Every finding on record at United Living Community

Based on observation, interview, and record review, the provider failed to maintain the kitchen floor and windowsill in the dish room in a clean and sanitary manner in one of one main kitchen.Findings include: 1. Observation on 12/2/25 from 8:17 a.m. to 8:41 a.m. during the initial kitchen tour in the main kitchen revealed the floor underneath the rubber mats in the dish room was caked with a brown and black substance. The rest of the tile floor in the kitchen was gray in color and appeared to be clean. The rubber mats in the dish room were the standard slip-resistant black rubber mats with drainage holes in it.The windowsill in the dish room was visibly dusty, with scattered food crumbs, dead flies, and mosquitoes. A large, white, fluffy seed, resembling a dandelion seed, was also present on the surface.Interview on 12/2/25 at 8:23 a.m. with cook U revealed that the dish room rubber mats were usually cleaned monthly in the warmer months. They would take the mats outside to pressure wash them. They could not do that now that it was below freezing temperatures outside. She could not remember the last time those mats were moved out of the way to clean the floor underneath.She was usually scheduled as a baker rather than as a cook. The cooks had a weekly and monthly cleaning checklist. The floors were supposed to be mopped daily. Once the cleaning checklists were filled out, they gave them to dietary manager (DM) I.2. Observation and interview on 12/4/25 at 9:57 a.m. in the dish room with cook J revealed that the floor beneath the rubber mats and the windowsill were in the same state as described above. [NAME] J did not know when the windowsills were last cleaned and agreed that it looked dirty. She said, the bugs are gross.When she helped clean the kitchen daily, she mopped the floors, but she did not move the rubber mats out of the way to clean the floor beneath them. She would mop around the rubber mats.3. Interview on 12/4/25 at 1:46 p.m. with DM I revealed that she was aware the floors were stained. She said, We have an issue in this kitchen. The maintenance department has a big machine that they were supposed to clean the floors with once a month, but that machine was broken. She expected staff to sweep and mop the floors daily, and to clean the rubber mats once a month. When asked if those tasks were documented, she explained that the monthly cleaning checklists included cleaning the rubber mats.She was not aware of the dirty windowsill. She did not know if that should be cleaned by the kitchen or maintenance staff. She confirmed the kitchen cleaning checklists did not include cleaning the windowsills.Review of the monthly cleaning checklists at that time with DM I revealed that the rubber mats in the dish room had not been documented as cleaned since June 2025, six months prior.

Based on observation, interview, record review, and policy review, the provider failed to follow the planned menu for the pureed diet, which had the potential to affect all residents who were prescribed the pureed diet, for two of two meals observed, and failed to follow the planned menu for all diet types for one of two meals observed which had the potential to affect all residents.Findings include: 1. Observation on 12/2/25 at 10:59 a.m. in the memory care unit dining room revealed the posted menu listed pulled pork sandwiches, potato salad, V8 juice (a brand of tomato juice), and pistachio dessert. Dietary aide (DA) S did not serve pureed potato salad to the residents on a pureed diet, as the kitchen did not send any pureed potato salad. Those residents were not offered an alternative to the potato salad. Instead, DA S only served them the pureed sandwich, V8 juice, and pureed dessert.2. Observation on 12/2/25 at 11:20 a.m. in the [NAME] View dining room revealed the posted menu was the same as listed above for the memory care unit. DA T did not serve the potato salad, instead offering either a fruit cup or pasta salad to the residents. Residents who were on a pureed diet were not offered an alternative to the potato salad.3. Interview on 12/2/25 at 3:50 p.m. with dietary manager I revealed that they ran out of potato salad for lunch because their food supplier did not deliver enough. She thought that the residents received coleslaw, rather than the pasta salad that was served as a substitute, instead of potato salad.4. Interview on 12/4/25 at 10:04 a.m. with cook U revealed that they did not receive enough potato salad from the food supplier to serve to the residents on 12/2/25. They used the pasta salad as a substitute. She did not puree the potato salad for the residents who were on a pureed diet that day because she wanted to save as much potato salad for the regular diets as possible. She said the residents on the pureed diet received V8 juice instead of the potato salad.She did not realize the V8 juice was on the regular menu and that the residents who were on a pureed diet were supposed to have a nutritionally similar substitute when they ran out of the potato salad. She confirmed the residents on a pureed diet did not receive an alternative food option during the noon meal on 12/2/25. She said that we make sure they have 3 items. They had the meat, the dessert, and the juice. She confirmed the residents on a pureed diet were not served a complete meal for lunch on 12/2/25 as compared to what other residents received and as compared to the written menu.She informed the dietary manager about the potato salad shortage after lunch on 12/2/25, not before. She did not record the menu substitution anywhere. There used to be a menu substitution log that was kept in the kitchen office, but she could not find it anymore.5. Observation on 12/4/25 from 10:48 a.m. to 11:23 a.m. in the South Ridge dining room revealed the posted menu included country fried steak, mashed potatoes, country gravy, [NAME] blend veggies (cooked broccoli, cauliflower, and carrots), and tropical fruit.The menu diet extension binder (a detailed menu of what each therapeutic diet was supposed to receive, including serving size amounts) indicated that the menu for lunch was supposed to include a 2-to-3-ounce (oz.) country fried steak, a half cup of mashed potatoes, a quarter cup of country gravy, a half cup of California blend vegetables, a 2-inch by 2-inch piece of cake, and a dinner roll with margarine. The menu posted on the wall did not include dinner rolls, but the menu extension binder did include dinner rolls. The menu posted on the wall included tropical fruit instead of cake, but the menu extension binder included the cake instead of tropical fruit. The tropical fruit was included in that night's supper menu instead.There were no dinner rolls available or served. The cake was served rather than the tropical fruit as posted on the dining room menu.Residents on the pureed diet were to receive a #8 scoop (about a half cup) of pureed vegetables, but dietary aide K only served them a quarter cup of pureed vegetables.6. Interview on 12/4/25 at 11:23 a.m. with DA K revealed that she knew she was supposed to have served a half cup of the pureed vegetables. The only resident on that unit that received a pureed diet was resident 49, and she knew that the resident did not have a big appetite, so she only served her a quarter cup of vegetables instead of a half cup.DA K confirmed she was not aware that the menu extension binder indicated that dinner rolls were supposed to have been served with lunch. The kitchen did not send any dinner rolls.7. Interview on 12/4/25 at 11:35 a.m. with cooks J and U revealed that neither of them were aware that dinner rolls were supposed to have been served for lunch that day. They confirmed that dinner rolls were included in the menu extension binder located in the kitchen. [NAME] J was not aware of what that binder was. 8. Interview on 12/4/25 at 1:46 p.m. with DM I revealed that she expected the cooks not to substitute a menu item unless they ran out of that food. She expected staff to contact her for approval of the substitute food item prior to serving the food. She confirmed there was no menu substitution log, so there was nothing for the registered dietitian to review to ensure the substitution was appropriate.She confirmed that the cooks should have prepared a pureed substitution when they ran out of the potato salad. She was not aware that the posted menu on the wall in the dining room did not match the menu extension binders. She was not aware that a dinner roll was supposed to have been served that day for lunch.Their food supplier did not always contact them beforehand to inform them of food supply issues, nor did they provide a reasonable alternative. She was able to make food order substitutions if their supplier informed her of shortages ahead of time.9. Review of the provider's 4/11/24 Substitutions policy revealed the policy statement read, Food substitutions will be made as appropriate or necessary. 1. The food services manager, in conjunction with the clinical dietitian, may make food substitutions as appropriate or necessary. The food services shift supervisor on duty will make substitutions only when unavoidable. 2. The food services manager will maintain an exchange list identifying the seven (7) exchanges of food groups. When in doubt about an appropriate substitution, the food services manager will consult with the dietitian prior to making the substitution. 3. Residents' likes and dislikes will be considered when making substitutions. 4. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for substitution. 5. The food services manager will review the substitutions regularly to avoid recurrences when possible.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident medications were securely stored for six of twenty-four sampled residents (8, 63, 64, 71, 72, and 73) in the South Ridge unit.Findings include:1. Observation on 12/2/25 at 10:10 a.m. in resident 8's room revealed there was a jar of Vick's VapoRub sitting on top of her overbed desk. It was in plain view from the doorway.2. Observation on 12/3/25 at 9:18 a.m. in resident 72's room revealed there was a bottle of Systane eyedrops, a tube of Vaseline, and a bottle of saline nasal spray sitting on his bedside table. They were in plain view from the doorway.Interview on 12/4/25 at 8:14 a.m. with resident 72 revealed that his wife brought in the Systane eye drops and the saline nasal spray to him. He confirmed the facility probably didn't know that his wife brought those medications in for him to use.3. Observation on 12/3/25 at 9:26 a.m. outside of resident 71's room revealed a cabinet with a combination lock drawer. The drawer was not locked. The following medications were accessible: Albuterol inhaler solution, a tube of miconazole (an antifungal cream), a tube of diclofenac ointment (a pain reliever), a tube of triamcinolone (a corticosteroid), and a bottle of fluticasone (a corticosteroid).4. Observation on 12/3/25 at 9:46 a.m. outside of resident 63 and 64's shared room revealed a cabinet with a combination lock drawer. The drawer was not locked. The following medications and care supplies were accessible: Albuterol inhaler, nystatin powder (an antifungal), and a tube of Desitin cream (a zinc oxide barrier cream).5. Observation on 12/3/25 at 9:50 a.m. outside of resident 73's room revealed a cabinet with a combination lock drawer. The drawer was not locked. The following medications were accessible: Duoneb inhaler (containing ipratropium bromide and albuterol, used to help open the lung airways), latanoprost eye drops (used to treat high blood pressure in the eyes), calcitonin salmon nasal spray (used to treat osteoporosis, a bone disease), erythromycin antibiotic, Systane eye gel, and a tube of lidocaine-prilocaine cream (a pain reliever).6. Interview on 12/3/25 at 10:21 a.m. with licensed practical nurse (LPN) P revealed that she did not know what the policy was regarding medication storage. She was super new here and only worked part time. She stated that she would go ask director of nursing (DON) B if she had any questions.7. Interview on 12/3/25 at 10:52 a.m. with registered nurse (RN) Q revealed that she expected the resident's medication cabinets and drawers to be locked. Medications like inhalers, eye drops, ointments, and creams were stored in the resident's medication cabinets and drawers. The medication cabinets and drawers were to be locked and inaccessible to unauthorized persons at all times. The combination lock code for residents' medication cabinets was the same throughout the facility.8. Observation on 12/3/25 at 1:51 p.m. in resident 8's room revealed a locked cabinet hanging on her wall. The cabinet was locked, but the key to unlock it was hanging on a screw to the left side of the cabinet. The cabinet and key were in plain view from the hallway. The cabinet was able to be unlocked and opened with that key.The following medications were in resident 8's cabinet: a Humalog insulin pen, two Troujeo Solostar insulin pens, Desitin cream, fluticasone, a Symbicort inhaler, an Albuterol inhaler, Diclofenac gel, and a Duoneb inhaler.9. Interview on 12/4/25 at 11:54 a.m. with LPN R revealed that she expected the resident's medication cabinets and drawers to be locked at all times and inaccessible to unauthorized persons.10. Interview on 12/4/25 at 1:08 p.m. with case manager G and RN O revealed they were not aware of the medications at residents 8 and 72's bedsides. They expected any resident medication to be securely locked for safety and to prevent access by unauthorized persons. If a staff noticed medications sitting out in a resident's room, they expected staff to notify a nurse or a manager to ensure the medications were stored safely. They expected the resident's medication cabinets and drawers to be locked at all times.11. Interview on 12/4/25 at 3:31 p.m. with DON B revealed she expected that all medications should have been locked up to prevent unauthorized persons from accessing the resident's medications. She was not aware of the unlocked medication cabinets and drawers on the South Ridge unit. She tried to discourage family from bringing in medications from the resident's home. If the resident or family wanted to bring in medications from home, she would have expected the nurse to obtain a physician's order and ask the pharmacy for a pharmacy label.12. Review of the provider's 5/15/25 Medication Administration and Destruction policy revealed the policy statement read, The purpose of this policy is to outline the guidelines for medication administration, management and destruction at United Living Community (ULC). Medications Received from Other Sources: .Each medication container shall be labeled with the resident's name, physician, physician assistant, or nurse practitioner's name, drug and strength, directions for use, and prescription date. Medications Brought from Home - Can be used: .Residents may not keep medications on their person or in their room without a physician's, physician assistant, or nurse practitioner's order allowing self-administration. Medication Storage: All medications will be stored in a locked medication cart or in a locked medication room.Separate storage of topical medications and oral medications.

Based on observation, interview, and record review, the provider failed to serve appropriate gluten-free foods to one of one sampled resident (70) who was on a gluten-free diet for one of two meals observed.Findings include: 1. Observation on 12/4/25 from 10:48 a.m. to 11:23 a.m. in the South Ridge dining room revealed the menu extension binder (a detailed menu of what each therapeutic diet was supposed to receive, including serving size amounts) indicated that the gluten-free diet was supposed to receive a plain hamburger, a half cup of gluten-free mashed potatoes, a quarter cup of gluten-free gravy, a half cup of California vegetable blend (cooked broccoli, cauliflower, and carrots), a gluten-free dessert (the menu did not specify what kind of dessert), and a gluten-free bun.Dietary aide (DA) K served resident 70 the regular menu which consisted of a country fried steak, mashed potatoes with country gravy, and cooked vegetables. He received two gluten-free [NAME] Krispie treats. Resident 70 ate the country fried steak, mashed potatoes, and country gravy.2. Interview on 12/4/25 at 11:23 a.m. with DA K revealed she knew resident 70 was supposed to receive a gluten-free diet. The cooks in the kitchen were responsible for making and sending the gluten-free foods, but they did not send the gluten-free alternatives for that meal. She mentioned that resident 70 has been known to eat gluten-containing foods before. For example, at breakfast that day, he was served his gluten-free pancakes, but he requested to eat the biscuits and gravy instead. She did not ask him, the nurse, or the resident's representative if it was okay to serve him the regular gluten-containing meal for lunch. 3. Review of resident 70's electronic care record revealed that a gluten-free diet with regular textures and regular consistency was ordered on 11/25/25, which was the day he admitted to the facility.4. Interview on 12/4/25 at 11:26 a.m. with resident 70's daughter revealed that she confirmed he had celiac disease (an autoimmune disorder that causes the immune system to attack the intestines when a person eats gluten) and ulcerative colitis (a condition where the colon is inflamed and ulcers form). He sometimes chose to eat gluten-containing foods. She did not know if he experienced negative reactions when he ate gluten. She would have preferred if the gluten-free diet was offered to him with each meal.5. Interview on 12/4/25 at 11:32 a.m. with cook U revealed that she was aware that resident 70 was supposed to receive a gluten-free diet. She was not the main cook that day. She expressed frustration with having to remind the other cooks about following his gluten-free diet.6. Observation on 12/4/25 at 11:34 a.m. in the kitchen revealed the nutrition facts labels for the country fried steak and the country gravy included wheat, which contains gluten. There were packages of gluten-free gravy mix available in the dry storage room.7. Interview on 12/4/25 at 11:35 a.m. with cook J revealed that she was aware that resident 70 was supposed to receive the gluten-free diet. She did not make any of the gluten-free menu items that day because she totally spaced [it]. There was a laminated list of resident dislikes/allergies taped on the prep table across from the ovens, but resident 70 was not on that list. She did not know how often that list was updated. Resident 70 was the only resident on a gluten-free diet.8. Interview on 12/4/25 at 1:46 p.m. with dietary manager I revealed that she was aware that resident 70 was supposed to receive the gluten-free diet. She did her best at trying to update the list of resident dislikes/allergies each time a new resident was admitted , or when a resident told her their likes or dislikes. She could not remember the last time she updated that list for the staff to reference. She expected her staff to follow the planned menu for each diet.

