, the provider failed to ensure Payroll Based Journal (PBJ) (information of the provider's daily staffing hours for the care of the residents) data was accurately completed before submission to the Center for Medicare and Medicaid Services (CMS) for four of four federal fiscal quarters (Quarter 1, 2025; Quarter 2, 2025; Quarter 3, 2025; and Quarter 4, 2025). Findings include:1. Review of the PBJ data submitted to CMS for the four quarters listed above revealed:*The following items were triggered:-Failed to submit data for the quarter.-One star staffing rating.*The following items were suppressed due to no nursing hours being reported:-Excessively low weekend staffing.-No RN hours.-Failed to have licensed nursing coverage 24 hours per day. 2. Review of the provider's October, November, and December 2025 employee staffing schedules and timecards revealed they had licensed nursing coverage 24 hours per day and eight continuous hours of RN coverage. 3. Interview on 1/20/26 at 1:49 p.m. with administrator A regarding Payroll Based Journal (PBJ) staffing data and reporting revealed:*He knew the PBJ hours were not getting reported.*He confirmed the staffing schedules were correct and they had met the requirements for PBJ staffing*The former health information manager (HIM) was responsible for submitting the staffing data *That employee stopped working for the facility in October 2024.He was told by his supervisor there would be some training on that in the future.He agreed the PBJ hours were not being completed as required. 4. Interview on 1/22/26 at 11:26 a.m. with regional director L regarding PBJ staffing data and reporting revealed:*He was aware the PBJ hours were not being completed.*The HIM person who was entering the PBJ hours had resigned about a year ago *after the HIM resigned, the PBJ education for reporting was passed on to the former administrator.The former administrator did not complete the education to complete the PBJ reporting by the time she resigned in December 2025.*Regional director L stated there was a PBJ education packet for administrator A to complete so he could input the PBJ hours.*Regional director L confirmed the PBJ staffing hours had not been submitted, as required, for the past four quarters. A policy for PBJ hours reporting was requested on 1/21/26 at 2:30 p.m. and the administrator stated there was no such policy in the facility.

Based on interview and policy review, the provider failed to deliver mail daily to ten of ten residents (10, 14, 15, 18, 24, 30, 31, 35, 37, and 38) within twenty-four hours after it was delivered to the nursing home by the local post office. Findings include: 1. Interview on 1/22/26 at 10:00 a.m. during the resident group meeting revealed:*Residents (10, 14, 15, 18, 24, 30, 31, 35, 37, and 38) stated they did not get their mail daily.*Mail was not delivered on Saturdays because there was no one to pass it out.*Activities director M usually delivered the mail to the residents during the weekdays. 2. Interview on 1/22/26 at 11:30 a.m. social services director C revealed she expected residents to be delivered mail on Saturdays. 3. Interview on 1/22/26 at 11:43 a.m. with activity director M revealed on Saturdays, the charge nurse would get the mail, and then she would pick it up on Mondays and deliver it to the residents because she did not work on Saturdays. 4. Review of the provider's May 2017 Mail and Electronic Communication policy revealed Mail and packages will be delivered to the resident within twenty-four (24) hours of delivery on premises or to the facility's post office box (including Saturday deliveries).

Based on interview and record review, the provider failed to have a qualified infection preventionist for the facility.Findings include: 1. Interview on 1/22/26 at 12:25 p.m. with director of nursing (DON) B revealed that she was in charge of the facility's infection prevention program but had not completed an approved infection preventionist (IP) course. She reported that she had been working on the IP course but had not found the time to complete it. She confirmed that she oversaw the facility's infection prevention program during the last recertification survey and had not completed the IP course then either.2. Review of the provider's infection control program binder revealed that the provider did not have an infection preventionist.

Based on observation, interview, and policy review, the provider failed to ensure proper infection control practices were followed for:*Cleaning one of one ice maker located outside of the kitchen.*Cleaning the refrigerator in one of one family room. Findings include: 1. Observation on 1/20/26 at 1:00 p.m. of the ice machine outside of the kitchen revealed that it was not clean. There was a dirty light green powder like substance on the outside corners of the machine above the level of the ice dispenser that fell off the machine during ice dispensing. There was heavy water spotting on the splash guard and visible rust on the metal grate above the water drain.2. Observation on 1/21/26 at 9:35 a.m. of the mini refrigerator in the family room there was a four-ounce serving of ice cream on the refrigerator's top shelf that had melted and spilled onto all the shelves in the refrigerator.3. Interview on 1/22/26 at 11:00 a.m. with housekeeper K revealed that she had been employed at the facility for less than a year. When asked if cleaning the family room refrigerator or ice machine was her responsibility, she did not think it was her responsibility. When asked how she knew what her responsibilities were as a housekeeper, she replied that there was a notebook with an outline of the daily responsibilities. She then provided a copy of the outline.4. Interview on 1/22/26 at 11:20 a.m. with licensed practical nurse (LPN) G revealed that she was not sure who's responsibility it was to clean the family room refrigerator or the ice machine. She thought that it were either maintenance or housekeeping.5. Interview on 1/22/26 at 12:30 p.m. with maintenance lead D revealed that he had been employed at the facility for less than a year and was the housekeeping supervisor. He reported that he did not receive much training on his responsibilities. He reported that housekeeping staff were responsible for cleaning the family room refrigerator, but he did not think they were responsible for cleaning the ice maker. He stated that the responsibility of maintenance was to just blow off the dust on the top of the ice maker.6. Interview and observation on 1/22/26 at 12:55 p.m. with director of nursing (DON) B revealed that she was unsure who's responsibility it was to clean the ice maker. She reported that she was not sure if it was the responsibility of the CNAs or housekeeping to clean the family room refrigerator. When she observed the ice maker, the appearance did not meet her expectations of cleanliness. She expected the surfaces to be clean, the grates to be clean and not rusted, and the dirt/debris on the outside corners to be clean.7. Review of the provider's undated housekeeping checklist revealed that number 4. Clean ice machine daily. Initial Sheet. Number 16. Check room fridge temps and chart daily (Clean and defrost TLC [Tekakwitha Living Center] fridges as needed.8. Review of the provider's February 2025 Infection Control and Prevention policy revealed a purpose of To establish comprehensive guidelines for preventing and controlling infections within the facility, protecting the health and safety of residents, staff and visitors. and principles of infection control were to Adhere to evidence-based practices for infection control.

Based on observations, interviews, and policy review, the facility failed to ensure proper storage and disposal of expired medications in one of one medication room and one of one medication cart that had expired medications and treatments.*One of one medication room and One of One medication cart (north) had expired medications and treatments. Findings Include:1. Observations on 1/22/26 at 11:00 a.m. with Licensed Practical Nurse (LPN) G in the Medication Room revealed expired medications and treatments.* Tuberculin Purified Protein Derivative (PPD) solution vial was ordered from the pharmacy on 10/27/25. The vial cap was removed and open with no open date. With no open date marked on box or vial, the opened vial should be discarded.2. Observation on 1/22/26 at 11:25 a.m. of the North Medication Cart revealed expired medications.* Resident 3's Novolog expired on 1/15/26 and had 1/3 of the used medication vial remaining and per the open date and written expiration date on the vial was expired.* Stock bottle of Senna Plus expired in November 2025 with approximately half of the bottle (500 tabs) remaining.* Stock Liquid Pain Relief expired in December 2025 with approximately half of the bottle remaining.2. Interview with Licensed Practical Nurse (LPN) G at 1/22/26 at 11:35 a.m. revealed:* The medications should have expiration dates on them when they were opened and discarded. The night shift staff are who usually go through and check the expiration dates.* The medications should have been checked by the nursing staff to ensure they do not expire prior to giving them to a resident.* If the medication was expired, it should be pulled from use and reordered.3. Interview with Director of Nursing (DON) B on 1/22/26 at 2:18 p.m. revealed:* Her expectation was that medications were checked for expiration dates prior to giving the medication and pulled from the medication cart if expired.4. Review of the providers' Medication Storage in the Facility policy revealed:* Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.* H. Outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled or without secure closures are immediately removed from inventory, disposed of according to procedures for medication disposal (See Section IE: DISPOSAL OF MEDICATIONS AND MEDICATION-RELATED SUPPLIES), and reorder from the pharmacy (SEE IC3: ORDERING AND RECEIVING NON-CONTROLLED MEDICATIONS FROM THE DISPENSING PHARMACY), if a current order exists.* Expiration Dating (Beyond-use dating) D. When the original seal of a manufacturer's container or vial is initially broken, the container or vial will be dated. 1. The nurse shall place a date opened sticker on the medication and enter the date opened and the new date of expiration (NOTE: the best stickers to affix contain both a date opened and expiration notation line). The expiration date of the vial or container will be [30] days unless the manufacturer recommends another date or regulations/guidelines require different dating (See APPENDIX 29 - MEDICATIONS WITH SHORTENED EXPIRATION DATES).

Based on observation, interview, document review, record review, and policy review, the provider failed to protect the resident's rights and ensure a resident's advance directive code status (an individual's desire to be resuscitated with cardiopulmonary resuscitation (CPR), specific limited interventions, or not resuscitated (DNR) if their heart stopped) wishes were identified accurately in the medical record for two of seventeen sampled residents (3 and 16). Findings include:1. Observation, interview, and document review on [DATE] at 4:18 p.m. with registered nurse (RN) E at the nurse's station revealed:*Resident paper charts that had a heart with a stethoscope logo on the outside of the chart indicated the resident's code status was a full code, so then CPR would have been performed. If a paper chart did not have that logo, it indicated the resident was a DNR, so CPR would not have been performed.*Resident 3's paper chart had the heart with the stethoscope logo on it.* Resident 3 had an advance directive in his paper chart that was signed on [DATE] that indicated he wanted CPR.*RN E would not have performed CPR on resident 3 because she knew he was a DNR, and he was admitted to hospice on [DATE].*She stated that someone who did not know resident 3 well may have performed CPR on him because that is what his chart indicated with the logo on it and the [DATE] advance directive. She stated, It must not have been updated.*In resident 3's paper chart, behind his full code advance directive, there was a living will (a document that specifies a resident's preferences about measures that are used to prolong life when there is a terminal prognosis) signed on [DATE] that indicated he was to be a DNR.*Resident 16's paper chart did not have the heart with the stethoscope logo on it.*RN E opened residents 16's chart and found an advance directive that indicated CPR should be performed, so she stated she would do CPR.*Upon further review, the advance directive that was in resident 16's chart belonged to a resident who had been discharged . Resident 16's advance directive was found on the backside of another page in his chart and indicated he was a DNR.*She verified that having the wrong resident's advance directive in his chart could have caused an error, and CPR could have been performed when it should not have been. 2. Review of resident 16's electronic medical record revealed:*His [DATE] BIMS score was 9, which indicated he had moderate cognitive impairment.*On [DATE], he had orders for DNR.*He had a diagnosis of congestive heart failure (your heart can not pump enough blood to meet your body's needs, causing blood and fluid to back up)(CHF). 3. Observation on [DATE] 8:55 a.m. outside of resident 3's room revealed there was a heart with a stethoscope logo posted on the wall next to his name. 4. Interview on [DATE] at 9:18 a.m. with licensed practical nurse (LPN) G revealed that if resident 3's heart stopped, she would have performed CPR because the logo posted by his name indicated he was a full code. 5. Review of resident 3's electronic medical record revealed:*His [DATE] brief interview for mental status (BIMS) score was 12, which indicated he had moderate cognitive impairment.*On [DATE], he had orders to be admitted to hospice on [DATE].*On [DATE], he had orders for DNR/DNI.*He had diagnoses of left femur fracture (broken hip), a stage four pressure ulcer (skin and/or underlying tissue injury from prolonged pressure that was open with full thickness skin and tissue loss. Bone, tendon, or muscle may be visible) to his sacral region (buttocks), osteomyelitis of his vertebrae and sacral region (infection of the bones of his spine), and CHF. 6. Interview on [DATE] at 1:53 p.m. with director of nursing (DON) B revealed:*The social worker completed the advance directive forms with the resident or family.*If there was a change to a resident's advance directive, the nurse was to notify either the DON or social worker, and said, There is a lapse at times [sometimes it was missed and not updated].*She stated that resident 3's advance directive should have been updated on his chart, and the logos by his room and chart should have been removed when his code status changed to a DNR and verified that resident 3 could have received CPR in error.*She stated that the discharged resident's advance directive should not have been in resident 16's chart and verified that resident 16 could have received CPR in error. 7. Review of the provider's [DATE] Advance Directive policy revealed:* Advance directives will be respected in accordance with state law and facility policy.* Information about whether or not the resident has executed an advance directive shall be displayed prominently in the medical record.* The plan of care for each resident will be consistent with his or her documented treatment preferences and/or advance directive.* Changes or revocations of a directive must be submitted in writing to the Administrator. The Administrator may require new documents if changes are extensive. The Care Plan Team will be informed of such changes and/or revocations so that appropriate changes can be made in the resident assessment (MDS) and care plan.

Based on interview, document review, and record review, the provider failed to provide adequate supervision to a dental appointment for one of one sampled resident (4) who had severe cognitive impairment and was at high risk for falling. Findings include:1. Interview on 1/21/26 at 11:17 a.m. with resident 4's granddaughter/power of attorney revealed:*A few months ago, a nursing home staff member called her and told her that her grandmother had a dental appointment in fifteen minutes.*She was unaware of that appointment and was not going to be able to meet her there.*She asked the staff member to reschedule it instead.*She received a phone call from the dental clinic asking her why her grandmother was at the appointment by herself.*Resident 4 rode the community transportation by herself and was dropped off at the dental clinic, where she was by herself for 45 minutes.*She was very upset that resident 4 went by herself to that appointment because of resident 4's cognitive impairment.*She talked to the previous administrator about the incident. 2. Interview and form review on 1/22/26 at 1:53 p.m. and 3:37 p.m. with director of nursing (DON) B revealed:*She verified that resident 4 was sent to that appointment by herself.*She stated that resident 4 should not have gone to the appointment by herself, and she expected the appointment to have been cancelled unless they had staff to take her.*Resident 4's granddaughter typically took her to her appointments.*Upon admission, in the admission packet, they have families/residents sign a Specialty Doctor's Appointments form. Resident 4 was admitted prior to the forms being implemented and did not have one signed.*The 10/7/25 form stated: In the event that [resident] needs to go to a specialty doctor's appointment, (which this means any appointment besides when his/her primary care physician comes to the facility to do regulatory check-ups), that you understand your loved one needs to be accompanied by family or friend at the appointment. This applies when your loved one's cognitive impairments make it unsafe for resident to go on his/her own to the appointment and/or if information given to resident at said appointment will not be able to be retained. The facility will work with you to line up these special appointments so that said person can go with and/or meet at that appointment. If you are unable to meet your loved one at said appointment understand that the clinic may cancel the appointment and you acknowledge there is a risk then for injury or information not to be relayed correctly. [There was a space for signatures.]*They did not have a policy regarding taking residents to appointments. 3. Review of resident 4's electronic medical record revealed:*She was admitted on [DATE].*Her 12/2/25 Brief Interview for Mental Status (BIMS) score was 3, which indicated she had severe cognitive impairment.*Her 8/13/25 Morse Fall Scale indicated she was at high risk for falling.*Her diagnoses were left femur fracture (hip fracture), dementia (a group of symptoms affecting memory, thinking, and social abilities), major depressive disorder (a serious, long-lasting mood disorder that goes beyond normal sadness), and anxiety disorder (a feeling of worry, fear, or unease about future events or a perceived threat).*A 10/4/25 progress note stated, Resident is alert with confusion noted.TABs/bed alarm/chair alarm [(a fall prevention device that alarms to notify staff of the resident's movement, such as standing)] on, as she is a high fall risk.*A 10/21/25 progress note stated, Resident left at 0900 for dental appt. at [dental clinic] via community transit and arrived back 1130.*Review of her 9/12/25 care plan revealed:- [Resident 4] has the potential to be physically aggressive r/t [related to] Dementia.- When [resident 4] becomes agitated: Intervene before agitation escalates; Guide away from source of distress.*[Resident 4] is able to identify her family but not other residents or staff and can follow one-word instructions.*[Resident 4] needs supervision and assistance with all decision making.*[Resident 4] uses psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications Quetiapine for Behavior management.

Based on observations, interviews, and policy review, the facility failed to complete a Trauma Informed Care assessment for one of one sampled resident (5) after they have experienced a loss of a loved one. Findings Include: 1. Interview on [DATE] at 3:55 p.m. with resident 5 noted that after each question asked during the interview, she would have discussed her husband passing away. The following statements were said:* I should have died before him* This is his shirt that he used to wear* I have to keep busy to not think about him.2. Observation on [DATE] at 11:10 a.m. of resident 5's wound care revealed she continued to reiterate sentiments for her husband passing away and how sad she was he was not here with her.3. Interview and chart review for resident 5 on [DATE] at 11:25 a.m. with director of nursing (DON) B confirmed she did not have a Trauma Informed Care completed and the Social Services Designee was responsible for completing the Trauma Informed Care assessments.4. Interview and chart review for resident 5 on [DATE] at 1:10 p.m. with Social Services designee (SSD) C revealed she could not find Trauma Informed Care on resident 5. She stated, I must have missed that one. She said she completed this on admission and as needed but completed the mood assessment quarterly within the MDS.5. Review of the providers [DATE] Trauma Informed Care policy revealed:* Purpose: To ensure facilities deliver care and services which meet professional standards, use approaches which are culturally competent, account for resident's expedience and preferences, and address the needs of trauma survivors.* Trauma Survivors - Military veterans, survivors of disasters, survivors of abuse, history of homelessness, history of imprisonment, and traumatic loss of a loved one.

Based on interview, the provider failed to employ a full-time, qualified registered dietitian or dietary manager who met the requirements to serve as the director of food and nutritional services. Findings include:1. Interview on 1/20/26 at 1:23 p.m. with dietary aide/cook I and restorative supervisor N revealed:*The facility did not have a dietary manager.*Restorative supervisor N was working as the dietary cook, she had been a cook there prior to her current role.*The previous dietary manager worked there for a few years, and after she quit, a certified nursing assistant (CNA) took over for a few weeks, but did not want to do it anymore, and went back to working as a CNA. *The administrator ordered food for the kitchen; they just wrote down for him what was needed. 2. Interview on 1/21/26 at 8:30 a.m. with cook O revealed:*She confirmed there was no dietary manager to oversee the process of the kitchen.*She would go to administrator A if there were issues.*She was not a certified dietary manager (CDM).*She completed the ServSafe training.*The regular registered dietitian (RD) was out on maternity leave.-There was a RD covering for her during her leave, and she was there a few weeks ago, wrote a few things down, and then left. 3. Interview on 1/22/26 at 8:45 a.m. and 2:08 p.m. with administrator A revealed:*Their previous dietary manager left her position on 1/7/26, after being in that role for a few weeks.-The dietary manager before her, left her position on 8/19/25.*They had the dietary manager position posted.*When asked who could answer dietary questions, he stated, I guess that would be me.*He was not a CDM.*Consultant RD was not full-time and came to the facility monthly.*Their regular registered dietitian (RD) was out on maternity leave, and another dietitian was covering for her.