Based on interview, record review, and policy review, the provider failed to ensure that one of eighteen sampled resident's (72) right to a sense of dignity and respect was maintained related to wearing incontinence products and experiencing an incontinence episode, and that preferences were followed related to staff assistance with walking.Findings include: 1. Interview on 12/4/25 at 8:14 a.m. with resident 72 revealed that he had a concern with the staffing levels and the amount of time he had to wait to get help since he admitted to the facility on [DATE]. He waited for over 20 minutes for someone to answer his call light on the morning of 11/19/25. He waited so long that he lost control of his bladder and urinated in bed. He expressed feelings of embarrassment after he wet the bed.He spoke with one of the facility managers about his experience and expressed his displeasure. Since talking to them, he has not had many issues with long call light wait times.He confirmed that he could tell when he needed to go to the bathroom. He had no issues with the feeling of the urge to urinate. He indicated that he had issues with urination anyway, explaining that as he has gotten older, he has needed to get up more frequently during the night to use the bathroom.He was admitted to the facility about three weeks ago. He was staying at the facility for rehabilitation therapy after having back surgery. At home, he did not usually wear incontinence briefs, but he began wearing them while staying at the facility. When he first arrived, he could not get up on his own. After wetting the bed, he started sleeping in the recliner because he believed it would be easier for staff to help him get to the bathroom. He normally slept in a bed, not in a recliner. He only slept in the recliner for a few nights, then went back to sleeping in the bed.He stated, I'm someone that had back surgery, so I'm pretty limited in what I'm doing. I'm not just a room number. He stated he was not impressed with how the facility was managed, as he said that he was a manager for his whole career.He guessed that because the facility was short-staffed, there may have been miscommunication between departments. Since he had been progressing in his rehab stay, the therapy department was telling him that he needed to get up and walk more, but I can't do anything without their [the nursing staff's] help. They put the belt on, and I always have to have someone walk with me.He mentioned that just the day prior on 12/3/25, sometime in the afternoon, he put on his call light and asked one of the nursing aides to help him go for a walk. The aide told him she could not walk with him because she was the only staff member on the unit at that time. He could not remember her name.2. Interview and call light audit review on 12/4/25 at 12:38 p.m. with director of social services (DSS) M revealed that there were a couple of longer call light wait times on the morning of 11/19/25, the day after resident 72 admitted to the facility. He talked to her about the long call light wait times on 11/19/25. She asked him if he wanted to file a formal grievance, but he declined.She spoke with the evening nursing staff on 11/19/25 about being attentive to residents when they put on their call lights. She spoke with resident 72 the next day on 11/20/25 to see how overnight went with the call light wait times, and he confirmed that he did not have any issues that night.She explained that the hospital information provided to the facility on his admission included information about incontinence briefs while he was a patient there, and they continued to provide the briefs during his stay at the facility. The facility staff included that he wore incontinence briefs on his initial 48-hour care plan.SSD M confirmed that resident 72 spoke to him about the embarrassment he felt when he was incontinent, and that they wanted to treat each resident with dignity. She said, it's a bummer. He did tell me about the embarrassment. I did not want him to feel like he was 'room number [XXX]. We want him to have a humanized experience.'3. Interview on 12/4/25 at 3:31 p.m. with director of nursing (DON) B revealed that when a resident presses their call light, the notification was sent to the facility phones that each nursing staff member carried with them during their shift. She indicated that a reasonable time for a resident to wait for a staff member to answer the call light was about five to ten minutes.She indicated that they were a little short staffed on 12/3/25, which was the date resident 72 said that a nurse aide told him that she could not take him for a walk because they were short-staffed.She explained that it's not our practice to say, 'sorry I can't do that right now because we're short.' If a staff member was unable to assist a resident when responding to a call light, she expected the staff to explain why and to tell the resident when they would return to help.4. Phone interview on 12/4/25 at 4:14 p.m. with unlicensed assistive personnel (UAP) L revealed she picked up a 2:00 p.m. shift on 12/3/25. She confirmed that she told resident 72 that she could not help him walk when he asked because I was the only one on the floor, and I had to count the cart, and they asked me to help bring people back from bingo. From 2:30 p.m. to 3:00 p.m., she was the only certified nursing assistant (CNA) on that resident's unit. She counted the medication cart because she was also a medication aide and administered medications to residents. She expressed feeling overwhelmed with the workload.5. Review of the nursing staff schedule from 12/3/25 confirmed that from 2:30 p.m. to 3:00 p.m., UAP L was the only aide scheduled for resident 72's unit. CNA C was scheduled to start her shift on that unit at 3:00 p.m., and CNA N was scheduled at 4:00 p.m.6. Review of resident 72's room call light log revealed that on 11/19/25, the bedside call light was triggered at 6:30 a.m. About 23 minutes passed until the alarm was cleared. The bedside call light was triggered again at 8:45 a.m. About 41 minutes passed until the alarm was cleared.7. Review of resident 72's electronic medical record revealed that he was admitted to the facility for a rehabilitation stay on 11/18/25 after having back surgery. His 11/18/25 admission Brief Interview for Mental Status (BIMS) score was 11, indicating he had mild cognitive impairment. His 12/4/25 BIMS score was 13, meaning he was cognitively intact.The 11/18/25 Clinical admission progress note indicated under the genitourinary (referring to the genital and urinary organs) section that Resident [is] continent of bladder. Urine [is] clear yellow. Denies urinary complaints. However, the Fall Risk Evaluation completed the same day indicated that Resident is ambulatory / incontinent.His current care plan indicated that he was dependent on staff assistance for toilet use and required Substantial/Max assist for transferring from surface to surface (such as from his bed to the toilet). Those interventions were created and revised on 11/20/25. Another intervention added on 11/20/25 read, Be sure [the] resident's call light is within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance.His wife signed the resident admission agreement on 11/18/25, indicating they received a copy of the resident's rights sheet that included details about a resident's right to dignity and respect.8. Review of the Family Sheets revealed there was a list of residents for each unit. The lists contained resident information such as their name, room number, diet order, incontinence products, code status, and any assistive devices. Resident 72 was noted to have Pull ups [incontinence briefs] under the PRODUCTS column. The Family Sheets were last updated on 12/2/25.9. Review of the provider's 3/18/24 Notice of Resident Rights and Responsibilities policy revealed the policy statement read, United Living Community shall inform the resident both orally and in writing of their rights as a resident, and the rules and regulations governing the resident's conduct and responsibilities during their stay.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (8 and 72) who had medications at their bedside were assessed for the ability to safely self-administer medications and had a physician's order to self-administer medications according to the provider's policy.Findings include: 1. Observation and interview on [DATE] at 10:10 a.m. with resident 8 in her room revealed she had a jar of Vick's VapoRub ointment on her overbed desk. She stated she was sick recently and she used the ointment to rub on her chest and under her nose to help her breathe.Review of resident 8's electronic medical record (EMR) revealed there was no physician's order for the use of the Vick's VapoRub. There was no evidence that a medication self-administration assessment had been completed to assess her competence and safety with using the medication by herself.Her [DATE] Brief Interview for Mental Status (BIMS) score was 15, meaning she was cognitively intact.Her diagnoses included weakness and rheumatoid arthritis (a disease where the body's immune system mistakenly attacks the joints, causing pain, swelling, and stiffness in the joints).2. Observation on [DATE] at 9:18 a.m. in resident 72's room revealed that there was a bottle of Systane eyedrops, a bottle of saline nasal spray, and a tube of Vaseline sitting on his overbed table. Resident 72's initials were written on the bottle of Systane eyedrops. There were no pharmacy labels on any of those medications.Interview on [DATE] at 8:14 a.m. with resident 72 revealed that his wife brought the nasal spray and eye drops in for him shortly after he was admitted to the facility on [DATE]. He confirmed the staff probably did not know that his wife brought those medications in for him. He kept those medications on his bedside table, so he had easy access to use them.Review of resident 72's EMR revealed that there were no physician's orders for the Systane eye drops or the saline nasal spray. He had an order for the Vaseline. There was no evidence that a medication self-administration assessment had been completed to assess his competence and safety with using those medications by himself. His [DATE] BIMS score was 13, meaning he was cognitively intact. His care plan did not include any information about medication self-administration.3. Interview on [DATE] at 1:08 p.m. with case manager G and registered nurse (RN) O revealed they were not aware of the Vick's VapoRub in resident 8's room. They confirmed there was no physician's order for resident 8 to have the Vick's VapoRub. They confirmed resident 8 had not been assessed to be able to use the ointment by herself. RN O indicated that due to resident 8's arthritis, she may have a hard time opening the jar.They were not aware of the Systane eyedrops and saline nasal spray in resident 72's room. They confirmed that resident 72 had a physician's order for the Vaseline ointment, but they were not sure if the ointment was considered a medication and required a self-administration assessment. Resident 72's Vaseline was ordered to be applied to his skin biopsy site every day and night shift until the site was healed. Resident 72 had not been assessed for medication self-administration for the saline nasal spray, Systane eye drops, or the Vaseline.They expected the nursing staff to pay attention to what residents were keeping at their bedsides. If someone noticed a medication in a resident's room, they expected them to tell a nurse or a manager for proper follow-up.4. Interview on [DATE] at 3:31 p.m. with director of nursing B revealed that she was not aware of the Vick's VapoRub in resident 8's room, or the saline nasal spray, Vaseline, and Systane eye drops in resident 72's room. She guessed that the resident's family members brought those medications in for them. She said, I try to discourage family from bringing medications in from home. If a resident's family did bring medications from home, the nurse would request an order from the resident's physician, request a label from the pharmacy, and assess the resident for safe medication self-administration before letting the resident store the medication in their room.5. Review of the provider's [DATE] Medication Administration and Destruction policy revealed the policy statement read, The purpose of this policy is to outline the guidelines for medication administration, management and destruction at United Living Community (ULC). Medications Received from Other Sources: .Each medication container shall be labeled with the resident's name, physician, physician assistant, or nurse practitioner's name, drug and strength, directions for use, and prescription date. Medication Brought from Home - Can be used:-If the drug container is labeled with the resident's name, physician, physician assistant, or nurse practitioner's name, drug and strength, directions for use, and prescription date.-If the drug container is not labeled with the above, the licensed nurse must administer the medication after verifying the medication with the original medication order.-Ordered by the attending physician, physician assistant, or nurse practitioner and, if prior to administration, is identified as the prescribed medication.-The medication name, dosage form, and strength have been verified by: .Residents may not keep medications on their person or in their room without a physician's, physician assistant, or nurse practitioner's order allowing self-administration. Self-Administration of Medication:-Residents may self-administer prescribed medications under the supervision of a licensed nurse.-A physician's order is required.-The resident must be able to demonstrate the administration of the medication and must be able to verbalize the drug name and strength and directions for use including the dose, route and time to be taken.-An evaluation and education will be documented every 90 days or upon any significant change regarding the resident's wish to self-administer from bedside or self-administer after setup will be documented.6. Review of the provider's [DATE] Self-Administration of Drugs policy revealed the policy statement read, Residents in our facility who wish to self-administer their medications may do so, if it is determined that they are capable of doing so by their physician. Policy Interpretation and Implementation:-1. As part of their overall evaluation, the practitioner will assess each resident's mental and physical abilities, to determine whether a resident is capable of self-administering medications.-2. If the practitioner determines that a resident cannot safely self-administer medications, the nursing staff will administer the resident's medications.-3. The staff or practitioner will ask resident who are identified as being able to self-administer medications whether they wish to do so.-4. The staff or practitioner will document if the resident is potentially capable of self-administering medications.-5. Staff shall identify and give to the Charge Nurse any medications found at the bedside of a resident who is not able to self-administer.-6. The facility will reorder medications for those who self-administer in the same manner as other medications.-7. Upon observation of a bedside medication that is expired, discontinued, or recalled, the staff will remove the medication and give it to the Charge Nurse to process.-8. Nursing staff is to record administration of medications on the medication administration record (MAR) appropriately.-9. The staff or practitioner will periodically (for example, during quarterly MDS reviews) reevaluate a resident's ability to continue to self-administer medications.

Based on South Dakota Department of Health (SD DOH), facility reported incident (FRI), interviews, and policy review, the provider failed to protect the resident's right to be free from neglect by certified nursing assistant (CNA) C who pivot transferred resident (28) causing her to have a fall without injuries. The resident was care planned for use of a stand lift with two staff assistance for all transfers.Findings include:1. Review of provider's SD DOH FRI dated 11/26/25 with attached care plan for resident 28, and disciplinary action for CNA C revealed:*The report was a FRI for suspicion of abuse or neglect.*Resident 28 had a fall on 11/24/25 at 6:03 p.m. in the facility.*Her Brief Interview for Mental Status (BIMS) score as of 11/26/25 was 99 meaning an incomplete or failed interview.*Resident 28's care plan indicated:-She needed physical staff assistance with guided limb placement and cueing using a stand aid (mechanical lift used to assist from a seated to a standing position).-To not leave the [resident 28] unattended for transfers and while she was in the bathroom.*CNA C did not follow resident 28's care plan or family sheet (a paper sheet for the unit that tells pertinent information for residents) to use the stand aid for a transfer. *Resident 28 was not injured during the fall on 11/24/25.*CNA C was given a written warning by registered nurse (RN) H on 11/26/25 for Resident fell due to the CNA neglectfully following the care plan, family sheet and care plan does state two [staff assistance] with stand prior to fall. 2. Interview on 12/3/25 at 3:40 p.m. with CNA D revealed:*She was working with CNA C on the memory care unit on 11/24/25 during the evening shift.*CNA C had not asked for assistance with transferring resident 28 from a stationary chair in the dining room area.*She returned to dining room area after assisting another resident and observed resident 28 on the floor and CNA C was standing next to her.*She had not observed the fall of resident 28.*Family sheets tell staff how residents are to be transferred and the type of lift to use if needed.*At the end of the staff's shift the family sheets were turned into director of nursing (DON) B. 3. Interviews on 12/3/25 at 3:49 p.m. and 4:52 p.m. with CNA C revealed:*She had worked for the provider for about two months.*She had returned to the dining room area after assisting an unidentified resident.*DA F had told her that resident 25 had assisted resident 28 from her wheelchair to the stationary chair in the dining room.*She had been assisting another resident in their room when the transfer occurred.*She had gone over and stand pivot transferred resident 28 from the stationary chair in the dining room area without a lift belt (a device placed around a person's waist used to hold onto during a transfer) back into her wheelchair.-When she pivot transferred the resident that evening resident 28's knees buckled, and CNA C lowered her to the floor.*She notified licensed practical nurse (LPN) E of that incident.*After LPN E assessed resident 28, LPN E and CNA C used a total lift (mechanical device that lifts the whole body) to assist resident 28 in her wheelchair.*The family sheets told staff how a resident was supposed to transfer and if a device such as a lift needed to be used during a transfer.*She thought the family sheet for resident 28 stated she was a two assist with stand lift for transfers.*Resident 28 had no injuries from the fall on 11/24/25.*She received a written warning disciplinary action after the incident occurred by RN H.*Based on her she was not supposed to operate mechanical lifts with the residents without other staff assistance.*She did not recall being trained and observed by another staff on the safe use of mechanical lifts. *She had asked DA F to come and stand by resident 28 during the pivot transfer in case something happened on 11/24/25. 4. Interview on 12/3/25 at 4:25 p.m. with DA F revealed:*On 11/24/25 she was training another dietary staff in the memory care unit.*She observed resident 25 pull resident 28 out of the wheelchair and had helped her stand up. *DA F went over by resident 28 and aided resident 28 to sit in a stationary chair in the dining room area.*She did not want to startle either of the residents as resident 28 was already in a standing position.*She returned to training the dietary staff after she assisted resident 28.*CNA C exited from a resident room and asked for DA F to help get resident 28 out of the stationary chair.*CNA C was already in the process of pulling and lifting resident 28 up from the chair with her hands on her waist.*DA F placed her hands above CNA C hands, resident 28 was already bent over and they lowered her to the floor.*She was hesitant to go help CNA C that day, but she did go over and help her.*CNA C had no transfer belt on resident 28.*She was unsure how residents were supposed to be transferred.*She had not completed any CNA training on how to transfer residents. 5. Interview on 12/4/25 at 10:15 a.m. with LPN E regarding resident 28's 11/24/25 incident revealed:*She had just come into work on 11/24/25 at 6:00 p.m. when she was told by a medication aide that CNA C had tried to pivot transfer resident 28 into her wheelchair.When she arrived to the memory care unit, resident 28 was sitting on the floor in the dining room.*She was unaware that DA F had been involved in the resident's transfer, DA F had left before LPN E arrived to the incident.*She was told by CNA C resident 25 had tried to pivot transfer resident 28 into the stationary chair.*Staff should have known how to transfer residents from the family sheets or the resident's care plan.*Case managers updated the family sheets every week.*She had assessed resident 28 for injuries after the incident and she had no injuries. 6. Interview on 12/4/25 at 10:28 a.m. with case manager G revealed:*Family sheets were updated with resident changes and new orders for residents and reviewed weekly.*Staff carry the family sheets the entire shift for documenting toileting, transfers and other pertinent care information for their shift.*Family sheets tell the staff how a resident is to be transferred and if a lift is to be used. 7. Interview on 12/4/25 at 2:03 p.m. with DON B revealed:*CNA C had not followed the care plan or family sheet for resident 28 to ensure a safe transfer on 11/24/25.*A written warning was completed for CNA C following the incident for that resident.*Education was provided during the above warning to CNA C. *LPN E had given CNA C education to follow care plan and that resident 28 required two staff members assistance with a stand lift for all transfers on 11/24/25.*Registered nurse (RN) H completes competencies on mechanical lifts use with staff upon hire. 8. Interview on 12/4/25 at 2:21 p.m. with RN H revealed:*CNA C had completed care plan education for residents at the time of her hire on 9/29/25.-That included the family sheets.*CNA C had competencies completed of her use of the stand lift on 9/29/25. *CNA C had completed education on the facilities of falls policy and procedures on 10/4/25.*Staff under [AGE] years old could not operate the mechanical lifts, but they could assist as a second staff member. *Care plans and family sheets tell staff how a resident is to be transferred.*CNA C had received a written warning from her that stated Resident fell d/t the CNA neglectfully following the care plan. Family sheet and care plan does state 2 with stand prior to fall. 9. Review of providers revised 3/3/25 Abuse, Neglect, Mistreatment and Misappropriation of Resident Property Policy revealed:*It is essential for facilities to prohibit and prevent abuse. Neglect, exploitation of residents, misappropriation of resident property, corporal punishment, and involuntary seclusion, including freedom from physical or chemical restraints not required to treat a resident's medical symptoms. The facility will have systems in place to encourage and support all residents, staff, families, visitors, volunteers and resident representatives in reporting any suspected acts of abuse, neglect, exploitation of residents, misappropriation of resident property, corporal punishment, and involuntary seclusion.*Neglect: the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress.-Neglect includes cases where the facility's indifference or disregard for resident care, comfort, or safety, results in or could have resulted in physical harm, pain, mental anguish, or emotional distress.-Neglect may be the result of a pattern of failures or may be the result of one or more failures involving one resident and one staff person.