A. Based on South Dakota Department of Health (SD DOH) complaint report review, observation, interview, record review and policy review, the provider failed to promote the residents' right to self-determination for four of four sampled residents (1, 2, 3, and 4) who ate in the east dining room and expressed they were unaware of what foods were planned to be served or what food choices were available until the meal service had started. Findings include: 1. Review of the 4/7/25 SD DOH complaint intake report revealed concerns regarding: *Residents were only given one choice for meals. *The kitchen staff refused to post a weekly/daily menu. *Dietary manager (DM) C was rude or verbally aggressive to many of the residents. *DM C was aggressive with and swore at other staff while residents were present. 2. Observation on 6/16/25 at 4:00 p.m. of menu choices available for resident meals revealed: *Menu choices were posted outside the kitchen door on the whiteboard. *Menu choices were posted outside the north dining room on the whiteboard. Observation on 6/16/25 at 4:12 p.m. in the east dining room revealed dinner menu choices were not posted on the whiteboard. Observation on 6/16/25 at 5:25 p.m. in east dining room revealed: *No meal choices were written on the whiteboard in that dining room area. *No staff asked residents what their meal choices were. *No diet cards were used when serving residents. Continued observation on 6/16/25 at 5:50 p.m. in the east dining room revealed: *Staff moved about the dining room and asked residents if they wanted anything else. *Two unidentified residents requested a chicken sandwich (the main entrée) and were given the chicken sandwich. Observation on 6/17/25 at 7:25 a.m. of north dining room revealed: *The whiteboard posted outside the door had the previous day's (6/16/25) menu listed and was dated 6/12/25. Observation on 6/17/25 at 11:00 a.m. of the menu whiteboard outside of the kitchen revealed: *Meatloaf, Au gratin potatoes, green bean casserole and diced pears were listed for the lunch meal that day. *The food substitute listed was ham. Observation on 6/17/25 at 12:25 p.m. of the east dining room revealed: *No meal choices were written on the menu whiteboard. 3. Interview on 6/16/25 at 4:05 p.m. with resident 3 revealed: *She was the resident council president. *Her 3/28/25 Brief Interview for Mental Status (BIMS) assessment score was 15 which indicated she was cognitively intact. *The menus were not posted in the east dining room for residents to know what meal was planned to be served or what the meal choices were. *Before a meal, the staff members would offer the residents two entrée choices. *Dietary would serve second helpings of food upon request. *There were drink choices at all meals. *Fresh fruit was on the menu. *There was a snack cart, and staff offered those snacks to residents before bedtime. Interview on 6/16/25 at 5:00 p.m. with resident 1 revealed: *He had resided at the facility for about six months. *His 5/1/25 BIMS assessment score was 14 which indicated he was cognitively intact. *The menu was posted by the north dining room and by the kitchen. *He ate in the east dining room. *He said he would show up to eat and that was how he would know what was being served for that meal. *He was unsure if they passed bedtime snacks. *He had snacks in his room. Interview on 6/16/25 at 5:45 p.m. with certified nursing assistant (CNA) J revealed: *There was confusion about who was supposed to ask the residents about their meal choices. *She was told by another CNA, whom she did not identify that they were not doing that anymore. *There was a meeting last week when CNA J was gone, where staff were directed that the dietary staff was to ask the residents what their meal choices were now. Interview on 6/17/25 at 9:32 a.m. with resident 4 revealed: *She had resided at the facility for about two years. *Her 4/25/25 BIMS assessment score was 14 which indicated she was cognitively intact. *She always had canned fruit, and bananas were the only fresh fruit. *Soup was never hot enough. *She had no idea what was on the menu. *She ate in the east dining room. *The staff would go around and ask the residents what they wanted just before serving the meals. *There was always a substitute item. *There had never been a menu posted in her room. *Occasionally meal choices would be posted in the east dining room, but that would remain there unchanged for days then it stays there for days. *She would have liked to know what was for meals. Interview on 6/17/25 at 4:20 p.m. with DON B revealed: *She had spoken several times with DM C to complete the meal tray cards for residents. *The meal tray cards would include the resident's name, diet, allergies and food dislikes. *She felt it was important that those cards would be available for the new staff to know those items for each resident. Interview on 6/17/25 at 4:35 p.m. with resident 2 revealed: *She had been living at the facility for two years. *Her 4/8/25 BIMS assessment score was 13 which indicated she was cognitively intact. *She ate her meals in the east dining room. *The menu was seldom posted on the east dining room whiteboard. *The menu was usually posted by the north dining room and by the kitchen door. Interview on 6/18/25 at 7:50 a.m. with DM C revealed: *She was responsible for completing the meal identification tray cards for the residents. Interview on 6/18/25 at 9:12 a.m. with administrator A revealed: *DM C was responsible for updating resident meal identification tray cards. *She was aware these were not currently being used by the dietary staff. 4. Review of provider's revised December 2016 Resident Rights Policy revealed: *Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: e. self-determination. B. Based on South Dakota Department of Health (SD DOH) complaint intake, interview, record review and policy review, the provider failed to protect the residents' right to an environment maintained in a respectful manner for two of four sampled residents (1 and 2) by dietary manager (DM) (C) who yelled and used foul language when the residents were present. Findings include: 1. Review of the 4/7/25 SD DOH complaint intake review revealed concerns regarding: *DM C was rude or verbally aggressive to many of the residents. *DM C was aggressive with and swore at other staff while residents were present. 2. Interview on 6/17/25 at 9:00 a.m. with dietary aide (DA) M revealed: *She had worked at the facility for many years. *DM C had yelled and used foul language towards other staff in front of residents before when tasks had not been completed by dietary staff. *She had told other co-workers about the incident of DM C yelling at others. *She did not report it to management staff. Interview on 6/17/25 at 9:45 a.m. with certified nursing assistant (CNA) N revealed: *She had observed DM C using foul language in front of residents about three weeks ago. *She heard DM C say, I am sick and tired of always pleasing everyone. *She heard DM C say. I am sick of this [profanity]. Interview on 6/17/25 at 11:35 a.m. with DA/cook O, cook K and cook L revealed: *DM C used foul language frequently, sometimes in front of residents. -Such as, I got a headache from all this [profanity]. *DM C has slammed items around in the kitchen when she was upset and residents were present outside the door. Interview on 6/17/25 at 3:55 p.m. with DA P revealed: *DM C would bang items around in the kitchen when she was upset and she would have to serve meals. *She had observed DM C in dining room areas yelling at dietary staff on several occasions. *Administration had been notified of DM C's behaviors. *DM C would berate her in front of others and blamed her when things did not go right. *DM C would use foul language under her breath in dining rooms, but she was unsure if residents heard it. Interview on 6/17/25 at 4:35 p.m. with resident 2 revealed: *She had lived at the facility for about two years. *Her 4/8/25 Brief Interview for Mental Status (BIMS) assessment score was 13 which indicated she was cognitively intact. *She had observed DM C yelling at DA M in the kitchen and DM C made DA M cry. *Resident 2 stated she heard DM C yelling whenever she walked by the kitchen door to get ice from the ice machine. Phone interview on 6/18/25 at 7:59 a.m. with DM C revealed: *There had been one or two instances where she had yelled or used foul language to her dietary staff in front of residents. *She agreed foul language was not appropriate to use at any time. *She had been reprimanded by administrator A following these instances. Interviews on 6/18/25 at 9:12 a.m. and 10:25 a.m. with administrator A revealed: *She expected staff to not use foul language in front of residents. *Foul language was not acceptable as the facility was the residents' home, and they should never have to listen to that. *She expected all facility policies to be followed. *DM C had been educated after each occurrence about how she talked to people and approaches people. *After almost every instance, she had been reprimanded for her behavior. *DM C was put on administrative leave on 6/11/25 and would possibly return to work on 6/23/25. Interview on 6/18/25 at 10:50 a.m. with resident 1 revealed: *His 5/1/25 BIMS assessment score was 14 which indicated he was cognitively intact. *He had observed DM C yelling at DA M in the east dining room approximately two weeks ago. *He had not reported that situation to anyone. *It made him feel uncomfortable. *He was not scared of DM C but felt bad for the staff member because she was crying. Interview on 6/18/25 at 11:04 a.m. with resident 2 revealed: *She had observed an incident in the east dining room when DM C was yelling at DA M, but she had not reported that situation to anyone. *She felt it was not right for DM C to do that in front of staff or residents. *She felt bad for DA M and comforted her later that day. *She was not fearful of DM C for herself. *It had made her wonder what DA M could have done to make DM C that mad. *She stated, You do not go after an employee like that in front of people. Interview on 6/18/25 at 11:11 a.m. with administrator A revealed she was unaware of an incident regarding DM C and DA M. Interview on 6/18/25 at 11:20 a.m. with business manager Q revealed: *Some staff had reported about an incident regarding DM C and DA M. to him and administrator A *He though the above incident weighed on the residents. *There were concern about resident care being impacted. *He though the residents worried how the above incident would impact them. Further interview on 6/18/25 at 11:27 a.m. with administrator A revealed: *She had spoken with residents about the situation between DM C and DA M that occurred in east dining room. *This caused them to have the dietary meeting on 6/10/25 to voice concerns. *She did not have any documentation regarding that dietary meeting or her investigation into the situation between DM C and the other staff. 3. Review of the provider's undated Certified Dietary Manager job description revealed: *The manager is responsible for overall supervision and coordination of the department, growth of facility and community resources, to provide comprehensive standards, practices and programs that meet the needs and best interests of the facility and residents. *Essential functions of the job, departmental expectations: -Ability to model effective communications between resident, family, staff and community. -Must be able to identify potentially unsafe situations and to respond appropriately. *It is the expectation that the employee complies with applicable standards of behavior and conduct, including but not limited to, standards of conduct, customer service standards, and professional code of ethics. Review of providers revised December 2016 Resident Rights Policy revealed: *Employees shall treat all residents with kindness, respect and dignity. 1. Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the residents right to: f. communication with and access to people and services, both inside and outside the facility. h. be supported by the facility in exercising his or her rights.

Based on South Dakota Department of Health (SD DOH) complaint report review, observation, interview, and policy review, the provider failed to maintain a homelike environment that was clean and free of wall and floor damage, chipped paint, and ceiling leaks in several identified areas throughout the facility. Findings include: 1. Review of the 4/7/25 SD DOH complaint intake report revealed concerns regarding: *Housekeeping does not clean floors in the dining room. *Tables in dining rooms are constantly dirty. 2.Observation on 6/16/25 at 4:12 p.m. of east dining room revealed: *Food crumbs were visible on the floor in the dining room. *A pink foot soak basin was on the floor with discolored water that had dripped in it from a leak in the ceiling. *The countertop by the sink had dried dark coffee-like stain rings on it. Observation on 6/17/25 at 7:30 a.m. of the east dining room revealed: *The countertop by the coffee maker had dried coffee-like stain rings still there. *The floors had food debris under the tables. *A pink foot basin was still on the floor with discolored standing water in it. Observation on 6/17/25 at 8:10 a.m. of the carpeting in hallways and common areas revealed: *Stains were on the carpeting in the front entrance by the large television and tables. *Stains were on the carpeting in the 200 hallway that leads to the east dining room. *Stains were on the carpeting from rooms 117 to 119. *Stains were on the carpet from room [ROOM NUMBER] to the north dining room door. *Stains were on the carpet by the north wing nurses' station. *The family room floor had wood chips on it and under the couch. *The family room floor had a small blanket on the floor. *Dark stains were on the carpeting in hallways by administration offices and by the therapy office door. *There was an area of missing paint on the wall across from the ice machine. *A large pink colored stain was on the carpeting approximately two feet by two feet in size, by the east wing reception area. *Stains in carpeting were visible outside of room [ROOM NUMBER]. *The wall paint was chipped between rooms 105 and room [ROOM NUMBER], between rooms 112 and room [ROOM NUMBER], between rooms 109 and room [ROOM NUMBER], and outside of room [ROOM NUMBER]. *The flooring in the east dining room was torn between the first two tables, approximately half a foot in length. *There were areas of missing paint on the walls in the east dining room. *The walls had scraped areas outside of room [ROOM NUMBER]. *The heat register outside of room [ROOM NUMBER] had areas where the paint had chipped off. *The flooring trim was missing a piece of trim from the television area by the north nursing desk. Observation on 6/17/25 at 12:25 p.m. of the east dining room revealed: *A pink foot soak basin of collecting dripping ceiling water remained on the floor. *There were missing ceiling tiles around the leak. Observation on 6/18/25 at 7:41 a.m. of the east dining room revealed: *The pink foot basin was on the floor with standing water sitting in it. *Dark coffee-like stains were on the counter next to the sink. 3. Interview on 6/16/25 at 4:12 p.m. with dietary aide (DA) F revealed: *After supper dietary staff were to wipe off tables and sweep the floors in dining rooms. *Housekeeping staff were to wipe tables and mop the floors daily. Interview on 6/17/25 at 7:20 a.m. with housekeeper G revealed: *Housekeeping staff would wash tables twice daily after breakfast and lunch. *Housekeeping staff would sweep and mop the dining room floors after breakfast and lunch. *He was unsure who did those tasks after the evening meal. Interview on 6/17/25 at 9:50 a.m. with housekeeper H revealed: *She washed the tables in dining rooms after breakfast and lunch. *She swept and mopped the floors in dining rooms after breakfast and lunchtime. *She was unsure who swept and mopped the dining room floors after the evening meal. Interview on 6/18/25 at 9:12 a.m. with administrator A regarding the conditions of the facility observed above revealed: *Maintenance staff was to be notified to check equipment or other building problems. *If maintenance staff could not fix the problem, they would call a service vendor to fix it. *She expected all facility policies to be followed. Interview on 6/18/25 at 9:30 a.m. with maintenance staff E revealed: *He was aware of the roof leak in the east dining room, and stated they had a lot of rain over the weekend. *He planned to get tar today (6/18/25) to get the roof leak fixed. *Maintenance staff were responsible for all building repairs. 4. Review of provider's undated Safe/Clean/Comfortable Homelike Environment Policy revealed: *The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. -Housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. -Environment refers to any environment in the facility that is frequented by residents, including (but not limited to) the residents' rooms, bathrooms, hallways, dining areas, lobby, outdoor patios, therapy areas and activities areas. -A homelike environment is not achieved simply through enhancements to the physical environment. It concerns striving for person-centered care that emphasizes individualization, relationships and a psychosocial environment that welcomes each resident and makes her/him comfortable. It is the responsibility of all facility staff to create a homelike environment and promptly address any cleaning needs. Review of provider's revised 12/2009 Laundry/Housekeeping Policy standard three and 11 revealed: *There are written policies and work routines for Laundry/Housekeeping Services. -4. Reviewed and revised annually. -7. Written cleaning schedules include at least the following: a) Daily/weekly/monthly routines. b) Quarterly/seasonal/annual routines. c) Defines cleaning agents/supplies utilized. d) Includes system of documentation demonstrating successful completion. * A clean, orderly and safe environment is maintained throughout the facility. d) Tile floors -Dust mopped and wet mopped daily with hospital approved germicidal solution. -Free of dust, dirt, spills, wax build-up and evidence of smooth and shiny surfaces. e) Carpets -Vacuumed regularly. -Cleaned as spills occur and shampooed routinely or when visibly soiled. _Free of dirt, litter, and stains. -Free of permeating odors. f) Walls have no chipped paint, peeling paper or gouged plaster. *Congregate areas. a) Cleaned routinely or when visibly soiled. d) Spills are wiped up as they occur with paper towel or wet mop.

Based on South Dakota Department of Health (SD DOH) complaint report review, observation, interview, and policy review, the provider failed to follow food safety standards for appropriate storage and labeling of food (where and how many items), monitoring of the low-temperature dishwasher in one of one kitchen, and the one of one leaking dishwasher in the kitchen area. Findings include: 1. Review of the 4/7/25 complaint intake report revealed concerns regarding: *Diet orders not being modified correctly. *Residents not receiving full servings of food items. *Denying residents room trays as requested. *Not offering second helpings to residents. *Bedtime snacks not available for residents. 2. Observation on 6/16/25 at 2:10 p.m. in the kitchen area revealed: *Two boxes of juice sitting on the floor in a cardboard box in the storage room. *A dented soup can in a box sitting on the floor in the storage room. *The June 2025 Sanitization/record of refrigerator temperature log revealed: -No temperatures were documented on 6/6/25 for the walk-in cooler, walk-in freezer, reach in freezer, reach-in cooler and reach-in juice cooler. *In the dishwashing room there was a bucket under the sink drain which had about an inch of brown discolored liquid sitting in it. *Under a blue bucket, there was hard water white dry discoloration on the floor. *A blue bucket under the dishwasher had a yellow sludge-like liquid in it. *The June 2025 Chemical sanitizing dishwasher temperature and parts per million (PPM) logs revealed there was: -No documentation on 6/7/25 and 6/8/25. -No lunchtime documentation on 6/14/25 and 6/15/25. *The AM (morning) aides checklist posted in the kitchen dated May 2-8, 2025, revealed: -No documentation of completed tasks on 5/2/25 through 5/4/25. -Incomplete documentation on 5/5/25 and 5/6/25. -No documentation of completed tasks on 5/7/25 and 5/8/25. *The PM (evening) aides daily task list posted in the kitchen dated May 2-8, 2025, revealed there was no documentation of tasks completed on 5/8/25. *The End of AM shift checklist for June 2025 revealed there was no documentation for the 6/3/25 tasks having been completed. *The End of PM shift checklist for June 2025 revealed there was no documentation for the 6/3/25 tasks having been completed including: -Clear and wash dining room tables. -Sweep dining room floors. Observation on 6/16/25 at 2:35 p.m. of the walk-in freezer and refrigerator revealed: *Fish patties were in an open bag on top right shelf of the freezer. That bag was not labeled or dated. *Steak patties were in an open bag on the left middle shelf of the freezer. The bag was undated. *A bag of cheese omelet was tied closed and was undated. *A bag of mini corn dog was open and undated. *There was a puddle of liquid (a slipping hazard) on the floor inside the door of the walk-in refrigerator. 3. Interview on 6/17/25 at 8:55 a.m. with dietary aide (DA) D revealed: *The blue bucket was under the dishwasher because the dishwasher sometimes leaked. *She was unsure how long it has been leaking, but thought the bucket had been there since September of 2024. Phone Interview with 6/18/25 at 7:59 a.m. with dietary manager (DM) C revealed: *The dishwashing machine had been leaking for almost three years. *The dishwasher was maintained by the dishwasher supplier. *The dishwasher supplier had replaced the hoses on the machine about two months ago. *Maintenance was responsible for checking machines and would call the suppliers to have them fixed. *The drain under the sink had been leaking off and on for about three years. *She was responsible for posting the AM and PM monthly checklists for dietary staff to document the completion of those tasks. *She was responsible for monitoring and checking it daily to see if the tasks were completed. -She would educate staff if tasks were not completed or documented as having been completed. *She was responsible for posting the weekly AM and PM aides' checklists in the kitchen. -She thought she wrote the wrong dates on the current checklists that were posted in the kitchen. *The dishwashing staff were responsible for monitoring the chemical sanitizing dishwasher after each meal for temperature and PPM. -She was to be notified if the PPMs were not at the level needed to sanitize the dishware and she would then notify maintenance. Interview on 6/18/25 at 9:12 a.m. with administrator A revealed: *Maintenance staff was to be notified to check equipment problems, and if they could not fix them, they would arrange for service to be completed on the equipment by the vendor. *DM C was responsible for monitoring the food storage and cleaning schedules and posting them for staff in the kitchen. *She expected all facility policies to be followed. Interview on 6/18/25 at 9:30 a.m. with maintenance E revealed: *He had worked here for two years. *He had been notified the drain under sink in the kitchen was leaking. -He stated it had been leaking for two years and all the piping would have to be replaced. *He had not noticed the yellow sludge sitting under the dishwasher machine. -The blue bucket had been there a couple years. 4. Review of the provider's revised July 2014 Food Receiving and Storage policy revealed: *Foods shall be received and stored in a manner that complies with safe food handling practices. -6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. -8. All foods stored in the refrigerator or freezer will be covered, labeled and dated ('use by date). -11. The freezer must keep frozen foods frozen solid. Wrappers of frozen foods must stay intact until thawing. -12. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day by the food and nutrition services manager or designee and documented according to state-specific requirements. Review of provider's 2013 Cleaning dishes/Dish machine Policy revealed: *All flatware, serving dishes and cookware will be washed, rinsed and sanitized after each use. Dish machines will be checked prior to meals to assure proper functioning and appropriate temperatures for cleaning and sanitization.