Based on record review, interview, and policy review, the provider failed to ensure four of four sampled residents' (1, 4, 28, and 30) right to immunize against pneumococcal disease was maintained and followed in accordance with national standards of practice. Failure to offer vaccination placed residents at increased risk for pneumococcal disease.Findings include:1. Record review of resident 1's electronic medical record (EMR) revealed he last had a pneumococcal vaccine on 1/8/20. The documentation did not indicate what exact vaccine he was administered. He did not have a documented allergy to the pneumococcal vaccine. He did not have a documented signed refusal document for the pneumococcal vaccine. He was admitted to the facility on [DATE]. 2. Record review of resident 30's EMR revealed no documentation that the resident received or had been offered and declined a pneumococcal vaccine. He did not have a documented allergy to the pneumococcal vaccine. He did not have a documented signed refusal for the pneumococcal vaccine. He was admitted to the facility on [DATE]. 3. Record review of resident 28's EMR revealed no documentation that the resident received or had been offered and declined a pneumococcal vaccine. She did not have a documented allergy to the pneumococcal vaccine. She did not have a documented signed refusal for the pneumococcal vaccine. She was admitted on [DATE]. 4. Record review of resident 4's EMR revealed she had a pneumococcal vaccine on 5/5/2008 recorded as dose 1. She received Prevnar 13 (vaccine that protected against 13 types of bacteria) on 8/28/2017. She did not have a documented allergy to the pneumococcal vaccine. She did not have a documented signed refusal for the pneumococcal vaccine. She was admitted on [DATE]. 5. Interview on 12/4/25 at 2:52 p.m. with registered nurse (RN) H revealed she was the full-time infection preventionist (IP) at the facility. She indicated when a resident was admitted to the facility, the resident and their family member received a document called a Why note. The Why note provided information on the vaccinations that were offered by the facility and the importance as to why the resident should receive those vaccines such as the pneumococcal vaccine. She indicated that her procedure to monitor the residents' vaccinations were correlated with their scheduled medical provider appointments. She stated that some mid-level providers would not order resident immunizations, as there were some medical doctors who wanted to be the provider who placed those orders for the residents. She stated that she would look at the list of scheduled provider appointments and then look at the resident's immunizations that were documented in their EMR. She indicated she also utilized the South Dakota immunizations web site for verification of residents' vaccinations. She stated if she found that a resident was not up to date with their immunizations, she relayed that information to their medical provider so it could be addressed at the resident's appointment. She indicated that the pharmacist who monitored the resident's medications also helped monitor the resident's immunizations, such as the pneumococcal vaccination. She indicated that the facility found that the previous IP did not document correctly in the resident's EMR or on the South Dakota immunization website to specify what pneumococcal vaccine the residents received. She confirmed the above resident's pneumococcal vaccination records and documentation was a concern. She confirmed there should be documentation in the residents' EMR if the resident declined the vaccine. She confirmed the national standards for the different types of pneumococcal vaccinations and different recommendations based on vaccination and the resident's age, diagnoses, or any other factors. She stated the facility did not have a performance improvement project (PIP) in place but were aware of the problem. 6. Review of the provider's Resident Vaccination Policy dated 3/31/25 revealed: Policy Statement It is the policy of United Living Community (ULC) to follow the recommendations of the Centers from Disease Control and Prevent (CDC) and the Advisory Committee on Immunization Practices (ACIP) from resident vaccination unless medically contraindicated, resident is already immunized, or the resident declines after the provision of education on risks and benefits or through shared decision making with their medical provider. Procedure All new residents will be screened and offered vaccines for influenza, pneumococcal disease and COVID-19 unless specifically ordered otherwise by the Primary Provider on admission orders- CMS does not require physician orders for influenza, pneumococcal, and COVID-19 vaccinations.- Provider orders are required for other vaccinations. Consider obtaining standing orders for other vaccinations.- Every resident upon admission is screened using the criteria contained in each vaccine section below.- Education on the risks of each vaccine in the form of Vaccination Information Statements (VIS) statements will be offered prior to vaccination administration.- Licensed nursing staff performs the screening and vaccine administration. The resident or the resident's representative has the opportunity to refuse any immunization. Pneumococcal Immunization Program Each new resident will be assessed and identified for the need to receive pneumococcal vaccine using the CDC's Pneumococcal Vaccine Timing for Adults. May use CDC's PneumoRecs VaxAdvisor to assist with evaluating of a resident's pneumococcal status.

Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, interview, and record review, the provider failed to protect one of one sampled resident's (1) right to be free from potential neglect by two of three certified nursing assistants (CNAs) (E and J) who had neglected to assist resident 1 off the toilet in a reasonable amount of time, and did not inform the oncoming shift that the resident was still on the toilet, which resulted in the resident sitting on the toilet for at least two hours.Findings include: 1. Review of the provider's 7/28/25 submitted SD DOH FRI revealed that on 7/27/25 at around 1:30 p.m., CNA I had helped resident 1 onto the toilet using a stand-aid (a mechanical lift used to assist from a seated to a standing position) and then left to assist another resident. CNA I told CNAs E and J that resident 1 was on the toilet before he left the unit.Around 3:40 p.m., CNA C found resident 1 sleeping on the toilet and helped her off the toilet. Registered nurse (RN) H checked resident 1's skin, found some redness, and applied zinc ointment. The next day, DON B checked the resident's skin again and found no redness or bruising.CNAs E and J did not report that resident 1 was on the toilet during their shift change around 2:30 p.m. and did not check if the resident needed help. Both CNAs received disciplinary action and retraining.Resident 1 did not get hurt and showed no signs of pain. Resident 1's care plan was updated to include that staff were to check on her every five minutes while she was on the toilet. The critical event checklist and witness descriptions were completed, and resident 1's family was notified. Staff were re-educated on rounds and care plans. 2. Interview on 8/14/25 at 9:08 a.m. with CNA F revealed she was working on 7/27/25 when resident 1 was left on the toilet. She said that as part of the provider's investigation process, she was interviewed by the social worker about what happened that day and she confirmed her statement.She said that the provider changed how the CNAs were to perform their shift-to-shift report. Instead of completing report in the nurse's station, they were to walk with the oncoming shift to lay eyes on each resident to know their whereabouts and then give their report in the nurse's station. They had been doing that new process for a couple of weeks, and she thought it had been working well. 3. Interview on 8/14/25 at 10:52 a.m. with licensed practical nurse (LPN) G revealed that she was not present at the facility when resident 1 was left on the toilet, but she received a report about the event the next time she was scheduled to work. She explained the new expectation was for the direct care staff to complete walking rounds with the previous shift to lay eyes on each resident to know their whereabouts. 4. Interview on 8/14/25 at 11:03 a.m. with CNA D revealed that she was one of the CNAs who found resident 1 on the toilet at around 3:30 p.m. on 7/27/25. She explained that CNA C found resident 1 asleep on the toilet. CNA C asked CNA D for help to assist resident 1 off the toilet. Resident 1 did not show any signs or symptoms of distress or injury.She confirmed that during that shift-to-shift exchange, neither CNA E nor J had informed the oncoming CNAs (C and D) that resident 1 was on the toilet. They informed RN H about the incident, and she assessed the resident who found that the resident's bottom was reddened and applied some ointment. Since that incident, the nursing staff were expected to complete walking rounds during the shift-to-shift exchange to know where each resident was at. 5. The survey team attempted to contact CNA E for an interview by phone on 8/14/25 at 11:27 a.m. and left a voicemail. CNA E did not contact the survey team by the end of the survey on 8/14/25 at 4:35 p.m. 6. Phone interview on 8/14/25 at 11:29 a.m. with CNA J revealed that on 7/27/25, she and CNA E were assigned to resident 1's unit. CNA I was the float CNA (had shared assigned areas) for resident 1's unit and another unit. CNA I had taken resident 1 to the bathroom roughly after lunch. CNA I informed CNA J and CNA E about it, then left the unit. CNA J said, I didn't really think anything of it, as she thought that CNA E was assigned to resident 1. CNA J stated, I wasn't really doing her [resident 1's] cares that day, and explained that CNA E had been taking care of resident 1 that day. CNA J indicated that she assumed CNA E and CNA I had helped resident 1 off the toilet.After the incident, the management team investigated the incident and interviewed her. She confirmed that she signed a disciplinary action form.Since the incident, the nursing staff were expected to perform walking rounds with the previous shift to visualize each resident. The nurse managers had also been assigning each CNA residents to be primarily responsible for on the family sheets. The family sheets included groups of residents that included pertinent information to care for each resident, such as their diet order, and adaptive equipment they might require, how the resident transfers from surface to surface, and their code status. There were usually two CNAs per unit, and each CNA was assigned to care for half of the residents in their assigned unit. 7. The survey team attempted to contact CNA I for an interview by phone on 8/14/25 at 11:38 a.m. and left a voicemail. CNA I did not contact the survey team by the end of the survey on 8/14/25 at 4:35 p.m. 8. Interview on 8/14/25 at 3:33 p.m. with administrator A revealed that an investigation was initiated immediately after staff had discovered resident 1 on the toilet. RN H completed a full skin assessment and found redness on the resident's bottom and applied zinc ointment. The nursing team completed a skin assessment for resident 1 each day for three days after the incident to rule out a deep tissue injury.All staff involved were interviewed as part of their investigation. CNA E and J received disciplinary action as it was their responsibility to care for the resident. They deemed that CNA I did everything he was supposed to do. He was the float CNA between two units and informed CNAs E and J that resident 1 was on the toilet before he left to go to the other unit. At that point, it was CNA E and J's responsibility to assist resident 1 off the toilet. As a result of the incident, nursing staff were expected to complete a walkthrough with the oncoming shift before giving a shift-to-shift report. That way, both shifts would see each resident to ensure their safety. 9. Interview on 8/14/25 at 3:57 p.m. with director of nursing (DON) B revealed that with the new expectations for the shift-to-shift reporting, she had been coming in early to inform the overnight shift staff of the new procedure. The new expectations were also included in the monthly all-staff meetings that occurred at the end of each month. They recorded those meetings and required those not in attendance to watch the video before their next working shift to ensure that each staff member was informed of the new expectations.She had been walking with the staff during their shift-to-shift exchange since the meeting to ensure that staff understood the new process. She came in early to observe the night staffs' reporting to the day shift and provided re-education to those who needed it. Staff had given her positive feedback about the new process. 10. Review of resident 1's electronic medical record revealed no documented evidence of skin injury or change in behaviors after the incident. Her weekly skin assessment completed on 8/2/25 indicated her skin was intact.Resident 1's quarterly Minimum Data Set assessment, submitted on 5/7/25, indicated the staff were unable to complete the Brief Interview for Mental Status assessment, and that resident 1 was rarely/never understood. The Staff Assessment for Mental Status section was completed and indicated that resident 1 was severely impaired when it came to making decisions regarding tasks of daily life, meaning that resident 1 never/rarely made decisions.Her care plan was updated following the incident to indicate that she should be checked on every five minutes while in the bathroom. 11. No further documentation was provided to support the other residents were checked to ensure they had not been left on the toilet for a prolonged period at the time of the incident, or that ongoing audits were completed to ensure staff understanding of resident safety and the education provided.