Based on observation, interview, record review, and policy review, the provider failed to prevent one of one sampled resident (23) from developing facility-acquired pressure ulcers. Findings include: 1. Interview on 7/17/24 at 8:00 a.m. with director of nursing (DON) B revealed resident 23 had on heel protectors but wasn't sure the thread in them had not caused his pressure ulcer. Observation on 7/17/24 at 10:15 a.m. of resident 23 revealed resident 23 was in bed lying on his back when licensed practical nurse (LPN) G went in to provide wound care. Interview on 7/17/24 at 10:41 a.m. with CNA H in regards to skin concerns revealed: *She stated, I think the skin issues are from the residents not being repositioned, and she had voiced her concerns to management. *Administrator A had started rounds and cares had improved. Interview on 7/17/24 at 12:45 p.m. with administrator A revealed: *She confirmed that resident 23's pressure ulcers on his sacrum and heel were avoidable, yes, they got to lay him down and get him off that area and he has boots on now. *She confirmed she had started rounds and things are better. Interview on 7/17/24 at 2:10 p.m. with LPN G in regard to resident 23's pressure ulcers revealed: *His sacral pressure ulcer was new in the last 30 days. *She stated, Yes they were preventable. *She stated she wondered if the certified nursing assistants (CNAs) knew what floating the heels meant. *They had changed out his entire bed and mattress a couple of weeks ago because his old one folded him he indicated like a V with both his head and feet elevated. *They changed his heel boots to bunny boots. *They should have changed the interventions for his skin sooner. *She thought his pressure ulcers were part of his dementia progression. *There had been some uneasiness among the CNAs playing the blame game in regards to care provided. -Administrator A had started doing rounds on the floor and followed up on complaints and things are better. *She did not work the night shift but the day CNAs did a good job but are rushed at times. Interview on 7/17/24 at 3:30 p.m. with DON B in regard to resident 23's pressure ulcers revealed: *His bed was changed to an air mattress because he would slide down in his old one. *She had placed a 'turn and reposition clock' in his room but the CNAs had taken it down and they would be written up for it but haven't been yet. *He has bunny boots now because he could feel the thread in the old ones which did not help. *His heels dug into the sheets when he moved around. *She agreed his pressure ulcers were avoidable and he should have been given an air mattress sooner. Observation on 7/18/24 10:45 a.m. of resident 23 with registered nurse (RN) F revealed he was in his bed lying on his back when RN F entered his room to provide wound care. Review of resident 23's electronic medical record (EMR) revealed his Braden scale for predicting pressure sores was scored at 13 (moderate risk) on 12/7/23 and 12 (high risk) on 7/17/24. Record review of resident 23's skin observation tool for his right heel pressure ulcer revealed: *It was discovered on 5/30/24 and measured 0.5 centimeters (cm) by 0.5 cm with no depth measurement noted. *It was staged at a two (partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled blister). *It worsened to measure 1.1 by 1.1 cm by 0.1 cm on 6/18/24. Record review of resident 23's skin observation tool for his sacrum pressure ulcer revealed: *It was new on 6/20/24 and measured 1.0 cm by 0.6 cm and stage two. *It was documented on 7/9/24 to have worsened to 7.0 cm by 7.3 cm and stage three (full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling). Review of the provider's undated pressure ulcer prevention and wound care policy revealed: *General skin care guidelines 1.c. noted, Nursing assistants and staff shall follow the turning schedule as assigned by the charge nurse, observe skin integrity and report changes to charge nurse immediately. -3.a noted, The resident shall be turned and repositioned every 2 hours and as needed, unless contraindicated. *General pressure ulcer management guidelines 1. Noted, the RN/LPN shall initiate Pressure Ulcer Management Guidelines for at risk resident on admission and/or later if the resident condition warrants.

Based on interview, observation, record review, and policy review, the provider failed to implement effective precautions and interventions to ensure the safety for one of one sampled resident (10) that contributed to multiple accidents involving woodworking equipment resulting in bodily injury. Specifically, the provider failed to either complete follow-up assessments, incident analysis, or review/revise/monitor interventions. Findings include: 1. Interview on 7/16/24 at 4:25 p.m. with resident 10 revealed he enjoyed woodworking and had a workshop in the facility's basement. Interview on 7/17/24 at 9:41 a.m. with activity director J regarding resident 10's woodworking interest revealed: *He used a room in the provider's basement as his workshop for his independent woodworking activity. *She stated that he carried a walkie-talkie with him while he worked in the basement workshop and garage to communicate with staff. Interview on 7/17/24 at 10:31 a.m. with director of nursing (DON) B regarding resident 10 revealed: *She stated he had been assessed by the provider's contracted therapy services for his ability to safely pursue his independent woodworking activities. *She provided the 11/9/23 Occupational Therapy (OT) Evaluation and Plan of Treatment. *She also provided an undated one-page printed paper titled Care Plan for [resident 10's name] for [NAME] Working. *When asked regarding ongoing assessments for the resident as he had a diagnosis of Alzheimer's Disease (a brain disease that gets worse over time), she agreed that ongoing assessments were necessary, but stated that since the 11/9/23 OT Evaluation, no other OT evaluation was completed. *After he had an accident in March 2024, she revealed the electric saw equipment was changed to the current equipment that had an automatic shut-off if a problem was detected. Interview on 7/18/24 at 9:54 a.m. with social service designee C regarding resident 10's woodworking revealed: *She agreed he was forgetful at times but stated he was very aware of what he was doing. *He was not doing the woodworking when he was admitted to the facility, but had started his woodworking last fall and she stated that his family was very supportive of his woodworking. *She was aware of the care plan interventions regarding his woodworking but was not sure if staff members supervised him while he used his woodworking saw. Interview on 7/18/24 at 10:21 a.m. with DON B regarding resident 10 revealed: *When asked about the care plan intervention that stated he was only to use the electric saw if supervised by a staff member, she stated -This does not happen all the time. -He was aware of the need to be supervised with the electric saw, but will use the saw unsupervised. -When the staff had a meeting and heard the electric saw in operation, a staff member went down to check on him. -He can get agitated with staff as he liked to be independent. *There was no video camera or alternative method that monitored his workshop activity when staff were not in supervising him. Interview on 7/18/24 at 10:25 a.m. with administrator A regarding resident 10's woodworking revealed: *The maintenance director's office and the provider's laundry area were also located in the basement, and maintenance and laundry staff checked with the resident during the day while they were working. *He was only to be working in the workshop between 7:00 a.m. and 8:00 p.m. *He had purchased a new electric saw in March 2024 after an incident had occurred. -The new saw had a special safety feature that shut off the saw if an error was detected. -When he was operating the saw, a staff member had to be supervising him. Observation and interview on 7/18/24 at 10:36 a.m. with resident 10 in his basement workshop revealed: *He was alone in his basement workshop. *He had a walkie-talkie on a shelf in his workshop and had his personal cell phone in the front pocket of his overalls. *When asked how often he used his electric saw, he stated, Maybe once a day. -He stated he had called the maintenance director many times to supervise him while he was operating the electric saw. -He wasn't sure where his safety gloves were that he was supposed to wear when using his electric saw. -He stated At times the staff was busy, and I don't always get someone [when operating the electric saw]. Interview on 7/18/24 at 10:55 a.m. with activity director J regarding resident 10's woodworking revealed: *She checked in with him throughout the day when she worked. *He would call me at times when he needed to cut a board on his electric saw. *She agreed with the safety interventions on his supplemental paper care plan. *She had no concerns with his woodworking. An interview on 7/18/24 at 1:36 p.m. with administrator A and DON B regarding the provider's walkie-talkies revealed that multiple staff members, including the administrator, DON, dietary manager, cooks, nurses, medication aides, certified nursing assistants, housekeepers, and maintenance director, had walkie-talkies with them while they worked. Review of resident 10's electronic medical record (EMR) revealed: *He moved into the facility on [DATE]. *His diagnoses included age-related cognitive decline and Alzheimer's disease. *A 10/23/23 Health Status progress note at 12:01 a.m. stated At approximately 7:30 pm last evening [10/22/23] resident came to this nurse with his left pointer finger bleeding, resident stated he was working with his table saw and the piece of wood slipped and got his finger, tip of finger noted to be cut off, area cleaned, Bactroban applied and covered with pressure bandage, Dr. [last name of resident's primary physician] and family updated on the above, new orders for Bactroban and dressing daily until healed. *An 11/9/23 Occupational Therapy (OT) Evaluation and Plan of Treatment documented: -Diagnoses Age-related cognitive decline. -Current Referral Reason for Referral: The patient has been referred for a cognitive evaluation s/p [status post] a wood working injury resulting in a cut to digit. -Background Assessment: Patient Preferences: Hobbies: [NAME] working, making bird houses. -A St. Louis University Mental Status (SLUMS) exam scored at 26 out of a possible 30 indicating Mild Neurocognitive Disorder. -An Assessment Summary that stated .The patient has been performing woodworking tasks for years and resulting [sic] had an accident resulting in a hand injury. The patient was alert and oriented x 4 on this date and did assist with making a safety plan for all his woodworking tasks/tools. Per the SNF [skilled nursing facility], the facility will be placing together a policy to ensure safety during such leisure tasks. The patient is motivated to follow recommendations and continue with his loved leisure task . Review of resident 10's initial care plan for his woodworking revealed the following interventions: *OT evaluation related to woodworking safety. *Orientate and instruct [first name of resident 10] and staff that he will use his cell phone and his pager to call the staff while in the basement or garage-Relate to anything that [first name of resident 10] may need. Cell Phone Number for [first name of resident 10] [10 digit phone number] *Attempt to check on [first name of resident 10] often. *Family aware of woodworking in the basement and aware of the risks of wood working. *Ventilation in room and wears a mask for dust. *Make sure that [first name of resident 10] has non-skid shoes while doing wood working. *[first name of resident 10] is aware to make sure the power switch is off before he plugs into a power tools. *[first name of resident 10] is aware to not use a tool that is damaged. *Reminders to [first name of resident 10] to not rush given daily. *Will continue to update plan with issues as they arise. *Given to Activities and Nursing Departments on-11/1/23. Continued review of resident 10's electronic medical record (EMR) revealed: *An 11/13/23 Daily Charting progress note at 10:30 a.m. stated Skilled OT d/c [discontinued] due to evaluation only 11-9-23 with safety recommendations issued. *An 11/17/23 Skin/Wound progress note at 9:10 p.m. stated Resident came to nurse's station after working in his shop, left arm noted to be bloody, resident stated he ran into a piece of wood downstairs, large abrasion to left arm, area cleaned, Bactroban applied and covered with 4X4 Island dressing, Tx [treatment] received to monitor and cover area during the day until healed. *An 11/18/23 Skin/Wound progress note at 9:54 a.m. stated Resident to nurses station, stated that he bumped his Lt. [left] thumb on hood, 1.5 x 1cm open area where skin was off, moderate amount of bleeding due to blood thinners. Tx. [treatment] received for cleanse with betadine, apply bactroban and dressing daily until healed. *No follow-up assessment or incident analysis had been documented in the resident's EMR for the 11/17/23 incident or the 11/18/23 incident. Review of resident 10's 11/23/23 woodworking care plan revealed an intervention had been added that stated Will Wear safety gloves . Continued review of resident 10's electronic medical record (EMR) revealed: *A 3/16/24 Incident progress note at 12:00 noon stated Resident called for help from basement work room and was assisted by med [medication] aide who entered to find resident with left hand wrapped in a bloody paper towel. Med [medication] Aide brought resident upstairs to nurses station. Resident is alert and oriented and conversing and answering questions appropriately. Moderate amount of blood covering hand. Noted deep, jagged cuts to 2nd, 3rd and fourth fingers. Immediately placed 4x4's and wrapped generously with kerlix, elevated the extremity. Resident placed call to his Grandson at this time and transport to CDP [Coteau des Prairies] ER [emergency room ] was arranged. *A 3/16/24 progress note at 2:00 p.m. stated Resident returned from CDP [Coteau des Prairies] ER [emergency room ] at this time. The affected fingers are wrapped. Resident states 20 stitches total. Written Orders Received: Wash the laceration with peroxide and apply and antibiotic ointment twice a day. Dr. [last name of resident's primary physician] to remove stitches on 03/28/24. *No follow-up assessment or incident analysis had been documented in the resident's EMR for the 3/16/24 incident. Review of resident 10's 3/24/24 woodworking care plan revealed an intervention had been added that stated Can only saw if he is supervised with a staff member. Continued review of resident 10's electronic medical record (EMR) revealed: *A 6/19/24 Skin/Wound progress note at 12:10 a.m. stated Resident rang call light at this time to ask to see the nurse, when nurse entered room resident was sitting in his recliner with shirt off and abdomen exposed, nurse noted a large bruise to the right side of abdomen that measured 5 in [inches] X 3 in [inches] with a small gash in the middle, resident then turned and showed nurse his left side of abdomen and nurse noted large bruise with scrape running through the middle of the bruise, area measures 10 in [inches] X 5 in [inches], both sides were cleaned and antibiotic ointment was applied to open area on right abdomen and then covered with 4x4 island dressing, resident denies pain to areas when asked, he states he was using his saw in his work shop and it kicked the boards back at him and hit his abdomen a few times, when asked about how long ago this happened and resident stated around 8 pm tonight [6/18/24], resident offered a cold pack and Tylenol but interventions were refused. *No follow-up assessment, incident analysis or review/revision of current interventions was documented in the resident's EMR for the 6/18/24 incident. *A recently completed Brief Interview for Mental Status (BIMS) exam on 7/12/24 was scored at 10 out of a possible 15 indicating he was cognitively moderately impaired. Review of the provider's undated policy on Resident safety during leisure tasks revealed: *Policy Statement: Resident will be free from accidents and hazards while doing leisure tasks. *Accidents and Supervision. -[Name of provider] will ensure that the resident's environment will be free from accidents and hazards over which the facility has control to prevent avoidable accidents and will provide supervision and assistive devices to each resident. This will include identifying, evaluating, analyzing and then implementing interventions to reduce hazards and risks and then monitoring for effectiveness and then modifying interventions if necessary. A request for resident 10's incident reports related to his woodworking was made on 7/18/24 at 10:20 a.m. from administrator A and no incident reports were received by the end of the survey.

Based on interview and record review, the provider failed to have a qualified infection preventionist for the facility. Findings include. 1. Interview on 7/15/24 at 6:05 p.m. with administrator A revealed: *Director of nursing (DON) B was the infection preventionist (IP). *DON B had not been trained as an IP but had been completing some of the tasks. *The provider had not had an IP for at least two years. Interview on 7/18/24 at 3:30 p.m. with DON B revealed she: *Had been acting as the facility's IP the last two years. *She had not signed off as an IP because she had no training or certification as an IP. *They had tried to get one of their registered nurses to take the program but it had not worked out for them. Record review of the providers infection control program revealed: *The provider did not have an IP. *The annual review signature form had not been signed by an IP for at least two years.

Based on observation, interview, and policy review, the provider failed to ensure expired medications were removed from one of one medication room, one of two medication carts, and one of two treatment carts. Findings include. 1. Observation and interview on 7/18/24 at 10:00 a.m. of the provider's north hall medication room, medication cart, and treatment cart with registered nurse (RN) F revealed: *Two of seven containers of stock aspirin enteric coated 25 milligram (mg) had expired in April 2024. *Eight of eight hydrogen peroxide had expired in April 2023. *Three of three isopropyl rubbing alcohol 70 % had expired in March 2023. *Two of two tubes of oral glucose gel had expired in October 2023. *Three of three Heparin injectable syringes had expired in December 2023. *Five of five Prevnar 13 (pneumococcal vaccine) injectable had expired in September 2023. *One of one bottle of Aalcare hand sanitizer had expired in March 2024. *Thirty two of thirty six packets of white petroleum had expired in 2019. *Six of six packets of Vaseline gauze six of six had expired in June 2022. *She stated medication expiration dates would have been checked before administering to a resident and should have been removed. Interview on 7/18/24 at 3:30 p.m. with director of nursing (DON) B revealed: *She had not been able to keep up with removing expired medications from the medication rooms and carts but should have been removed and destroyed. *She confirmed the pharmacy audits were completed but their audits did not include expired medications. Review of the provider's undated storage of medications policy revealed 4. NO discontinued, outdated, or deteriorated drugs or biologics are available for use in the facility, All such drugs are destroyed. Review of the provider pharmacy 5/29/24 and 6/27/24 audits revealed that outdated medications were not part of their audit.

Based on observation, interview, record review, and policy review, the provider failed to assess and monitor one of one sampled resident (37) who was at risk for coffee burns. Findings include: 1. Observation on 12/9/19 at 5:24 p.m. revealed resident 37 was seated in his wheelchair in the dining room with an enclosed coffee mug. It was in a holder on the right side of his wheelchair (w/c). Interview on 12/10/19 at 8:46 a.m. with registered nurse C regarding resident 37 revealed he had a burn on his upper, right outside leg area due to spilling hot coffee. He had informed her he had switched his coffee from his mug to a paper cup. The coffee had spilled out of the paper cup. Review of resident 37's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED]. Review of resident 37's 3/5/19 annual Minimum Data Set (MDS) assessment and his 11/22/19 quarterly MDS assessment revealed: *His Brief Interview of Mental Status (BIMS) assessment score was fifteen indicated he was cognitively intact. *He had no behaviors. *He had upper extremity impairment on one side. *He was independent with eating after set-up assistance. *His quarterly MDS progress note revealed: -He was alert with intermittent confusion. -Both his legs had scattered scabbed over areas and very dry skin. -He used a w/c to propel himself around his room and the facility. -He was independent with eating after set-up help. Review of resident 37's culinary service progress notes revealed: *On 5/29/19: he had a cup of coffee on his w/c that he drank from all day. *On 8/22/19: he drinks a lot of coffee throughout the day. Review of resident 37's 11/19/19 mini-nutritional assessment revealed: *He drank greater than five cups a day of fluid (water, juice, coffee, tea, and milk). *He fed himself with some difficulty. *He drinks coffee continually no way to measure how much fluid he is getting as multiple people fill his cup during the day. Review of resident 37's nursing progress notes revealed: *On 11/30/19 at 9:09 p.m.: he was noted to have peeling skin on the top and side of his right thigh, when asked what happened he stated that he spilled hot coffee on it earlier in the day, and that he put cold water on it. Area appears to have blistered and then popped, area is red in color and resident states that it does hurt especially when he bumps it. *On 12/1/19 at 3:27 p.m.: he was seen by his physician and same order for burn to his right thigh continued. *On 12/2/19 at 10:38 a.m.: Areas at right upper leg redressed at this time. Areas measured. Top of outer right leg burn area measures 12 cm (centimeters) x (by) 8 cm and 1 mm (millimeter) deep. Areas all beefy red and no s/s (signs or symptoms) of infection noted at this time. Small area noted above outer area that measures 1.8 cm x 2 cm and 1 mm depth. Area at inner right upper leg measures 18 cm x 6 cm and 1 mm depth. Smaller area above large area measures 2 cm x 2 cm and 1 mm depth. Areas cleansed and [MEDICATION NAME] applied with new dressings over area. Kling around dressings. Resident denied pain at throughout dressing change. *On 12/3/19 at 3:11 p.m.: Wounds cleansed with mild soap and applied [MEDICATION NAME] cream as ordered, covered with nonadherent dressing and wrapped with kerlix. No s/s of infection at this time. *On 12/3/19 at 9:30 p.m.: Treatment done as ordered to burn on right thigh. No s/s of infection. Area is sore, while dressing is changed. There is a small area of blistering to lower part of thigh. 1st Degree Burned areas are red in color. There are also areas of 2nd degree burns. *On 12/5/19 at 10:13 p.m.: Treatment done as ordered to burn on his right thigh. Cleansed wound with sterile water and soap, pat dry, applied silver [MEDICATION NAME] to burns, covered with nonadhesive dressing, and wrapped in kerilex. No s/s of infection. Resident given scheduled pain medication 30 minutes before doing treatment. Resident rates pain '9/10; constant pain'. Area is painful to touch while dressing is being changed. 1st [MEDICAL CONDITION] 2nd [MEDICAL CONDITION] present and red in color with serosanguineous drainage. Resident tolerated treatment well. *On 12/6/19 at 11:14 a.m.: Treatment to right thigh burn done per doctor's orders. Areas show no s/s of infection and are showing improvement since day of first burn. There are no blistered areas, all open at this time. 2nd degree areas are bright red in color, boarders are approximated and clean. Resident complains of 'mild' pain while doing treatment. He states that if he bumps it or his pants are too tight the pain is 'horrible'. He states he does not need anything for the mild pain he is experiencing right now and that 'it goes away after you stop touching it'. *On 12/7/19 at 6:20 a.m.: Treatment done to right thigh as ordered. Scheduled pain medication was given 30 minutes before treatment. Area showing improvement since last time this writer changed dressing. No signs of infection. 2nd [MEDICAL CONDITION] bright red in color. Borders are approximated and clean. Resident tolerated treatment well. Resident states '7/10' pain during dressing change and once complete it goes down quite a bit. Resident called me back to room to re-do the wrap due to it sliding down when standing/sitting. *On 12/7/19 at 10:50 a.m.: Treatment done to right thigh as ordered. No filled blisters noted. All areas are open with skin pealing. Moderate amount of yellowish drainage on old dressings. Wound beds are beefy red in color. Small area towards the top right thigh has yellow slough noted. Resident states that pain is getting better but is still bothersome. *On 12/7/19 at 9:30 p.m. recorded as late entry on 12/8/19 at 3:14 a.m.: Treatment done to right thigh area, as ordered. No s/s of infection. Resident tolerated well. Areas are healing. Clenased (sic) with [NAME]on, and [NAME]on/sterile water. Generous amount of [MEDICATION NAME] applied over all burned areas. Covered with three 15 x 15 cm Eclypse Super absorbent dressings, when wrapped with Kerlix. *On 12/9/19 at 10:03 p.m.: Treatment done to right thigh as ordered. Cleansed with [NAME]on & [NAME]on soap with water, pat dry, applied Siladene, covered with non-adhesive bandages, and wrapped with Kerlix. Scheduled pain medication given 30 minutes before treatment was started. No signs of infection the the (sic) area. Burn areas are healing well. Resident rated pain' 7/10; but feels way better now' during treatment. Will continue to monitor area. *On 12/10/19 at 7:02 a.m.: Areas at right upper leg redressed at this time related to having shower this AM. Area of burn covered until after shower. Areas measured. Top of outer right leg burn area measures 9 cm x 7 cm and 1 mm deep areas. Small area noted above outer area is healed and granulated in with new skin. Area at inner right upper leg measures 12 cm x 6 cm and 1 mm depth. Smaller area above large area is now granulated in with new skin and no s/s of infection noted. Areas not healed are beefy red in color with no s/s of infection noted. Areas cleansed and [MEDICATION NAME] applied with new dressings over area. Kling around dressings. Resident denied pain at throughout dressing change. No s/s of infection noted. *On 12/10/19 at 9:30 p.m. recorded as late entry on 12/11/19 at 4:32 a.m.: Treatment done to right thigh area, as ordered. No s/s of infection. Resident tolerated well. Areas are healing, and not as sore when treatment done. Clenased (sic) with [NAME]on, and [NAME]on/sterile water. Generous amount of [MEDICATION NAME] applied over all burned areas. Covered with non-adherent dressing, then wrapped with Kerlix. Review of resident 37's 9/3/19 care plan revealed: *A hand written notation 11/30 burn. *Problem areas related to his: -History of [MEDICAL CONDITION]. -Memory problems related to his dementia and impulsive decision making following [MEDICAL CONDITIONS]. -Risk for falling related to impaired and impulsive decision making. -Self care deficit related to his [MEDICAL CONDITION]. *No problem, goal, or approach had been noted regarding his coffee consumption and potential for coffee burns. Review of resident 37's 12/10/19 care plan approaches started on 11/30/19 revealed: *He had [MEDICAL CONDITION] the top part of his left thigh/groin due to getting his own coffee. -Treatment was in place. *He will often not wait for assistance in getting coffee. Makes attempts to get it on his own. Staff to reeducate on the importance and safety of staff assisting him. *Remind and educate (Name) that if he is not in the dining room, coffee must be in a closed cup with proper fitting lid for his safety. Interview on 12/11/19 at 1:42 p.m. with the Minimum Data Set assessment coordinator regarding resident 37 revealed: *He was known to be an avid coffee drinker. *He should have been assessed as at risk for coffee burns. *She had done the hand written note on his previous care plan regarding the 11/30/19 burn. *His care conference had been on 12/6/19. -His care plan had been updated after that care conference. *He had been given a covered coffee mug. -Areas of the facility with access to coffee now had locks on the doors. Interview on 12/11/19 at 2:28 p.m. with the director of nursing regarding resident 37 revealed: *She knew he liked his coffee and drank it morning and night. *He demanded his coffee be extremely hot. -If his coffee cooled down he would throw it out and demand to get hot coffee. *They had given him several different coffee mugs. -The lid on his current coffee mug basically locks. *She had numerous conversations with him regarding the temperature of his coffee. *Since his burn he had not been as demanding for extremely hot coffee. *They knew he was at risk for spilling his coffee. *He should have been assessed [MEDICAL CONDITION] to extremely hot coffee. *His care plan should have included approaches related to his risk of coffee burns. Review of the provider's 12/5/19 Hot Beverage policy revealed: *Hot beverages for drinking would be filled in a carafe before meal service, so the liquid could cool down. *If a resident expressed a desire for very hot coffee or water and was safe to handle it they might have the hot liquid out of the machine. *Any coffee taken out of the dining room must have been in a covered cup with a tight fitting lid.