Based on the South Dakota Department of Health (SD DOH) complaint intake review, interview, observation, record review, and policy review, the provider failed to communicate with staff and implement fall prevention interventions, which potentially contributed to at least six falls (four of which resulted in injuries) from 2/1/25 to 7/6/25 for one of two sampled residents (1).Findings include: 1. Review of the SD DOH complaint intake received on 4/7/25 revealed:*An anonymous community member called to express their concerns about resident falls at the facility.*They specifically mentioned resident 1's falls which had resulted in issues.-They did not explain what those issues were. 2. Review of resident 1's electronic medical record (EMR) revealed:*Her 6/10/25 Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated had severe cognitive impairment.*Her diagnoses included Parkinson's disease, dementia, anxiety, muscle weakness, repeated falls, hypertension, chronic pain, and wandering.-Parkinson's disease affects brain cells, causing movement and balance problems.-Dementia causes memory loss and confusion, affecting daily life activities.-Anxiety makes a person feel worried or scared about things often.-Muscle weakness means a person's muscles are too weak to work well.-Repeated falls means falling often without a clear reason.-Hypertension is high blood pressure.-Chronic pain means the person experiences long-lasting pain that does not go away easily.-Wandering is when a person becomes lost or moves around without purpose.*She fell on 2/1/25 in the dining room when staff had briefly left her alone.*She fell on 2/8/25 in the dining room and sustained a tiny skin tear on her left hand.*She fell on 2/17/25 in the dining room and sustained a bump to the side of her head.*She had fallen on 4/1/25 at around 7:13 p.m. in the hallway and was found lying face down and sustained a laceration (cut or torn skin) on her cheek.-She went to the emergency room for evaluation.-Per the 4/1/25 fall report, staff were to assist her with using the toilet her every two hours. The last time she was assisted to the bathroom was at 4:30 p.m., which was 2 hours and 43 minutes before fall. Staff were to also monitor her closely when she was out of her room.*She fell in her bathroom on 6/22/25 after a CNA left her alone to grab supplies. As the CNA was re-entering the bathroom, resident 1 attempted to stand up and fell.*She fell on 7/6/25 in her bathroom after a CNA left her alone to grab supplies.-Per her care plan, she was not supposed to be left alone.-She sustained a bump to the back of her head and a skin tear to her right elbow that required Steri-Strips [adhesive strips used to close a wound]. 3. Interview on 7/9/25 at 10:13 a.m. with certified nursing assistance (CNA) N revealed:*Resident 1 had fallen before, but she could not remember if she had fallen recently.*A few months prior, resident 1 had fallen and received a bruise to her face.*The care plan (a personalized plan that addresses a resident's care needs, goals, and interventions) binder was not up to date, as it contained care plans for residents who had since passed away or moved to other halls.*Sometimes there were pocket care plans (a document that identifies residents' care needs and interventions) inside the resident's closet or cabinet in their rooms.*She indicated the lead CNAs would help with updating the resident pocket care plans. 4. Observation on 7/9/25 at 10:42 a.m. of resident 1's room revealed:*There was a sign on the outside of the bathroom door and above the toilet that stated, Please do not leave me unattended while I am using the bathroom.*There was no pocket care plan inside her closet or cabinet doors. 5. Interview on 7/9/25 at 3:00 p.m. with CNA I revealed:*Resident 1 had a diagnosis of Parkinson's disease.*A therapy wedge pillow block was placed by resident 1's right side when she was lying in bed to help her identify where the edge of the bed was. The wedge also helped her legs from flailing around due to her Parkinson's disease.*She stated that resident 1 was the biggest fall risk in the building.*Resident 1 was in a wheelchair for a while after she had fallen, as she was scared of falling. CNA I indicated that resident 1 was also scared to sit on the toilet.*Staff were supposed to always keep resident 1 within their eyesight and were to chart about her whereabouts every two hours in the EMR.-Resident 1 required 24/7 [24 hours a day, 7 days a week] supervision.*Resident 1 was not allowed to be in the bathroom by herself, and that staff were to remain in the bathroom with her. 6. Interview on 7/9/25 at 3:15 p.m. with unlicensed assistive personnel (UAP) G revealed:*Resident 1 was impulsive, would stand up from her chair quickly, and often tripped over her shoes.*Resident 1 was not included in the pocket care plan binder, but she was included on the family sheet located in a different binder.-The family sheets included a list of residents on that unit and their special care needs, such as their diet order, code status, what size of incontinence products to use, and how the resident transferred. 7. Review of the undated SUNSHINE [the secured memory care unit] FAMILY 1 sheet regarding resident 1 revealed:*She needed one staff member to assist her with transfers and required the use of a walker.* Special equipment included a VST (a motion-detection device that alerted staff of a resident's movement), and a WanderGuard (a wearable door-alarming device).* Hip pads under her pants was included in the miscellaneous section.*It also included her code status, diet order, the size of her incontinence products, and that she wore glasses.*No other safety interventions were included. 8. Interview on 7/9/25 at 3:39 p.m. with licensed practical nurse (LPN) E revealed:*Family sheets should have included the residents' fall prevention interventions.*Family sheets were updated by director of nursing (DON) B.*The CNAs wrote notes and updates on the family sheets and turned them in to DON B to update the family sheets. 9. Interview on 7/10/25 at 8:14 a.m. with LPN F revealed:*Resident 1 was very impulsive. She had a hard time understanding directions, as she would usually do the opposite of what was asked of her.-She frequently fidgeted and had tremors (involuntary shaking movements) due to her Parkinson's disease.*Staff tried to engage her with meaningful activities like folding laundry and coloring.*Resident 1 ambulated with staff using a four-wheeled walker.-Staff used a gait belt (a waist strap gripped as support for safe mobility and transfers) around her waist for stability and to remind her to slow down. *Resident 1 walked with a shuffled gait and normally wore tennis shoes. 10. Continued interview with LPN F and review of resident 1's care plan revealed fall-prevention interventions that included: * Follow signage, I will not be left alone in bathroom. That was created on 6/24/25 and revised on 7/7/25.* I will not be left alone in public areas. That was created on 6/24/25.* Ensure that [the] resident is wearing appropriate footwear nonskid shoes/socks when out of bed. That was created on 2/18/25 and revised on 3/10/25.* PT [physical therapy] and OT [occupational therapy] [to] evaluate and treat as ordered or PRN [as needed]. That was created on 11/18/22 and revised on 6/19/24.* Sign on walker to remind to use. That was created on 7/24/24.* I will not be put to bed before 1900 [7:00 p.m.]. That was created on 6/24/25.* 10/30/24: Poor gait balance awareness.* Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, book. Resident prefers: That was created on 12/11/22.-The care plan was not personalized to indicate what type of pleasant diversions the resident prefers.* AMBULATION: Resident['s] usual [performance] consists of supervision/touching assist [assistance] with walker; staff assists as needed. Resident may refuse her walker at times; staff assists as needed. That was created on 11/19/22 and revised on 7/9/25.* DRESSING: .Hip pads [extra padding to provide cushion] to hips per family request; staff assists as needed. That was created on 11/18/22 and revised on 7/9/25.*Her care plan included several restorative therapy interventions. LPN F indicated that resident 1 did not participate in the restorative therapy program. 11. Interview on 7/10/25 at 8:40 a.m. with CNA K revealed the family sheets included that resident 1 was supposed to use hip pads. There were no fall interventions for resident 1 on the family sheets. 12. Observation on 7/10/25 at 8:48 a.m. of resident 1 in the dining room revealed:*She was coloring a picture while seated at a dining room table.*Her feet and her head were tremoring.*She was wearing sneakers. *Resident 1's spouse, who also resided in the memory care unit, was sitting on resident 1's four-wheeled walker and propelling himself in the dining room.*There was no sign on her walker to remind resident 1 to use her walker. 13. Interview on 7/10/25 at 8:58 a.m. with CNA J revealed that resident 1 had a restorative program but had not participated in it for a while, and that it stopped a few months ago after resident 1 fell. 14. Interview on 7/10/25 at 9:59 a.m. with physical therapy assistant H revealed that resident 1 had not been assessed by PT/OT since 6/19/24. 15. Interview on 7/10/25 at 10:12 a.m. with CNA J revealed:*She confirmed resident 1 did not have a sign on her walker to remind her to use it.*The pocket care plans in the care plan binder were not up to date.-The pocket care plans in the binder included several residents that were no longer residing on that unit and was missing seven current residents.*She would have expected to find the residents' fall interventions listed on the pocket care plans or family sheets.-She confirmed that the family sheets did not include resident 1's fall interventions.*She stated that she usually would not look in the provider's EMR for fall interventions.*CNA J was only able to pull up and view the first page of resident 1's 28-page care plan in the EMR. 16. Interview on 7/10/25 at 12:54 p.m. with case managers C and D revealed:*Resident 1 was very impulsive, and did not always voice her needs or wants.*Resident 1 spent a lot of time in the common areas and staff tried to always be present in those areas.*Resident 1's walker was supposed to have been kept within reach with the brakes on.*Resident 1's gait was shuffled, and she tripped over her feet, so they tried to always have someone near her.-Her care plan included interventions such as I will not be left alone in bathroom and I will not be left alone in public areas.*Case manager C was not aware that resident 1 used a blue wedge for positioning and expected that to have been included on the resident's care plan.*She indicated that a lot of people are responsible for updating the care plan.*Both case managers C and D were new to their positions, and they were learning what to include on the residents' care plans.*The facility transitioned to using the family sheets in March 2025 rather than the pocket care plans. -Several people were responsible for updating the family sheets, including the DON, the case managers, and the lead CNAs.*They were not sure what the expectation was for CNAs to have access to the residents' care plans. 17. Interview on 7/10/25 at 2:05 p.m. with DON B revealed:*Resident 1 had a decline in her cognition with her dementia.*She confirmed the resident's sign to remind her to use her walker was not on her walker.*Pocket care plans were no longer to be used. Staff were to use the family sheets for resident care information.-Family sheets were to be updated when a new resident was admitted , and as needed with pertinent resident care information.*CNAs could not access the resident care plans in the EMR.-CNAs were to use the family sheets to understand how to care for the residents.*They also utilized shift-to-shift report to update staff on new resident information.*The family sheets included resident care information, such as the resident's diet, how they ambulate, how they transfer, if they wear hearing aids or dentures, their code status, what they prefer in their room, and if they were on enhanced barrier precautions.*She hung a sign on resident 1's bathroom door on 7/7/25, after the resident was left alone in the bathroom again and fell, to remind staff that resident 1 should not be left alone while in the bathroom. 18. Review of the providers 4/11/24 Falls and Fall Risk, Managing policy revealed:* Definition*.Fall Risk Factors-1. Environmental -a. wet floors -b. poor lighting .f. footwear that is unsafe or absent.-2. Resident conditions that may contribute to the risk of falls include: -a. fever -.d. pain -e. lower extremity weakness -.k. incontinence-3. Medical factors that contribute to the risk of falls include: -.e. balance and gait disorders; etc.* Resident-Centered Approaches to Managing Falls and Fall Risk-1. The staff, with the input of the attending physician, will implement a resident-centered fall prevention plan to reduce the specific risk factor(s) of falls for each resident at risk or with a history of falls.-2. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.-3. Examples of initial approaches might include exercise and balance training, a rearrangement of room furniture, improving footwear, changing the lighting, etc.-.6. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified and unavoidable.-7. In conjunction with the attending physician, staff will identify and implement relevant interventions (e.g., hip padding or treatment of osteoporosis, as applicable) to try to minimize serious consequences of falling.-8. Position-change alarms will not be used as the primary or sole intervention to prevent falls, but rather will be used to assist the staff in identifying patterns and routines of the resident. The use of alarms will be monitored for efficacy and staff will respond to alarms in a timely manner.* Monitoring Subsequent Falls and Fall Risk-1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling.-2. If interventions have been successful in preventing falls, staff will continue the interventions.-3. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified.-4. The staff and/or physician will document the basis for conclusion that specific irreversible risk factors exist that continue to present a risk for falling or injury due to falls. Review of the providers 4/11/24 Care Planning-Interdisciplinary Team policy revealed:* Policy Statement: Our facility's care planning/interdisciplinary team is responsible for the development of an individualized comprehensive care plan for each resident.* Policy Interpretation and Implementation-.2. The care plan is based on the resident's comprehensive assessment and is developed by a care planning/interdisciplinary team which includes, but is not necessarily limited to the following personnel:--a. The residents' attending physician;--b. The registered nurse who has responsibility for the resident;--.f. Therapists (speech, occupational, recreational, etc.), as applicable;--.h. The director of nursing (as applicable);--i. The charge nurse responsible for the resident's care;--j. Nursing assistants responsible for the resident's care.

Based on the South Dakota Department of Health (SD DOH) complaint intake review, record review, interview, and policy review, the provider failed to adequately monitor for neurological changes and follow the provider's falls protocol for two of three sampled residents (1 and 2) after they had fallen.Findings include:1. Review of the SD DOH complaint intake received on 4/7/25 revealed:*An anonymous community member called to express their concerns about resident falls at the facility.*Resident 1's falls, which had resulted in issues, was specifically mentioned with no explanation of what those issues were. 2. Review of resident 1's electronic medical record (EMR) revealed:*Her 6/10/25 Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment.*Her diagnoses included Parkinson's Disease, dementia, anxiety, muscle weakness, repeated falls, hypertension, chronic pain, and wandering.-Parkinson's Disease affects brain cells, causing movement and balance problems.-Dementia causes memory loss and confusion, affecting daily life activities.-Anxiety makes a person feel worried or scared about things often.-Muscle weakness means a person's muscles are too weak to work well.-Repeated falls means falling often without a clear reason.-Hypertension is high blood pressure.-Chronic pain means the person experiences long-lasting pain that does not go away easily.-Wandering is when a person becomes lost or moves around without purpose.*Her care plan interventions included:-She needed the assistance of one staff member for transfers and supervision/touching assistance with her walker, staff assisted her as needed, and used a wheelchair as needed.-She refused to use her walker at times.*She fell, unwitnessed, on 1/25/25.-Her neurological evaluation (an assessment of nerve function, reflexes, coordination, motor skills, sensation, reflexes, and mental status) (neuro eval) was not fully completed.--Staff failed to assess her level of consciousness (LOC), pupil response, motor functions, pain, and temperature at 5:30 p.m. Staff also did not assess her LOC, pupil response, motor function, and pain response at 6:30 p.m. *She fell, unwitnessed, on 1/28/25.-Her neuro eval was not fully completed.--Staff failed to assess her pupil response, motor function, pain response, and vital signs at 5:55 p.m. A note stated, getting ready for bed/BR [bathroom]. Between 6:10 p.m. and 8:25 p.m. her LOC, pupil response, motor functions, and pain response was not completed. At 9:25 p.m. and 10:25 p.m. her LOC, pupil response, motor functions, and pain response were not completed, and the nurse did not initial the assessments.-Her blood sugar was not measured as part of the falls protocol (assessment and follow-up processes after a resident falls).*She fell, unwitnessed, on 2/1/25.-Her neuro eval was not fully completed.--At 11:15 a.m. staff did not assess the pupil response, motor functions, pain response, or vital signs. A note stated, eating lunch-no issues noted.-Her blood sugar was not measured as part of the falls protocol.*She fell, unwitnessed, 2/17/25 and sustained a bump to the side of her head.-Her neuro evaluation was not fully completed.--The staff failed to assess the pupil response and obtain vital signs between 2:00 p.m. and 3:45 p.m. Staff did not assess her LOC, pupil response, motor functions, pain response, or vital signs at 7:00 p.m.-Her blood sugar was not measured as part of the falls protocol.*She fell, witnessed, on 3/18/25.-Her blood sugar was not measured as part of the falls protocol.*She fell, unwitnessed, on 4/1/25.-Her neuro evaluation was not fully completed.--The staff did not initial the completed assessments between 7:30 p.m. and 8:00 p.m. On 4/2/25 at 1:00 a.m., her LOC, pupil response, motor functions, and pain response were not assessed. At 2:00 a.m., her LOC, pupil response, motor functions, pain, and vital signs were not assessed. At 6:00 a.m. her LOC, pupil response, motor functions, and pain response were not assessed.-Her blood sugar was not measured as part of the falls protocol.*She fell, unwitnessed, on 5/25/25.-Her evaluation was not fully completed.--Staff failed to assess her LOC, pupil response, motor functions, and pain response from 6:50 p.m. to 9:20 p.m., and from 10:20 p.m. to 5:20 a.m. on 5/26/25.-Her blood sugar was not measured as part of the falls protocol.*She fell, witnessed, in her bathroom on 6/22/25.-Her blood sugar was not measured as part of the falls protocol.*She fell, unwitnessed, on 7/6/25 in her bathroom.-Her neurological evaluation was not fully completed.--Staff failed to initial the completed assessments at 9:05 a.m., 9:20 a.m., 12:50 p.m., 1:50 p.m., and 3:50 p.m. Staff failed to assess pain, vital signs, and initial the assessment at 11:20 a.m.-Her blood sugar was not measured as part of the falls protocol. 3. Review of resident 2's EMR revealed:*Her 6/18/25 BIMS assessment score was 3, which indicated she had severe cognitive impairment.*Her diagnoses included unspecified dementia, dysuria, chronic kidney disease stage 3, and type 2 diabetes mellitus.-Dysuria means pain with urination.-Chronic kidney disease stage 3 means a person's kidneys are working at half the capacity.-Type 2 diabetes mellitus means a person's blood sugar cannot be controlled well by insulin.*She fell, unwitnessed, on 2/8/25.-Her neuro eval was not fully completed.--Staff did not document the assessment of the resident's LOC, pupil response, motor functions, or pain response from 8:30 p.m. on 2/8/25 until 5:30 a.m. on 2/9/25. Staff also did not obtain a set of vitals at 10:30 p.m. and 11:30 p.m., noting that resident 2 was sleeping.-Her blood sugar was not measured as part of the falls protocol.*She fell, unwitnessed, on 2/28/25.-Her neuro eval for the unwitnessed fall on 2/28/25 was not fully completed.--At 10:55 p.m., 11:55 p.m., 12:55 a.m. on 3/1/25, and 1:55 a.m. on 3/1/25, her LOC, pupil response, motor functions, pain response, and vitals were not obtained, noting that she was sleeping.*She fell, witnessed, on 3/10/25 and sustained an injury to her face.-Her neuro eval after she fell on 3/10/25 was not fully completed after the resident returned from the emergency room.--The discharge paperwork from the emergency room indicated that she sustained a contusion (a bruise) to her face.-Her blood sugar was not measured as part of the falls protocol.*She fell while she was out with her family on 4/9/25.-There was no documented neuro eval, post-fall assessment, or communication with resident 2's primary care provider related to her having fallen on 4/9/25.*She fell, unwitnessed, on 5/24/25.-Her neuro eval for the unwitnessed fall on 5/24/25 was not fully completed.--From 11:45 p.m. on 5/24/25 to 6:15 a.m. on 5/25/25, her LOC, pupil response, and motor functions were not assessed.--Her vitals were not obtained at 3:15 a.m., 5:15 a.m., and 6:15 a.m. on 5/25/25.-Her blood sugar was not measured as part of the falls protocol. 4. Interview on 7/9/25 at 3:39 p.m. with licensed practical nurse (LPN) E revealed:*They started neuro checks on residents who had unwitnessed falls whether the resident hit their head or not.*Blood sugar levels were to be measured for each resident after they fell.*The neuro checks were to be performed every 15 minutes for one hour, every 30 minutes for two hours, every hour for four hours, (but after two checks during those four hours, it was at the nurse's discretion to discontinue the neuro checks or not), and then every four hours for four times, if not discontinued by the nurse before that.*She would only discontinue the neuro checks on a resident if it was really obvious that the resident had not hit their head, such as, if the resident said they did not hit their head and there were no bumps or bruises.-She would write the reasons why the neuro checks were discontinued on the resident's neuro check sheet.*The neuro check sheets were to be filled out completely.*She indicated that the nurses sometimes struggled to complete the neuro check sheets depending on the care needs of other residents. 5. Interview on 7/9/25 at 4:39 p.m. with the director of nursing (DON) B revealed:*After a resident fell, she expected the nurses to start neuro checks immediately, assess the resident for injuries, and obtain the resident's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate).*She expected neuro checks to be completed and documented every 15 minutes for one hour, every 30 minutes for two hours, every hour for four hours, and then every four hours for 16 hours.-She expected the neuro check sheets to be filled out completely.-If the resident refused to have their neuros checked or vitals taken, she expected the nurse to document those refusals on the neuro check sheet.-All fall reports and neuro check sheets were to be given to her for her to review, and then they were to be scanned into the resident's chart.*She confirmed the neuro check sheets for residents 1 and 2 were not filled out completely, as described above.*The falls policy was scheduled to have been reviewed, updated, and approved at their next quality assurance and performance improvement meeting, originally scheduled for 7/10/25 which had to be rescheduled due to the survey.-They had been using the falls protocol check sheet as their falls policy prior to the development of that new policy. 6. Review of the provider's undated FALLS, WHAT TO DO IN THE EVENT OF A FALL document revealed:* All Falls - Witnessed or Not Witnessed-.5. Orthostatic Vital Signs (first lying, before getting [the] resident up.) Chart if unable or inappropriate for the situation.-.7. Full set of vitals (blood pressure, pulse, respirations, temp, O2 sat).-8. Get [the resident's] blood sugar reading.-9. Assess the reason for [the] fall. Things that will need to be in the fall report:--a. Last time rounded [checking on residents' status and assistance needs]--b. Last time toileted [assisted with bathroom needs]--c. Change in medication--d. Medication[s] administered in the last 2 hours---i. PT/INR [prothrombin time/international normalized ratio]--e. What was on residents' feet i.e. socks, grip socks, shoes, barefoot--f. Environment [conditions]--g. Recent changes in resident condition--h. Diabetic conditions.* .Witnessed with NO head injury-may exclude neurological checks/flow sheet.* Neurological checks/Flow Sheet-All unwitnessed falls and witnessed falls with Head Injury.-Must be initiated for 24 hours and documented.-Time frame: every 15 min x 4 [four times], every 30 min x 4, every hour x 4, every 4 hours x 4.-Nurses will be permitted to vary the neuro assessment time frames slightly due to other resident needs or schedules.-Neuro checks may be discontinued at the nurse's discretion after two 60 min [minute] checks have been completed and the resident appears to be stable.-Follow up with [the] physician as appropriate or indicated.