Based on observation, interview, record review, and policy review, the provider failed to ensure pressure ulcers were consistently monitored and documented, effective interventions were in place and updated, and the physician was notified of new opened areas for one of one sampled resident (22) who had recurring pressure ulcers. Findings include: 1. Review of resident 22's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Muscle weakness. -Constipation. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Heart failure. -Gastro-[MEDICAL CONDITION] reflux disease without esophagitis. -Chronic lymphocytic [MEDICAL CONDITION] of B-Cell type in remission. -[MEDICAL CONDITION]. -Hypertension. -[MEDICAL CONDITION]. Review of resident 22's 7/24/19 Minimum Data Set (MDS) assessment revealed: *His Brief Interview for Mental Status (BIMS) assessment score was eleven indicating his cognition was moderately impaired. *He required extensive assistance from one staff member for bed mobility, transferring, dressing, toilet use, and personal hygiene. *He was not at risk for developing pressure ulcers. *However he currently had one, stage two, facility acquired pressure ulcer. *The skin and ulcer treatment interventions were: -Pressure reducing device in his bed and chair. -Nutrition and hydration intervention to manage skin problems. -Pressure ulcer care. -Application of ointments/medications other than to feet. Review of resident 22's 10/20/19 MDS assessment revealed: *His BIMS assessment score was twelve indicating his cognition was moderately impaired. *He required extensive assistance from one staff member for toileting and personal care. *He was at risk for developing pressure ulcers. *He did not currently have a pressure ulcer. *He had moisture associated skin damage. *The skin and ulcer treatment interventions were: -Pressure reducing device in his bed and chair. -Nutrition and hydration intervention to manage skin problems. -Application of ointments/medications other than to feet. Observation and interview on 12/9/19 at 5:33 p.m. with resident 22 revealed: *He was sitting in his recliner. *He often got sores on his bottom and pointed to the left side of his buttocks. *He had a cushion in his recliner to help with the sores. *He slept in his recliner and not in his bed. *He used a walker. Interview on 12/10/19 at 9:04 a.m. with registered nurse (RN) A regarding resident 22 revealed he took himself to the bathroom. Observation on 12/10/19 at 9:13 a.m. in resident 22's room revealed the gel cushion in his recliner was approximately one inch thick. The gel was an orange color. Looking down at the cushion the four corners appeared to be darker in color. Upon lifting up the cushion from the corner it stuck to this surveyor's hand. The gel was leaking out of the cushion. The top of the cushion had wrinkles across the whole thing. Observation on 12/10/19 at 10:18 a.m., 1:49 p.m., 3:07 p.m., 3:54 p.m., and 5:20 p.m. and again on 12/11/19 at 8:31 a.m. of resident 22 revealed he was sitting in his recliner in his room with the above mentioned gel cushion in the chair. Interview on 12/11/19 at 11:10 a.m. with RN A revealed the certified nursing assistant had just gone on break at 11:00 a.m. but would be back to take resident 22 to the bathroom at 11:30 a.m. That had contradicted what she had said above about him taking himself to the bathroom. Surveyor: Observation on 12/11/19 at 11:20 a.m. of resident 22 with RN A revealed: *A dark, red oval area to his buttocks that went from his gluteal crease to both buttocks. -It covered approximately half the width of his buttock and the entire length of the buttock. *The left gluteal buttock had a darker red area towards the crease of his buttock approximately a quarter in size. *No drainage noted to any of the areas. *He denied pain when asked if it hurt. Surveyor: Interview on 12/11/19 at 1:55 p.m. with RN A regarding resident 22 revealed: *He had struggled with pressure ulcers for a long time. *He had a wound that was continually opening and closing. *His most recent wound had healed on 12/8/19. *She was considered the wound nurse but had not had any special training in wound care. *Wound measurements were supposed to be done weekly. *All wound documentation was under nursing progress notes or an Event assessment if it was a big wound. -She could not explain what a big wound was. *They had a wound specialist outside of the facility they could call if they needed to, but they had not contacted that person regarding the resident. *She referred to that type of skin condition as recliner butt. Review of resident 22's nursing progress notes from 6/1/19 to 12/11/19 revealed: *From 6/30/19 through 7/30/19: -6/30/19: a small open area on left buttock. Resident states that it is painful to touch. Area 0.2 cm (centimeter) X (by) 0.2 cm bag balm applied to buttocks as ordered. -7/4/19: No open areas noted to buttocks. -7/5/19: No open areas noted to buttocks. -7/18/19: Area on left buttock is getting larger and it is bleeding. Resident states that it is painful. Area 0.5 cm X 0.5 cm. Bag balm applied to buttocks as ordered. -7/18/19: physician notified and order to apply meplix dressing to left buttock, check daily, change q3d (every 3 days) and PRN (as needed) until healed. -7/24/19: Left buttock is showing improvement. Measures 0.3 (cm) X 0.2 cm. Area clean, no bleeding, scabbed over. Surrounding tissue intact. -7/26/19: Stage 2 pressure ulcer to left inner buttock is healing. Treatment in place. -7/30/19: Buttocks has no further open area. --There was no documentation of his physician being notified of the opened area until 7/18/19. --There was no documentation of staging or identifying it as a pressure ulcer until 7/26/19. *9/2/19: Area to resident's upper Left buttock reopened, area approximately 0.5 cm in diameter, wound bed pink with calloused skin surrounding. *9/4/19: Was seen by wound nurse yesterday, new orders processed for Collagen/anasecpt mixture to Lt. upper buttock stage 2 pressure ulcer daily until healed-cover with meplex. *9/10/19: Treatment done to Lt, buttock, pin point open area remains. *9/16/19: Treatment done to left lower buttock. Area has thin layer of skin but to look like a scrape. Measures 1.2 cm X 0.8 cm round with no coloring surrounding area is healthy skin. *9/18/18: Area has no open areas and is healed, but will continue dressing until skin is less fragile. *10/11/19: Left buttock does have a scab that is 0.2 cm round area cleansed and bordered foam dressing applied. *10/14/19: Changed dressing on left buttock and noted 0.2 mm (millimeter) scab that is round, no discharge or s/s (signs and symptoms) of infection noted at this time. *11/24/19: Resident has 4 small open areas to buttock; right side: 0.2 (cm) X 0.5 cm, 0.4 (cm) X 0.2 cm, 0.3 (cm) X 0.2 cm; Left side: 0.1 (cm) X 0.4 cm. Staff to apply bag balm with each brief change for barrier protection. N.O (nursing order) to monitor open areas daily until healed, notify MD (medical doctor) if worsening or s/s of infection noted. Staff and resident also encouraged to reposition when sitting in recliner throughout the day and night. *12/8/19: Open areas to buttocks healed, new pink skin, will continue with bag balm with brief changes. *The documentation was inconsistent and lacking regarding staging, measurements for depth, descriptions, and physician notification. Review of resident 22's following skin assessments with the Braden Scale scoring revealed: *7/24/19: -His risk factors were not marked such as cardiovascular disease and terminal illness/cancer. -He was scored at twenty-two indicating he was not at risk for developing pressure ulcers. --He currently had a stage 2 pressure ulcer to his bottom. *10/20/19: -His risk factors were not marked such as cardiovascular disease and terminal illness/cancer. -He was scored at twenty-two indicating he was not at risk for developing pressure ulcers. -He currently did not have a pressure ulcer. Review of resident 22's following event reports revealed: *11/24/19: he currently had an opened area caused from moisture/shearing. -As of 12/11/19 the 11/24/19 event report had not been completed. *There were no other event reports for any of the above mentioned pressure ulcers. Review of resident 22's 11/3/19 care plan revealed: *There was no problem area for pressure ulcers. *There was a problem area for (Name) experiences frequent bowel and bladder incontinence. -Interventions were: --[MEDICATION NAME] cream to groin and penis as ordered; approach date 5/7/19. --Bag balm to buttocks with each brief change; approach date 2/7/18. --(Name) received a multivitamin as ordered; approach date 11/29/17. --High protein snack BID (twice per day) to prevent skin breakdown; approach date 11/29/17. --Pressure reducing mattress to bed and gel cushion in recliner; approach date 11/29/17. --Receives [MEDICATION NAME] as ordered; approach date 8/14/17. --(Name) wears a brief at all times. Requires extensive assist with hygiene after incontinent episode; approach date 5/30/17. --Report any signs of skin breakdown (sore, tender, red, or broken areas); approach 5/30/17. --Report signs of UTI (urinary tract infection) (acute confusing, urgency, frequency, bladder spasm, nocturia, burning, pain/difficulty urinating, nausea, emesis, chills, fever, low back/flank pain, malaise, foul odor, concentrated urine, blood in urine); approach date 5/30/17. *There were seven interventions that had no change since (YEAR). Interview on 12/11/19 at 4:20 p.m. with the director of nursing regarding resident 22 revealed: *She knew he slept in his recliner. *She was not aware of the state of the gel cushion. -He was sleeping when attempting to show her the cushion. -She stated she would come back later to look at it. *She was not aware his care plan had not included his pressure ulcer injuries. -She tried to find documentation in his care plan, but stated I do not see it in there. *Documentation regarding pressure ulcers was supposed to be done in the nursing progress notes or on a event report. *Nurses were to notify the physician of new and worsened pressure ulcers. Review of the provider's policy regarding Pressure ulcers/impaired Skin revealed: *Nurse on duty when pressure ulcer/impaired skin integrity is discovered, will perform an assessment. *An assessment includes measurement of area affected including Length, width and diameter. Character of wound bed, any drainage, or odor or condition of surrounding skin, and complaints of pain. *The nurse will then notify medical doctor with assessment and follow recommendations/orders given. *Documentation of the pressure ulcer/impaired skin integrity to be done in a Matrix event or progress note. *Regular documentation of impaired skin integrity to be done until area healed. *Pressure ulcers will be followed and assessed weekly by designee. *Notify dietary department of wound. *Observations will then be completed until area is healed. *MDS coordinator to be notified of pressure ulcer/impaired skin integrity. *MDS will be updated accordingly.

Based on observation, interview, record review, and policy review, the provider failed to: *Secure an exit door leading into a child daycare area resulting in a fall with major injury for one of one (12) sampled resident. *Alarm two exit doors (numbers four and six) and secure one of one courtyard gate resulting in an elopement for one of one (4) sampled resident. *Secure or alarm one of one elevator leading to a basement door that lead outside to the employee parking lot. *Ensure four randomly observed resident's (16, 17, 18, and 19) beds were free from entrapment hazards. Findings include: 1. Review of a [DATE] event report to the South Dakota Department of Health (SD DOH) regarding resident 12 revealed: *He was missing on [DATE] at approximately 9:00 p.m. *He was found with his wheelchair at the bottom of a stairwell in the child daycare area of the building. *He had opened two doors to get to the stairs. *He was taken to the hospital and found to have a broken arm. *A lock has been placed on the day care door. Closed record review for resident 12 revealed: *He had dementia. *His [DATE] Minimum Data Set (MDS) Brief Interview of Mental Status (BIMS) assessment was three indicating severe mental impairment. *He was at a high risk for falls. *He was unable to walk on his own and used a wheelchair. He would wheel around the facility by himself. *He wore a TABS alarm. *On [DATE] after a fall down some stairs he was sent to the hospital. They called at 11:17 p.m. to report he had a broken right arm along with bumps and bruises. *He had died on [DATE]. Observation on [DATE] during the initial tour of the East wing and dining hall revealed a door leading from the dining hall into the daycare that had a keypad with the numbers posted on it. Observation on [DATE] at 3:00 p.m. of the same daycare door revealed: *It opened into a child daycare after pressing the keypad number. *After entering the daycare a hallway to the right ended with another door leading to a stairway to the outside. That door currently had a bolt lock at the top of it. *Those were the two doors resident 12 had gone through before falling down the stairs. Observation on [DATE] at 3:40 p.m. of an unidentified staff member revealed: *He walked through the daycare door without punching in the numbers into the keypad. *There was a faint chiming noise heard as he went through the door. Interview immediately afterward with daycare worker H revealed both of the above doors were unlocked during the day. They were locked at 5:30 p.m. when they left for the day. Interview on [DATE] at 4:30 p.m. with the director of nursing (DON) and the social service designee regarding the above doors and the event with resident 12 revealed: *The doors had not been locked. *The doors had not been alarmed at the time of the incident to prevent his fall with a major injury. 2. Review of a [DATE] event report to the SD DOH regarding resident 4 revealed: *She and her roommate were missing on [DATE] at approximately 7:00 p.m. *They were found at a relative's home in a neighborhood away from the facility. Review of resident 4's medical record revealed: *She was admitted on [DATE] the day before her elopement. *She had dementia with confusion. *Her [DATE] MDS BIMS assessment was four indicating severe mental impairment. Surveyor Observation and interview on [DATE] at 4:20 p.m. at exit number four revealed: *The alarm to the door had been switched off. *An unidentified staff member stated it had been turned off when a resident went out to smoke, and it should have been turned back on. *The door led to a fenced courtyard with a gate at one end. -Testing of the gate revealed it could be unlatched without difficulty. Surveyor Observation and interview on [DATE] at 9:15 a.m. with licensed practical nurse (LPN) I revealed: *Exit doors number four and six were in the East wing near resident 4's room. *Those doors were used by resident smokers to go outside the facility to smoke. *The alarms currently went off when they left and when they come back in. Interview that same day at 3:05 p.m. with LPN I regarding exit doors four and six revealed: *She had been working the day resident 4 and her roommate had eloped. *Both doors alarms had been turned off, so the smokers could go in and out without setting off the alarms. Interview on [DATE] at 3:00 p.m. with a family member of resident 4 who did not want to be identified revealed: *She was aware of resident 4's elopement. *Resident 4's current roommate had been her roommate at her previous residency. *She had told them (provider) the day the resident was admitted she would try to elope. Interview on [DATE] at 4:30 p.m. with the director of nursing (DON) and the social service designee regarding the above elopement revealed they had been unaware exit doors 4 and 6's alarms had been turned off. Review of the provider's undated Exterior Door Alarms policy revealed: *East door/day care door - daycare will set daily. *All exterior doors will be alarmed at all times unless there is direct supervision of that door. 3. Observation on [DATE] at 8:33 a.m. in the east dining room revealed: *There was a door that exited the nursing facility into an attached childrens daycare center. *An adult and small child used the door to enter the daycare center from the nursing home. *No code was entered or alarm sounded when they passed through the door. Observation on [DATE] at 12:10 p.m. in the east dining room revealed: *A daycare center staff member exited through the above door. *It did not alarm, and no code had to be entered. On [DATE] at 12:15 a.m. testing of the east dining room exit door revealed: *The door did not alarm when this surveyor passed through the door. *The dining room exit door led to an entry way into the daycare center. *There were two additional doors after passing into the entry way. -An unlocked and unalarmed door led to the outside of the building. -At the end of the hallway there was a door that led down a flight of stairs. -A bolt latch was on the upper portion of the basement door, but it was not in place. Interview on [DATE] at 9:00 a.m. with the maintenance supervisor regarding the east dining room exit door revealed: *The alarm in place sounded at the door but was not wired into the facility alarm system. *He acknowledged the alarm to the daycare had been acting up for approximately one week. *He verified it was not alarmed at this time. *He was unable to supply documentation regarding a work order or alert status on the door. Interview on [DATE] at 4:45 p.m. with the director of nursing (DON) revealed: *There was no wander monitoring device or wired alarm on the east dining room exit door. *An company had been contacted regarding safeguarding the exit doors and stated that it would be unable to be modified. Review of the provider's undated Exterior Door Alarms policy revealed: *East door/day care door - daycare will set daily. *All exterior doors will be alarmed at all times unless there is direct supervision of that door. 4. Observation and interview on [DATE] at 9:50 a.m. of the elevator and basement exit door with the maintenance supervisor revealed: *The elevator was used to travel from the first floor to the basement. *There was a door at the end of the hall that led outside to the staff parking lot. *The elevator and exit door were unlocked at this time. *He stated It does get locked at night when referring to the exit door. *He was unable to give specifics on the time or duration that the door was locked. Interview on [DATE] at 4:45 p.m. with the DON regarding the elevator and basement exit door revealed: *There was no wander monitoring device on either door. *She verbalized staff would sometimes lock the elevator at night. -That was based on staff preference and was not a consistent practice or per policy. *She acknowledged there were no safeguards in place to prevent a resident from taking the elevator to the basement and exiting out the door. Review of the provider's undated Exterior Door Alarms policy revealed, All exterior doors will be alarmed at all times unless there is direct supervision of that door. 5. Observation on [DATE] from 3:30 p.m. to 3:45 p.m. regarding side rails revealed: *There were four residents with half side rails that had three spindle-like openings with each measuring 8 inches in length by 8 inches in height. -Resident 17,18 and 19 had one upper side rail that fit the above dimensions. -Resident 16 had both upper side rails with the above dimensions. Interview on [DATE] at 3:50 p.m. with the DON, maintenance supervisor, and environmental services supervisor revealed: *They were unaware those above side rails were in place. *They acknowledged the side rails were an entrapment hazard. *They placed spacer modifications on each of the side rails listed above during the survey to fix the issue. Review of the provider's [DATE] Accident/Incident Prevention Environmental policy revealed: *Accident hazards are defined as physical features in the environment that can endanger a resident's safety. *The facility should undertake an environmental assessment to modify the environment to improve mobility and safety, including, but not limited to .individualizing resident room with appropriate bed, toilet/chair height.