Based on record review and interview, the provider failed to implement and effectively manage a nursing restorative therapy program for one of one sampled resident (1).Findings include: 1. Review of the SD DOH complaint intake received on 4/7/25 revealed:*An anonymous community member called to express their concerns about resident falls at the facility.*They specifically mentioned resident 1's falls, which had resulted in issues.-They did not explain what those issues were. 2. Review of resident 1's care plan revealed:*A focus area that read, I am in need of restorative therapy to maintain my functions and abilities. Created on 6/25/24.*Interventions that included restorative programming included:- NURSING REHAB/RESTORATIVE: Transfer Program #1 : Nu-step at level 5 for up to 15 minutes up to [6 to 7] days a week. Created on 6/25/24.- NURSING REHAB/RESTORATIVE: Transfer Program #1 : Nu-step at level 5 for upto 15 minutes up to [6 to 7] days a week. Goal to maintain ability [and] strength to remain free of fall with a major injury. Created on 2/25/24. Revised on 2/25/24.- NURSING REHAB/RESTORATIVE: PASSIVE ROM [range of motion] Program #1 Static stretchingwith 30 second holds to upper and lower extremities for 15 minutes up to [6 to 7] days aweek. Goal to prevent contractures [and] remain comfortable. Created on 2/25/24. Revised on 2/25/24.- Restorative program for balance and lower extremity strengthening. Created on 12/4/24. 3. Review of resident 1's electronic medical record (EMR) revealed:*One of the items on the tasks page for certified nursing assistants (CNAs) to chart on included Restorative Nursing-RESTORATIVE: Transfer Program #1 : Nu-step at level 5 for up to 15 minutes up to [6 to 7] days a week.-In the 30-day lookback report, the response was charted as Not Applicable on 7/6/25, Resident Not Available on 7/7/25, and 0 in the Amount column on 7/9/25.*Her diagnoses included chronic pain, low back pain, neurocognitive disorder with Lewy bodies, muscle weakness, unsteadiness on feet, anxiety disorder, dementia, and Parkinson's disease with dyskinesia (involuntary, uncontrolled muscle movements often caused by neurological disorders).-Chronic pain means the person experiences long-lasting pain that does not go away easily.-Neurocognitive disorder with Lewy bodies is a brain disorder causing memory loss, hallucinations, and movement problems.-Muscle weakness means a person's muscles are too weak to work well.-Unsteadiness on feet means trouble standing or walking without losing balance.-Anxiety disorder makes a person feel worried or scared about things often.-Dementia causes memory loss and confusion, affecting daily life activities. 4. Interview on 7/10/25 at 9:00 a.m. with CNA J revealed:*There were two restorative CNAs in the therapy department.*She believed that resident 1 was the only resident on the memory care unit that had a restorative program.-Resident 1 had not participated in the restorative therapy program for several months.*She explained that resident 1 had a fall with injury, and the restorative program would probably restart after she was more stabilized.-She did not explain when resident 1 had that fall, or what type of injury the resident sustained. 5. Interview on 7/10/25 at 9:59 a.m. with physical therapy assistant (PTA) H revealed:*She confirmed that resident 1 was not currently receiving skilled therapies.*The last time resident 1 was discharged from skilled therapies was on 6/19/24. 6. Interview on 7/10/25 at 11:37 a.m. with CNA L revealed:*She was one of the restorative CNAs and had been working at the facility for nine years.-She had been the only restorative CNA for the past three to four years.*A second restorative CNA was recently hired, and she helped train them on restorative programming.*She confirmed resident 1 had a restorative program in place.-Resident 1 would refuse to participate in the programming.*She confirmed she was supposed to chart that the resident had refused, but she had not been doing that.*She explained, when I was by myself, I focused on the other people who would be more willing to do the program.*It had been several months since resident 1 last participated in the restorative program.*She would often get pulled from the restorative therapy program as she was reassigned to fill in for other CNAs that called out.*There were about 25 residents with a custom restorative therapy program.-She could not handle that caseload by herself, which is why a second restorative aide was hired.*She confirmed that director of nursing (DON) B oversaw the restorative therapy program.*The restorative program got pushed to the side because she was getting pulled to work the nursing floor often. 7. Interview on 7/10/25 at 12:53 p.m. with case managers C and D revealed:*They denied that the restorative program was pushed to the side, explaining that it was hard to keep up with because they had one restorative aide conducting the program. They hired a second restorative aide to help with the caseload.*They confirmed that DON B managed the restorative therapy program.*They expected the restorative aides to chart each time a resident refused or participated in the restorative program. 8. Interview on 7/10/25 at 2:05 p.m. with DON B revealed:*She confirmed that resident 1 was supposed to have a restorative therapy program.*She had identified a problem with their restorative therapy program.-Restorative therapy was not being captured on the Minimum Data Set as it should have been.-The restorative program was not fully implemented as the case load was too large for one restorative aide to handle.-Resident refusals were not documented consistently.*They recently had a meeting between the nursing managers and the restorative aides to discuss improvements.*The physical and occupational therapists helped develop a resident's restorative therapy program.*She confirmed that CNA L has been getting pulled to the floor.*She confirmed that she took over managing the restorative therapy program in March 2025 since the previous program manager had left.*They were hoping the restorative therapy program would improve with the hiring of a second restorative aide. 9. Surveyors requested the restorative therapy program policy from administrator A on 7/10/25 at around 4:07 p.m. Administrator A explained that the program booklet was a large document and did not know which part to print. Surveyors asked if the program booklet could be sent via email and administrator A agreed. Surveyors requested for the program booklet to be emailed by 5:00 p.m. on 7/11/25. The program booklet was not received by the survey team by 5:00 p.m. on 7/11/25.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to protect one of two sampled resident (1) from physical and verbal abuse, and one of two sampled resident (2) from verbal abuse and involuntary seclusion by resident 3's spouse. Findings include: 1. Review of the SD DOH FRI submitted on 6/15/24 at 7:35 p.m. revealed: *Registered nurse (RN) D reported that certified nurse aide (CNA) C witnessed resident 3's spouse wheeling resident 1 down the hall. *Resident 1 was holding his hand up as if he may have been attempting to grab resident 3's spouse. *In response to resident 1's action, resident 3's spouse hit [resident 1] over the head with her right hand. *RN D immediately assessed resident 1 and when asked if resident 3's spouse hit him, his response was that resident 3's spouse tried to hit him, and I blocked her. *RN D's physical assessment of resident 1 did not reveal any redness, bruising, or raised areas on resident 1's head. *Resident 1 then stated that resident 3's spouse did hit him on his temple, but not very hard. *During interview with resident, he did not show any fear of the situation. *RN D notified the facility administrator. Administrator will be in the facility to discuss the situation with [resident 3's spouse]. *The report indicated that local law enforcement and the South Dakota Department of Human Services (DHS) were not notified. -Under the section Why or why not? for law enforcement notification, the report indicated, Administrator will be in facility in am [a.m.] -Under the section Why or why not? for DHS notification, the report indicated, Notified Ombudsman via email. 2. Observation on 6/24/24 at 5:15 p.m. in the South Ridge common area revealed: *The common area consisted of the dining room and television room. *Residents were eating supper at the time. *Resident 1 was sitting at a table near the window. *Residents 2 and 3 were sitting at the same table. *Resident 3's spouse was sitting in a recliner in the television room. *Interview at that time with resident 3's spouse revealed: -She came to the facility twice per day, every day. -She helped resident 3 with lunch and supper and to get ready for bed each night. 3. Interview on 6/24/24 at 5:32 p.m. with administrator A regarding the FRI revealed: *The incident happened on Saturday 6/15/24 around 6:30 p.m. *She was informed of the incident on 6/15/24 and instructed RN D to complete a state report. *Director of human resources (DHR) I and administrator A came to the facility on Sunday 6/16/24 and met with resident 3's spouse to discuss the incident. *Administrator A told resident 3's spouse that you can't move or touch other residents. *Resident 1 was interviewed several times on the evening of 6/15/24. -He was not a good historian. -One time he said that resident 3's spouse hit him, and another time he said that I blocked it. -He was not consistent with answering if he was hurt or not. *CNA C witnessed the incident and immediately informed RN D. *RN D immediately assessed resident 1 and found no injuries. *She confirmed that resident 3's spouse continued to assist resident 3 with his nighttime routine and left the building around 7:30 p.m. *Resident 3's spouse came back to the facility on [DATE] around 11:00 a.m. to meet with DHR I and administrator A. -During that conversation, resident 3's spouse admitted to moving resident 2 to his room and told him, You can come out when you can act like a grown man. -Resident 3's spouse did not admit to hitting resident 1. -They verbally made an agreement with administrator A to not touch other residents. *Resident 3's spouse had a pattern of when she visited. She came around 11:00 a.m., stayed through the lunch hour, left for a couple of hours in the afternoon, came back to the facility around 4:00 p.m., and stayed until resident 3 went to bed. -This pattern was an everyday occurrence. *Administrator A contacted the regional ombudsman regarding the incident. -The ombudsman came to the facility on [DATE] to act as an advocate for resident 1 since he did not have a power of attorney. 4. Interview on 6/24/24 at 6:25 p.m. with CNA E regarding the above incident revealed: *He confirmed he was working on the evening of 6/15/24. *He did not witness the incident. *There was a meeting about the incident at the nurse's station including CNA E, CNA C, and RN D. -During the meeting, CNA C said, [resident 3's spouse] slapped resident 1 on the back of his head for no reason. *He verbalized the correct procedure for reporting potential abuse or neglect. 5. Interview on 6/24/24 at 6:37 p.m. with resident 3's spouse regarding the above incident revealed: *When asked about the incident, resident 3's spouse said, That was resolved with [administrator A]. That's all I'm [going to] say. *Resident 3's spouse said, I've held up my end of the bargain. -The bargain was to not speak with resident 1, and to not push any other resident in their wheelchairs. *Surveyors then explained that law enforcement had been contacted by the provider to report the incident. *Resident 3's spouse said, I will not speak to him or her on these premises. 6. Interview on 6/24/24 at 6:45 p.m. with licensed practical nurse (LPN) J regarding the above incident revealed: *She was not at the facility at the time of the incident, but had been made aware of it by RN L. *She explained that resident 1 and resident 2 were known to [NAME] with each other, which was normal for those residents. *Regarding the bickering, she said that staff monitored them and separated them as needed. *When asked about resident 3's spouse, she said, I was surprised that it happened, but not surprised that it was [resident 3's spouse]. 7. Interview on 6/25/24 at 10:20 a.m. with resident 1 regarding the above incident revealed: *When asked how he would get help, he said, I would tell them. *He was unable to express how to use his call light. The call light was next to him within his line of sight. *When asked if he remembered the incident, he said, not really. *When asked about the care he received from staff, he said, I'm well taken care of. 8. Interview on 6/25/24 at 12:41 p.m. with dietary aide F regarding the above incident revealed: *She confirmed she was working on the evening of 6/15/24. *No one had interviewed her about the incident to obtain her formal statement. *She was in the South Ridge kitchenette doing dishes when CNA C came to her looking stressed and informed her of what happened. *The incident must have happened down the hallway because it did not happen in the living room or dining area. *She had not seen the events on 6/15/24 unfold but had seen a similar situation between resident 1 and resident 3's spouse before. -It happened within the previous week of 6/15/24. It may have happened on 6/13/24, but she could not remember. -Resident 2 was sitting in his normal spot in the dining room. -Resident 1 wheeled himself into the dining room. -They started bickering with each other. -She could not understand what they were arguing about. -Resident 3's spouse grabbed resident 1's wheelchair to take him out of the dining room. -She overheard resident 3's spouse call resident 1 incompetent and asshole. -Regarding that incident, she said, those two [residents 1 and 2] are defenseless against [resident 3's spouse]. -Dietary aide F reported what she overheard to both the CNA and the nurse on duty at that time. -She could not remember the names of the CNA or the nurse. -She was not sure what was done with her report. *Dietary aide F indicated that resident 3's spouse was known to fly off the handle with staff, and sometimes other residents. 9. Interview on 6/25/24 at 1:10 p.m. with RN D regarding the above incident revealed: *When asked about the relationship between residents 1 and 2, she said, they get into verbal confrontations, and we intervene, and redirect and they are okay. *She was not aware of resident 1 and resident 2 ever having a physical confrontation. *When asked about resident 3's spouse, she said that resident 3's spouse visited frequently. -She explained that resident 3's spouse would get frustrated when residents 1 and 2 were bickering. *She said that if staff were not around, resident 3's spouse would intervene between residents 1 and 2. 10. Interview on 6/25/24 at 1:32 p.m. with administrator A regarding the above incident revealed: *She was aware that the resident 3's spouse had been verbal with other residents before. -The social worker had been involved. -Resident 3's spouse was educated that she must get staff to move patients away from each other. *When asked if there had been any additional interventions to prevent resident 3's spouse from handling other patients, administrator A said that staff were paying closer attention to resident 3's spouse but there was no additional documentation. 11. Interview on 6/25/24 at 3:25 p.m. with CNA C regarding the above incident revealed: *He confirmed he was working on 6/15/24 and witnessed the incident. *Residents 1 and 2 did not like each other. -He said, they really can't hurt each other, they fight like siblings, and they just yell at each other. *He said that resident 3's spouse was there on most days and is usually in good spirits, but resident 2 definitely annoys [resident 3's spouse]. *He recalled that residents 1 and 2 were bickering with each other from across the dining area on the day of the incident. -When the meal was over, he went to the nurse's station for shift-to-shift report. *When he left the nurses station, he saw that resident 2's door was closed and assumed someone had already transferred him to his room for the night. *He then observed resident 1 making animal noises. -This was normal behavior for resident 1. *He saw resident 3's spouse transferring resident 1 down the hall in his wheelchair. -Resident 1 raised his right hand as if to grab at resident 3's spouse. -Resident 3's spouse whacked him on the side of his head with her right hand. *He was able to hear the slap and confirmed that resident 1 made a verbal response. -He was not sure if the response was because of pain or not. *He immediately reported what he had seen to RN D and LPN K. *He was not sure if resident 3's spouse was asked to leave the facility. *He said that a nurse told him that a couple weeks prior, resident 3's spouse had been reported for calling resident 1 useless and other unpleasant comments. -He could not remember which nurse reported this to him. 12. Interview on 6/25/24 at 3:50 p.m. with resident 3 regarding feelings of safety revealed: *He indicated that staff treat us very good. *He denied having issues with other residents. *He indicated the survey team could talk to my [spouse] when [they] get here, when asked about concerns with specific incidents. 13. Interview on 6/25/24 at 4:17 p.m. with LPN K regarding the above incident revealed: *She was working 6/15/24 when the incident happened, but she did not witness the incident. *She was aware of the relationship between residents 1 and 2. -She said that resident 1 thinks it's funny, he pushes resident 2's buttons. *She said that staff were aware of their arguing and kept them separated. *She noted that resident 3's spouse was there every day. She is very dedicated. She does a good job with resident 3's care. *When asked if she knew of any other incidents between other residents and resident 3's spouse, she said that last year, there was a resident with dementia, and she snapped at him, nothing over the top. -See F610, finding 16. 14. Interview on 6/25/24 at 4:53 p.m. with director of social services G regarding the above incident revealed: *Regarding the relationship between residents 1 and 2, she said, they periodically [NAME], staff usually intervene, and they are easy to redirect. *She said that there had never been physical aggression between them. *When asked if there had ever been a discussion about moving them to separate units, she revealed that resident 2 was recently moved to a room in a different hallway from resident 1. -She said that this has been helpful because they do not always see each other when they come out of their rooms. -Regarding moving one of them to a different unit, she said, you hate to uproot. *She said that resident 3's spouse is a consistent person in the building, visiting multiple times a day. *She was not aware of any previous physical aggression from resident 3's spouse. I've never seen that side of her. 15. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the above incident revealed: *When asked if there were any other known incidents between resident 3's spouse and resident 1, she was not aware of a previous incident. *She reviewed resident progress notes and was not able to find any information about any other incidents between resident 3's spouse and resident 1. 16. Continued interview on 6/26/24 with administrator A regarding the above incident revealed: *The first step in the facility's investigation process when there was a complaint of potential abuse of a resident was to ensure resident safety. -RN D performed her assessment of resident 1 and notified administrator A. -RN D then had CNA C give a handwritten statement of what he had witnessed. -She asked RN D where resident 3's spouse was and was told that she was in the room with resident 3 helping him get ready for bed. -RN D completed the FRI that evening. -She said that she entered the facility at 8:00 a.m. the next morning and talked to resident 3's spouse, RN D, and the ombudsman. -She said that she asked the ombudsman if law enforcement needed to be notified, and the ombudsman did not tell her that it was required. -She said that resident 1 was asked if he wanted to call law enforcement regarding the incident and he did not. -When asked if there were any interviews of involved staff or residents and she said she had not. She felt that resident 3's spouse gave enough information about the incident, that there was no need to interview any other residents or staff. *She said that there had been increased education to staff regarding incident reporting. 17. Phone interview on 6/26/24 at 9:48 a.m. with RN D regarding the above incident revealed: *She was unaware of any other incidents in which resident 3's spouse was verbally aggressive with other residents. *She said that she did hear from RN L that resident 3's spouse had spoken to resident 3 in an unpleasant manner before. 18. Interview on 6/26/24 at 9:56 a.m. with RN M regarding the above incident revealed: *She was the case manager for the nursing home. *She revealed that resident 3's spouse was at the facility often. *She said that she was present for resident 3's senior psychological appointment in which resident 3's spouse voiced concerns that resident 3's roommate always has his TV volume very loud. -During the appointment, resident 3's spouse reported that [they] would turn down the volume and turn off the TV when the volume bothered resident 3. -She said that it was verbally reinforced that resident 3's roommate has rights and that resident 3's spouse must not control the TV belonging to resident 3's roommate. -[They] were not happy about this. *Resident 3's spouse said that if the volume is bothering resident 3, [they] would turn the TV off. 19. Interview on 6/26/24 at 10:21 a.m. with DHR I regarding the above incident revealed: *She stated that she was present for the meeting between administrator A and resident 3's spouse on 6/16,24. -She said that she was there to take notes on the conversation and was not an active participant. *Regarding the demeanor of resident 3's spouse, she said that resident 3's spouse did not want to be there. *She said that resident 3's spouse wanted to record the conversation and was given the opportunity to do so but did not record the conversation. *She said that resident 3's spouse then wanted to take written notes regarding the conversation and was given the opportunity to do so but did not take notes. *During the conversation, resident 3's spouse said that resident 1 had hit her. *When asked if resident 3's spouse had hit resident 1, she did not answer the questions and just shook her head. *Administrator A then told resident 3's spouse that she was not to move or touch other residents and not to talk to resident 1 going forward. *Resident 3's spouse then agreed to these terms as a verbal agreement. The agreement was not put in writing. 46453 20. Review of resident 1's electronic medical record revealed: *He was admitted on [DATE]. *His medical diagnoses included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, vascular dementia, moderate, with agitation, major depressive disorder, unspecified anxiety disorder. *His most recent Brief Interview for Mental Status (BIMS) score from 3/15/24 was a 13, which indicated he was cognitively intact. *An incident note from 6/15/24 at 7:02 p.m. read: -Staff reported to nursing during shift change that they had witnessed a visitor hit resident in the head when pushing him down the hall to his room. -This resident and another male resident had been verbally arguing with each other and the visitor had separated them and took resident down the hall to his room. -Per the staff member, the visitor did not know he was behind them when she was rolling resident to his room. -This writer did an interview with resident, and it is unclear other than the witnessed event as to what happened. -Writer asked resident what happened between him and the other male resident to start the conversation. -Resident initially would not answer, once writer explained to him it was ok to talk about that writer was trying to figure out the situation for them to both be safe. -Resident stated he and the other 'guy' were cussing at each other. -He denies each other having physical contact. -It is not uncommon for the two residents to argue at each other; however, staff do monitor as they do have a history with each other. -This writer did ask if the visitor had taken him to his room and he stated yes. -Writer asked resident if the visitor had hit him and he originally stated, 'She tried to,' I asked resident what he did and he stated, 'I blocked her.' -Later in the conversation resident did state the [visitor] hit him and when asked how hard [the visitor] hit him he stated, 'not very hard.' -Writer asked resident where the [visitor] hit him at, and he pointed to the left side of his temple. -An assessment was completed head to toe and no redness is noted, no bruising is noted, and no raised area is noted. -Writer assured resident that we are here to ensure he is safe and that we would monitor and keep all safe in the facility. -Resident when asked if he would like to press charges on the [visitor], he made the comment 'I want to make them pay, they took all my money I had saved up.' -Writer attempted to notify [resident's] daughter to notify her of the situation, however, when calling a recording comes across 'the person you are calling cannot take calls at this time, the number you have dialed is not answering, please try later.' -Administrator was notified of the situation and will be here tomorrow while the visitor is in the facility to take care of the situation. *A follow-up health status note entered on 6/16/24 at 1:10 a.m. read: -Resident has been monitored frequently this shift for any s/s [signs or symptoms] of distress related to recent incident early in the shift. Resident has been resting in bed with eyes closed. Has not shown any distress this part of the shift. *A follow-up health status note entered on 6/16/24 at 12:15 p.m. read: -Resident denies having any pain. Transfers per usual. Alert and out for meals. No bruising noted. Denies having any pain. *A social work note entered on 6/18/24 at 3:49 p.m. read: -[This] writer met with resident to follow up on recent incident involving another resident's family member hitting him on the head. -Writer and resident visited about this incident. -Resident initially did not recall the incident, however, was able to briefly state that he remembers 'that [person] that pushed me back to my room.' -Writer asked resident if he is fearful of this person and he said 'no.' -This writer asked resident if he feels safe at [facility] and he stated 'yes.' -Will continue to check in with resident. *There were no other follow-up notes regarding the incident between resident 1 and resident 3's spouse. 21. Review of CNA C's handwritten statement revealed: *[Resident 1] and [resident 2] altercation led to [resident 3's spouse] wheeling [resident 1] back to his room. *While doing so, [resident 1] was holding up his right hand possibly trying to [grab] her. *In response, [resident 3's spouse] hit [resident 1] over the head with her right hand. *It was hard enough to be clearly heard 20 feet back and led to a vocalization of pain from [resident 1]. *[Resident 3's spouse] appeared to be angry about [resident 1] and [resident 2's] altercation. 22. Review of staff schedules from the evening of 6/15/24 on the South Ridge unit revealed the following employees were on-site: *CNA C from 2:15 p.m. to 10:45 p.m. *CNA E from 2:15 p.m. to 9:00 p.m. *LPN K from 6:00 a.m. to 6:30 p.m. *RN D from 6:00 p.m. to 6:30 a.m. *Dietary aide F from 4:30 p.m. to 7:30 p.m. 23. Review of resident 2's electronic medical record revealed: *He was admitted on [DATE]. *His medical diagnoses included: Hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side, unspecified anxiety disorder, major depressive disorder, vascular dementia. *His most recent BIMS score from 4/10/24 was 13, which indicated he was cognitively intact. *A social work progress note entered on 6/18/24 at 2:16 p.m. read: -[This] writer met with resident to follow up on incident of him being wheeled into his room by other resident's family member. -Resident was able to recall this incident, but did not feel threatened by the family member and stated he does not feel fearful of her. -This writer asked resident if he feels safe at [facility] and he stated 'yes.' *There was no indication that the resident's wife, his responsible party, was notified of the incident. 24. Review of resident 3's admission documentation revealed that his spouse signed the acknowledgement that they received a copy of the Residents' Rights document on 5/31/23. 25. Review of the provider's March 2017 Acknowledgement of Resident Rights and Responsibilities policy revealed: *Policy Statement: Each resident (or resident representative) will be provided and must acknowledge receipt of a written copy of resident rights and all rules, regulations, and policies governing the resident's conduct and responsibilities during his/her stay in the facility. *Policy Interpretation and Implementation: -1. Prior to or upon admission, a representative of the admitting office will give the resident, or the resident's representative, a written copy of resident rights and responsibilities, including facility rules, regulations, and policies governing the resident's conduct and responsibilities during his/her stay in the facility. -2. A representative from the business office or from social services will review the rights and responsibilities with the resident or the resident's representative. This review will occur as soon as possible within the first week of the individual's admission to the facility. -3. The resident, or the resident's substitute decision maker or representative, will be required to sign a statement acknowledging his/her receipt of a written copy of resident rights and responsibilities and that an oral review of such rights and responsibilities was conducted. -4. For individuals who have been formally declared incompetent or who cannot make decisions in accordance with this state's current laws, regulations, and guidelines, the resident's representative will be informed of the resident's rights and the representative will be entitled to act on the resident's behalf. -5. A representative of the administration or business office will inform residents orally and in writing of changes in federal or state regulations relative to resident rights or when changes in facility policy affects the rights or responsibilities of residents. Notices will be provided within 14 days of such change(s) taking effect. -6. Signed and dated copies of the resident's acknowledgement of rights and responsibilities and any subsequent revisions are maintained in the resident's medical record. 26. Review of an email communication sent by RN M following resident 3's psychological appointment on 3/28/24 revealed: *RN M provided education to resident 3's spouse on resident rights. -Resident 3 and his spouse had been expressing feelings of frustration because they had been continually turning down resident 3's roommate's television because it was too loud. -RN M wrote, Please remind her that this is a violation of [roommate's] rights. 27. Review of a Formal Grievance submitted by resident 3's spouse on 5/15/24 revealed: *Resident 3's spouse submitted a formal grievance to discuss the care that resident 3 was receiving. *Resident 3's spouse named a specific CNA in their grievance, stating that [I find] bruises on [resident 3] when [I come] to see [resident 3] in the morning. -Resident 3's spouse did not provide any specific situations, nor could she recall any. *Education was provided to [resident 3's spouse] regarding how [facility] investigates suspicious bruising and the importance of reporting these concerns when they happen so they can be properly investigated . Information provided regarding [facility's] zero tolerance for retaliation, specifically regarding incident reporting. *Education regarding policy on when/how police are called was given to [resident 3's spouse], specifically that [facility] would not call Police before attempting to contact [resident 3's spouse], with the only exception being imminent danger to staff or [resident 3]. *[Resident 3's spouse] expressed verbal understanding . *Education regarding Resident Rights provided at this time. *Action Plan: -1. Monthly Care Conferences will be held with [resident 3's spouse], [director of social services G] and [DON B] to address any concerns and follow up on the Grievance action plan. These meetings will begin the week of June 17th, 2024, at [resident 3's spouse's] request. - .4. Education regarding Resident Rights will be given to [facility] staff at the next all staff meeting on May 28th, 2024. 28. Review of the provider's undated Nursing Home Resident's Rights document revealed: *Residents of nursing homes have rights that are guaranteed by the federal Nursing Home Reform Law. The law requires nursing homes to promote and protect the rights of each resident and stresses individual dignity and self-determination. Many States also include residents' rights in state law or regulation. *Right to a Dignified Existence -Be treated with consideration, respect, and dignity, recognizing each resident's individuality. -Freedom from abuse, neglect, exploitation, and misappropriation of property . - .Quality of life in maintained or improved. -Exercise rights without interference, coercion, discrimination, or reprisal. -A homelike environment . -Equal access to quality care. 29. Review of the provider's February 2024 Abuse policy revealed: *Policy Statement: Each resident has the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. *Policy Explanation and Compliance Guidelines: -1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures. -2. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. -- .Instances of abuse of all residents, irrespective of any mental or physical condition, cause physical harm, pain, or mental anguish. --It includes verbal abuse .physical abuse, and mental abuse . --'Willful' means the individual deliberately, not that the individual must have intended to inflict injury or harm. -3. 'Verbal Abuse' means the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to resident or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. - .5. 'Physical Abuse' includes, but not limited to hitting, slapping, punching and kicking. It also includes controlling behavior through corporal punishment. -6. 'Mental Abuse' includes, but is not limited to, humiliation, harassment, threats of punishment or deprivation . - .8. 'Involuntary Seclusion' refers to the separation of a resident from other residents or from his/her room or confinement to his/her room against the resident's will or the will of the resident's legal representative . - .11. 'Mistreatment' means inappropriate treatment or exploitation of a resident. *The facility must: -1. Not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion. - .5. Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: -- .d. Provide education on what constitutes abuse, neglect and misappropriation of property. --e. React to all allegations or questions of abuse by residents, family members, employees or visitors. --f. Take appropriate actions when abuse, neglect or exploitation is suspected.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), investigation review, interview, and policy review, the provider failed to thoroughly investigate an allegation of physical abuse and verbal abuse experienced by one of two sampled residents (1), and involuntary seclusion and verbal abuse experienced by one of two sampled residents (2). Findings include: 1. Review of the SD DOH FRI submitted on 6/15/24 at 7:35 p.m. revealed: *Registered nurse (RN) D reported that certified nurse aide (CNA) C witnessed resident 3's spouse wheeling resident 1 down the hall. *Resident 1 was holding his hand up as if he may have been attempting to grab resident 3's spouse. *In response to resident 1's action, resident 3's spouse hit [resident 1] over the head with her right hand. *RN D immediately assessed resident 1 and when asked if resident 3's spouse hit him, his response was that resident 3's spouse tried to hit him, and I blocked her. *RN D's physical assessment did not reveal any redness, bruising, or raised areas on resident 1's head. *Resident 1 then stated that resident 3's spouse did hit him on his temple, but not very hard. *During interview with resident, he did not show any fear of the situation. *RN D notified facility administrator. Administrator will be in the facility to discuss the situation with [resident 3's spouse]. 2. Review of the provider's investigation documentation regarding the above incident revealed: *There was a handwritten statement from CNA C. *There was a typed summary of the conversation administrator A had with resident 3's spouse from the morning of 6/16/24. -The summary revealed that resident 3's spouse admitted to bringing resident 2 back to his room and told him he had to stay there 'until he could learn to be a grown man.' -There was no documentation to support that the provider investigated this allegation further. *There was no documentation to support that other staff had been interviewed about the incident. *There was no documentation to support that residents had been interviewed, other than residents 1 and 2. 3. Interview on 6/24/24 at 5:32 p.m. with administrator A regarding the above incident revealed: *The incident happened on Saturday 6/15/24 around 6:30 p.m. *She was informed of the incident on 6/15/24 and instructed RN D to complete a state report and obtain a written statement from CNA C. *Director of human resources (DHR) I and administrator A came to the facility on Sunday 6/16/24 and met with resident 3's spouse at around 11:00 a.m. to discuss the incident. -They made a verbal agreement with resident 3's spouse to not move or touch other residents. -During that conversation, resident 3's spouse admitted to moving resident 2 to his room and told him, You can come out when you can act like a grown man. -Resident 3's spouse did not admit to hitting resident 1. *Resident 1 was interviewed several times on the evening of 6/15/24. -He was not a good historian. -One time he said that resident 3's spouse hit him, and another time he said that I blocked it. -He was not consistent with answering if he was hurt or not. *Resident 3's spouse had a pattern when she visited. She came around 11:00 a.m., stayed through the lunch hour, left for a couple of hours in the afternoon, came back to the facility around 4:00 p.m., and stayed until resident 3 went to bed. -This pattern was an everyday occurrence. *Administrator A met with the manager's team on the morning of 6/17/24 to inform them of the situation. -She instructed the managers to make more of a presence throughout the facility during the times that resident 3's spouse was known to be in the building. -She confirmed there was no documentation to support the increased surveillance of resident 3's spouse. *Administrator A confirmed she had not informed staff of that specific incident or to keep a closer eye on resident 3's spouse. Rather, she explained that staff were reeducated on monitoring call lights more closely. -There was no documentation to support that. *The regional ombudsman was scheduled to present on resident rights at the provider's all-staff meeting on 6/25/24. 4. Interview on 6/24/24 at 6:25 p.m. with CNA E regarding the above incident revealed: *He confirmed he was working on the evening of 6/15/24. *He did not witness the incident. *There was a meeting about the incident at the nurse's station including CNA E, CNA C, and RN D. *He was not interviewed as part of a formal investigation into that incident. *He had not been re-educated or briefed about the incident or to keep an eye out for family members or visitors interacting with a resident who was not their person. 5. Interview on 6/24/24 at 6:39 p.m. with resident 3's spouse about the above incident revealed: *A verbal agreement was made between the administrator and resident 3's spouse to not speak with resident 1, and to not touch any resident except resident 3. *Resident 3's spouse declined any further interview with the survey team. 6. Interview on 6/25/24 at 10:20 a.m. with resident 1 regarding the above incident revealed he: *Denied having any issues with other residents, staff, or visitors. *Was unable to remember the incident. *Confirmed he felt safe in the facility and had not concerns regarding his safety. 7. Interview on 6/25/24 at 10:51 a.m. with resident 4 regarding safety revealed he: *Confirmed he felt safe in the facility. *Got along with the other residents. *Denied seeing any arguments between other residents and/or their visitors. 8. Interview on 6/25/24 at 11:00 a.m. with resident 5 regarding safety revealed she: *Had no concerns about her safety. *Denied seeing any altercations with other residents, family, or visitors. 9. Interview on 6/25/24 at 11:09 a.m. with resident 6 regarding safety revealed he: *Stuck to his room most of the time because people yell a lot. *Gave nondescript answers to questions. *Did not confirm nor deny worries of safety concerns. 10. Interview on 6/25/24 at 12:41 p.m. with dietary aide F about the above incident revealed: *She confirmed she was working on the evening of 6/15/24. *No one had interviewed her about the incident to obtain her formal statement. *She was in the South Ridge kitchenette doing dishes when CNA C came to her looking stressed and informed her of what happened. *She had not seen the events on 6/15/24 unfold but had seen a similar situation between resident 1 and resident 3's wife before. -It happened within the previous week on 6/15/24. It may have happened on 6/13/24, but she could not remember. -Resident 2 was sitting in his normal spot in the dining room. -Resident 1 wheeled himself into the dining room. -They started bickering at each other. -She could not understand what they were arguing about. -Resident 3's spouse grabbed resident 1's wheelchair to take him out of the dining room. -She overheard resident 3's spouse call resident 1 incompetent and asshole. -Dietary aide F reported what she overheard to both the CNA and the nurse on duty at that time. -She could not remember the names of the CNA or the nurse. *Dietary aide F indicated that resident 3's spouse was known to fly off the handle with staff, and sometimes other residents. 11. Interview on 6/25/24 at 1:10 p.m. with RN D regarding the above incident revealed: *As part of the investigation, she assessed resident 1 immediately. *She had CNA C write down his statement before his shift was over. *She reported the incident to the SD DOH. 12. Interview on 6/25/24 at 1:30 p.m. with administrator A revealed: *She confirmed resident 3's spouse has had inappropriate verbal altercations with residents before. -We talked about going to get a staff member if someone is bothering [them]. *They have had conversations previously with resident 3's spouse about resident rights. -She did not have documentation to support all their conversations with resident 3's spouse about her behavior. *She confirmed there was no visitor sign-in sheet. *She confirmed there was no documentation to support her and the management team's increased presence throughout the building to monitor resident 3's spouse. 13. Interview on 6/25/24 at 3:24 p.m. with CNA C regarding the above incident revealed: *After supper on the evening of 6/15/24, he was in the nurse's station to receive shift-to-shift report. *After report, he walked out into the hallway. -Resident 2's door was already closed, so he assumed resident 2 already went back to his room for the night. -He walked past the main hallway and witnessed resident 3's spouse wheeling resident 1 towards his room. -He saw resident 1 reaching upwards at resident 3's spouse with his right hand. -Resident 3's spouse whacked resident 1 across the head with their right hand. -He went directly to the nurse's station and reported what he saw to RN D and licensed practical nurse (LPN) L. -LPN K left after that because it was the end of her shift. *He confirmed that no one assessed resident 2. I didn't even think to check on him. *He confirmed no one asked resident 3's spouse to leave. They left at their usual time of 7:30 p.m. *He confirmed he gave a written statement to RN D, but no one else had interviewed him about the incident. 14. Interview on 6/25/24 at 2:52 p.m. with resident 3 regarding safety revealed he: *Had no concerns with other residents or staff. *Verbalized no complaints. 15. Interview on 6/25/24 at 4:06 p.m. with resident 2 regarding safety revealed he: *Confirmed that the staff treat him well and that he felt safe within the facility. *Could not remember any specific incident where a visitor said any unkind things to him. *Indicated there was one resident [resident 1] that annoyed him, but other than that he felt safe. 16. Interview on 6/25/24 at 4:18 p.m. with LPN K regarding the above incident revealed: *She confirmed she was working on 6/15/24, but she was on a different unit at the time of the incident. *The incident happened after 6:00 p.m. *She went to the South Ridge unit to give report to RN D for the night. *CNA C came into the nurse's station and informed them of what happened. *She recalled another time about a year ago where resident 3's spouse snapped at another resident. -That resident had dementia and talked non-stop. -She could not recall any more details regarding that incident. *No one had formally interviewed her as part of an investigation regarding the 6/15/24 incident. *She voiced no concerns regarding resident safety when resident 3's spouse was present. 17. Interview on 6/25/24 at 4:53 p.m. with director of social services G about the above incident revealed: *As part of the investigation into this incident, she interviewed only residents 1 and 2 regarding their feelings of safety. *No other residents were interviewed. 18. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the incident revealed: *She confirmed she was not aware of the previous situation with resident 1 and resident 3's spouse when dietary aide F overheard the spouse calling resident 1 incompetent and asshole. Continued interview on 6/26/24 at 9:15 a.m. with administrator A revealed: *She confirmed she did not talk to other staff again as part of the investigation. The only staff interviews conducted were with RN D and CNA C. -I felt I didn't need to do that because [resident 3's spouse] admitted to everything. *She confirmed they had a verbal agreement with resident 3's spouse to not touch other residents and to not speak with resident 1. -There was no written or signed agreement. *To further prevent something like that from happening again, she and the management team were making more of a presence on the floor when resident 3's spouse was there. -She confirmed again that they were making visual observations and not making any written accounts. Continued interview on 6/26/24 at 10:57 a.m. with administrator A revealed: *She confirmed the only residents interviewed as part of the investigation were residents 1 and 2. *Residents were asked about feelings of safety with their normal quarterly assessments. *When asked why they did not interview any other residents regarding feelings of safety or if anyone else had noticed strange interactions with visitors, she said, You guys already asked other residents and they said they feel safe. 19. Review of the provider's February 2024 Abuse policy revealed: *Policy Statement: Each resident has the right to be free from abuse, neglect . This includes but is not limited to freedom from corporal punishment, involuntary seclusion . Residents must not be subject to abuse by anyone, including, but not limited to; facility staff, other residents, consultants, contractors, volunteers, or staff of other agencies serving the resident, family members, legal guardians, friends, or other individuals. *Policy Explanation and Compliance Guidelines: -1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures. *The facility must: - .5. Prevention of Abuse, Neglect, and Exploitation - The facility will consider utilization of the following tips for prevention of abuse, neglect, and exploitation of residents: -- .e. React to all allegations or questions of abuse by residents, family members, employees or visitors. --f. Take appropriate actions when abuse, neglect or exploitation is suspected. - .6. Identification of Abuse, Neglect, and Exploitation - The facility will consider factors indicating possible abuse, neglect, and/or exploitation of residents, including, but not limited to, the following possible indicators: --a. Resident, staff, or family report of abuse -- .e. Verbal abuse of a resident overheard. --f. Physical abuse of a resident observed. - .7. Investigation of Alleged Abuse, Neglect and Exploitation. - When suspicion of abuse, neglect, or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. --Once the resident is cared for and initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: ---a. Interview the involved resident, if possible, and document all responses. If a resident is cognitively impaired, interview the resident several times to compare responses. ---b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. ---c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. ---d. Document the entire investigation chronologically. - .9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: -- .c. Initiate an investigation immediately. -- .e. Obtain witness statements, following appropriate policies. Suspend the accused employee pending completion of the investigation. Remove the employee from resident care areas immediately. -- .i. Document actions taken in steps above in the medical record. - .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -- .b. Have evidence that all alleged violations are thoroughly investigated. -- .d. Report the results of all investigation to the administrator or his or her designated representative and to the other official in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. *The policy did not indicate what actions should have been taken if the alleged abuse involved a family member or visitor.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to notify the required entities of an allegation of physical abuse by resident 3's spouse towards one of two sampled residents (1), and an allegation of verbal abuse and involuntary seclusion by resident 3's spouse towards one of two sampled residents (2). Findings include: 1. Review of the SD DOH FRI submitted on 6/15/24 at 7:35 p.m. revealed: *Registered nurse (RN) D reported that certified nurse aide (CNA) C witnessed resident 3's spouse wheeling resident 1 down the hall. *Resident 1 was holding his hand up as if he may have been attempting to grab resident 3's spouse. *In response to resident 1's action, resident 3's spouse hit [resident 1] over the head with her right hand. *RN D immediately assessed resident 1 and when asked if resident 3's spouse hit him, his response was that resident 3's spouse tried to hit him, and I blocked her. *RN D's physical assessment did not reveal any redness, bruising, or raised areas on resident 1's head. *Resident 1 then stated that resident 3's spouse did hit him on his temple, but not very hard. *During interview with resident, he did not show any fear of the situation. *RN D notified facility administrator. Administrator will be in the facility to discuss the situation with [resident 3's spouse]. *The report indicated that local law enforcement and the South Dakota Department of Human Services (DHS) were not notified. -Under the section Why or why not? for law enforcement notification, the report indicated, Administrator will be in facility in am [a.m.] -Under the section Why or why not? for DHS notification, the report indicated, Notified Ombudsman via email. 2. Interview on 6/24/24 at 5:32 p.m. with administrator A regarding the FRI revealed: *She had contacted both her advisor and the regional ombudsman and asked if they should contact the police. -Both her advisor and the ombudsman had said to not contact the police because resident 1 did not want to press charges. *She confirmed that no one had contacted law enforcement or DHS about the incident. 3. Interview on 6/24/24 at 6:15 p.m. with the SD DOH long term care nurse advisor about the above incident revealed she confirmed the provider was obligated to contact law enforcement. 4. Interview on 6/24/24 at 6:39 p.m. with resident 3's spouse about the above incident revealed: *A verbal agreement was made between the administrator and resident 3's spouse to not speak with resident 1, and to not touch any resident except resident 3. *Resident 3's spouse declined any further interview with the survey team. *Two police officers arrived at that time to gather statements. 5. Interview on 6/25/24 at 12:41 p.m. with dietary aide F about the above incident revealed: *She confirmed she was working on the evening of 6/15/24. *No one had interviewed her about the incident to obtain her formal account. *She had not seen the events on 6/15/24 unfold but had seen a similar situation between resident 1 and resident 3's wife before. -It happened within the previous week of 6/15/24. It may have happened on 6/13/24, but she could not remember. -Resident 2 was sitting in his normal spot in the dining room. -Resident 1 wheeled himself into the dining room. -They started bickering at each other. -She could not understand what they were arguing about. -Resident 3's spouse grabbed resident 1's wheelchair to take him out of the dining room. -She overheard resident 3's spouse call resident 1 incompetent and asshole. -Dietary aide F reported what she overheard to both the CNA and the nurse on duty at that time. -She could not remember the names of the CNA or the nurse. *Dietary aide F indicated that resident 3's spouse was known to fly off the handle with staff, and sometimes other residents. 6. Interview on 6/25/24 at 2:42 p.m. with the regional ombudsman revealed that calling the ombudsman did not fulfill the mandatory reporting requirements, as the ombudsman was not a mandatory reporter. 7. Interview on 6/25/24 at 5:24 p.m. with administrator A regarding the above incident revealed: *She was not aware of dietary aide F's account as explained in finding 5. *She was not aware that the ombudsman was not part of the required reporting network. *She stated again that the ombudsman recommended to not contact the police as resident 1 did not want to press charges against resident 3's spouse. 8. Review of the provider's investigation documentation revealed: *Administrator A, director of human resources I, and resident 3's spouse met at the facility on 6/16/24 at around 11:00 a.m. *Resident 3's spouse admitted to bringing resident 2 back to his room and told him he had to stay there 'until he could learn to be a grown man.' 9. Review of resident 2's electronic medical record revealed there was no documentation to support the resident's wife or his primary care provider had been notified about the incident between resident 2 and resident 3's spouse as explained in finding 8. 10. Review of the provider's February 2024 Abuse policy revealed: *Policy Explanation and Compliance Guidelines: *1. The Abuse coordinator in the facility is the Director of Nursing, Administrator, or facility appointed designee. Report allegations or suspected abuse, neglect, or exploitation immediately to: Administrator, Other Officials in accordance with State Law, State Survey and Certification agency through established procedures. * .9. Response and Reporting of Abuse, Neglect and Exploitation - Anyone in the facility can report suspected abuse to the abuse agency hotline. When abuse, neglect or exploitation is suspected, the Licensed Nurse should: - .d. Notify the attending physician, resident's family/legal representative and Medical Director - .f. Contact the State Agency and the local Ombudsman office to report the alleged abuse. -g. If a crime, or suspicion of a crime has occurred, notify the local law enforcement agency. *10. The facility must annually notify covered individuals' obligation to comply with the following reporting requirements: -a. Each covered individual shall report to the State Agency and one or more law enforcement entities for the political subdivision in which the facility is located any responsible [reasonable] suspicion of a crime against any individual who is a resident of or is receiving care from the facility. -b. Each covered, individual shall report immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury. * .13. In response to allegations of abuse, neglect, exploitation or mistreatment, the facility must: -a. Ensure that all alleged violations .are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve resident abuse or result in serious bodily injury .to the administrator of the facility and to other official (including the State Survey Agency and adult protected services where state law provides for jurisdiction in long-term care facilities) in accordance with State law. *The Administrator should follow up with government agencies, during business hours, to confirm the report was received, and to report the results of the investigation when final, as required by state agencies.

Based on observation, interview, and policy review the provider failed to ensure food items were appropriately labeled, stored, handled, prepared, and served in a safe and sanitary manner in one of one kitchen and one of four kitchenettes for the following: *One of one commercial refrigerator that contained food items that were not labeled, dated, or discarded by the use-by date, *One of one commercial freezer that contained food items that were not labeled or dated. *One of one kitchen and one of four kitchenettes that contained dry food items that were not labeled or dated. *Appropriate glove use and hand hygiene by cook G while preparing food. *Appropriate glove use and hand hygiene by dietary aide F and by unlicensed assistive personnel (UAP) H while handling food. Findings include: 1. Observation on [DATE] at 1:11 p.m. of the kitchen revealed: *A commercial refrigerator contained: -One container of pickles that was not covered or dated. -One jar of barbecue sauce that was opened and not dated. -One bottle of ranch dressing marked as opened on [DATE]. --There was no expiration date found. -A container labeled broccoli broth use by ,d+[DATE]. -A sliced onion in a plastic bag that was not labeled or dated. -A flour tortilla labeled use by [DATE]. -A package of deli pepper jack cheese labeled use by [DATE]. -A tub of palmetto cheese spread labeled use by date [DATE]. -Two heads of lettuce in a plastic bag that had browned in areas. -Several stacks of sliced cheese, wrapped in plastic wrap, one with what appeared to be a spot of mold, that were not labeled or dated. -Two apple pies on a tray covered with plastic that were not labeled or dated. *A commercial freezer contained: -At least 10 packages of opened frozen meat items that were not labeled or dated. *Two open bags of puffcorn that were not dated. *An open bag of shredded coconut labeled sell by date [DATE]. -There was no open or use-by date. *An open bag of cereal that was not labeled or dated. 2. Observation on [DATE] at 2:1p.m. in the 500-hall kitchenette revealed: *A package of what appeared to be French Toast in the freezer that was not labeled or dated. *A bottle of liquid that appeared to be pancake syrup that was not labeled or dated. *Three containers of dry cereal that were not labeled or dated *An open plastic bag of what appeared to be pancake mix dated ,d+[DATE]. 3. Observation and interview on [DATE] at 3:51 p.m. with cook G revealed he: *Wore gloves to place raw chicken on a pan, removed those gloves, seasoned the chicken- without washing his hands, and then put on a new pair of gloves. *Checked the temperature of the lasagna while wearing those gloves, removed those gloves, and without washing his hands put on a new pair of gloves and then touched the ready-to-eat garlic bread with those gloved hands. 4. Observation on [DATE] 10:38 a.m. with dietary aide F in the main kitchen revealed: *While wearing gloves, he opened the walk-in cooler door, took two containers from the cooler, and set them on the cart. *With those same gloved hands, he picked up a lid to a coffee pot, set it on the counter, filled it, picked up a lid, and screwed it on the coffee pot. *With those same glove hands he delivered the cart to the kitchenette on Morningview hallway and came back to the main kitchen. *He continued to move between the main kitchen and the Morningview kitchenette while he touched several surfaces and resident food items (silverware, BBQ sauce, straws, beverage cans and water glass rims) with those same gloved hands. *At 11:18 a.m. he removed those gloves, did not wash his hands and put on a new pair of gloves and again touched several surfaces and resident food items (utensils, buns, plates, and cupboards) while he served lunch. *He picked up a clipboard and documented resident meal intakes with those same gloves on. *At 11:50 a.m. he removed those gloves and did not wash his hands. 5. Interview on [DATE] at 11:52 a.m. with dietary aide F regarding glove use and handwashing revealed he stated: *Gloves are to be worn whenever handling food or beverages. *If he left the serving area and changed gloves, he would wash his hands before putting on the new gloves. 6. Observation on [DATE] at 11:18 a.m. with UAP H revealed: *She wore gloves while serving a resident meal plate in the 500-hall dining room, without changing those gloves she took a bottle of ketchup out of the refrigerator, then served the next plate while wearing those same gloves. *While wearing those same gloves she left the dining room and delivered a meal tray to resident room [ROOM NUMBER]. *She returned to the serving area, removed those gloves, did not wash her hands, put on a new pair of gloves and delivered a meal tray to resident room [ROOM NUMBER]. *She removed those gloves as she walked to the serving line, discarded them in the trash, did not wash her hands and put on a new pair of gloves. *She then stated, We don't have to, but I like to wear gloves when I serve food. 7. Interview on [DATE] at 9:00 a.m. dietary manager (DM) D regarding glove use, hand hygiene, and food storage, handling, preparation, and serving revealed: *Food items were labeled with a black marker that indicated an intake date. *The manufactured date was the date used for the expiration date. *Prepared or leftover food was to have been labeled with a sticker that identified the food, the date it was placed in the refrigerator, and the date it should have been discarded. *She would have expected expired food to have been thrown away. *Dry cereal, once removed from the box, should have been labeled with a sticker indicating what kind of cereal it was, and when it was to have been discarded. *She would have expected gloves to have been worn when touching ready-to-eat foods. *She stated gloves needed to be changed when moving on to a new task. *She would have expected staff to wash their hands when they arrived at work, before starting a task, before putting on gloves, after removing gloves, and when their hands were soiled. *Gloves were not to have been worn while delivering food to residents at the table or to their rooms. *Hand sanitizer should have been used in the dining room between each task. 8. Interview on [DATE] at 3:10 p.m. with registered dietitian E, by email, , regarding food handling, glove use, and hand hygiene revealed: *I expect that staff will use gloves whenever handling ready-to-eat foods that are not going to be cooked further. *They should be washing hands before putting [on] the gloves. *Hand washing needs to be done frequently and often between tasks and after breaks . *I expect dining room staff to wash [their] hands prior to serving. -I don't expect them to wear gloves when serving meals unless they are touching a ready to eat item like a roll or bun. Review of the provider's 2017 Food Receiving and Storage policy revealed: *Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). *All food stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Review of the provider's 2017 Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices policy revealed: *Employees must wash their hands: whenever entering or re-entering the kitchen; before coming into contact with any food surfaces; during food preparation, as often as necessary to remove soil and contamination and to prevent cross contamination when changing tasks . *The use of disposable gloves does not substitute for proper hand washing. Review of the provider's 2009 Personal Protective Equipment - Gloves policy revealed: *Wash your hands after removing gloves or use alcohol hand rinse if appropriate. 45683

Based on record review, interview, and policy review, the provider failed to provide bed-hold notices to the resident or resident's responsible party at the time of transfer to a hospital and ombudsman notification for four of four sampled residents (6, 4, 25 and 27). Findings include: 1. Review of resident 6's electronic medical record (EMR), revealed: *On 12/04/23, she had been transferred to the hospital at the request of her family representative due to her becoming shaky and she could not stand on her own. *There was no written notification to the resident or her responsible party regarding the Bed Hold policy, and no documented notification to the Ombudsman that resident 6 had been sent and admitted to the hospital. 32332 2. Review of resident 4's EMR revealed: *On 2/29/24 at 10:30 p.m. resident 4 fell outside the restroom by the nurses' station. *He reported back pain. *Emergency medical services (EMS) was called and he remained on the floor while the staff waited for the ambulance. *Resident 4 was taken to the hospital and remained there until he returned on 3/2/24. *There was no documentation the resident or his responsible party had received information about the bed-hold policy. 3. Review of resident 25's EMR revealed: *On 9/25/23 at 5:37 p.m. the hospital called to inform the nurse that resident 25 had a critical value blood glucose of 835. *Ecare (an online health service) called soon after with orders to send her to the emergency room . *A phone call was made to her husband who gave permission to send her to the hospital. *Resident 25 was transferred by ambulance to the hospital and remained there she returned on 9/29/23. *There was no documentation the resident or her responsible party had received information about the bed-hold policy. 49958 4. Review of resident 27's EMR revealed: *A health status progress note (PN) on 3/21/24 at 11:52 a.m. indicated the resident .transferred to the ER [emergency room ] for further evaluation. Resident left [facility name] at 1130 via ambulance. *A PN on 3/21/24 at 1152 a.m. indicated her son was notified of the resident's transfer to the ER. *A PN on 3/22/24 at 4:04 p.m. indicated she had returned to the facility. *A PN on 4/7/24 at 12:30 p.m. indicated her son . agree to transport patient to the hospital for evaluation. *A PN on 4/10/24 at 1:44 p.m. indicated she had returned to the facility. *There were no documentation the resident or her responsible party had received information about the bed-hold policy. 5. Interview on 5/23/24 at 10:22 a.m. with social service designee (SSD) C revealed: *The bed-hold information was located in the welcome book. *Residents signed an Admission Acknowledgement form, that acknowledged receipt of the Welcome Handbook upon admission. *She was not aware if a written form had been completed at the time of transfer. *She did not know it was her responsibility. 6. Interview on 5/23/24 at 10:52 a.m. with administrator A revealed: *She would have expected the nurse to notify the family verbally at the time of transfer and the social worker to follow up regarding the resident's return to the facility during a hospitalization . *A bed hold should have been completed at the time of transfer. *She stated, We are not completing a written bed-hold form. 7. Review of the provider's undated Holding Bed Space policy revealed: *Upon admission and when a resident is transferred for hospitalization or for therapeutic leave, a representative of the Social Services Department will provide information concerning our bed hold policy. *When emergency transfers are necessary, the facility will provide the resident or representative (sponsor) with information concerning our bed-hold policy. (Copy of Bed Hold Policy is mailed to resident or resident representative.)

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were revised to reflect the current needs for three of twenty-one sampled residents as follows: *Three of three sampled residents (6, 50, and 54) who had VirtuSense VSTAlert motion detection systems installed in their rooms. *One of one sampled resident (50) who had a side rail on her bed. Findings include: 1. Observation on 5/23/24 at 10:25 a.m. of resident 6's room revealed a VST motion sensor located on the far wall that had been directed at the residents' bed. 2. Review of resident 6's electronic medical record (EMR) revealed: *An order dated 05/17/24 indicated Resident may use VST monitor per order received on 5/3/24. *There was no documentation of the use of the VST monitor in the resident care plan. *There was no consent documentation for the use of the VST monitor. 49958 3. Observation on 5/20/24 at 2:27 p.m. of resident 50's room revealed: *A side rail on the left side of her bed. *A VST motion sensor located on the far wall that had been directed at the residents' bed. 4. Interview on 5/21/24 at 8:51 a.m. with an unidentified nurse revealed: *Resident 50 used the side rail to reposition herself. *The VST motion sensor alerted the nurses by phone when the resident attempted to get out of bed. 5. Review of resident 50's EMR revealed: *An order dated 12/28/23 indicated Facility has added a bed monitor to patient room. *A fall progress note (PN) dated 1/4/24 at 4:10 p.m. indicated the resident fell in her room. -Interventions added to care plan: use VST monitor. --This intervention had not been added to her care plan. *There was no documentation of the use of the side rail in her care plan. 6. Interview on 5/22/24 at 1:08 p.m. with director of nursing (DON) B revealed: *An order for the VST monitor for resident 50 was added by the Hospice physician on 1/3/24. -It had not been added to her medication administration record (MAR) or her care plan. --The family is aware however we just didn't document it. *She would have expected the VST monitoring to have been added to the MAR and the care plan, and the resident's or resident's representative's consent to have been obtained and documented. *She stated the side rail documentation for resident 50 had not been completed because the family wanted it so she could move in the bed. *She would have expected a quarterly side rail assessment for resident 50 to have been completed, a physician's order to have been obtained, and the side rail to have been added to her care plan. 7. Observation and interview on 5/22/24 at 12:46 p.m. with resident 54 while in her room revealed: *A VST motion sensor located on the far wall directed at her bed. -The sensor system announced resuming when the resident stepped near her bed. *The resident stated, who said that? -She indicated she did not know where the noise came from. 8. Review of resident 54's EMR revealed: *A PN dated 3/31/24 at 11:42 p.m. indicated The resident's VST alarm is not working tonight. *There was no documentation of the use of the VST monitor in her care plan. 9. Interview on 5/22/24 at 3:40 p.m. with administrator A revealed: *The VST system was used for fall prevention for residents at the highest risk of falls. *She confirmed a physician's order and the resident's representative's consent should have been obtained and the use of the VST monitoring system should have been added to the care plan. * They did not have a specific policy regarding the VST monitoring system. Review of the providers' 2016 Proper Use of Side Rails policy revealed, The use of side rails as an assistive device will be addressed in the resident care plan. Review of the providers' undated Care Plan Policy revealed: *The purpose of the care plan is to provide a centralized coordination of the services that will be provided to each resident, based on his or her individual needs, abilities, and preferences. *The care plan should address, but is not limited to the following: -Fall history and/or risk.

Based on observation, interview, and policy review, the provider failed to ensure: *Licensed practical nurse (LPN) O and certified nursing assistant (CNA) P had performed hand hygiene and glove use according to the provider's policy during a dressing change for sampled resident (164). *Registered nurse (RN) K had performed hand hygiene and glove use according to the provider's policy during a nebulizer treatment with resident (115). Findings include: 1. Observation and interview on 5/22/24 at 12:30 p.m. with LPN O and CNA P during a dressing change for resident 164 revealed: *LPN O entered the resident's room and into the bathroom. *Then CNA P entered the room. *Both LPN O and CNA P put on gloves without washing their hands. *LPN O: -Removed the soiled wound dressings from the residents buttock and removed her gloves. -Put on clean gloves without washing her hands. -Placed some paper towels at the head of the bed. -Placed the resident's new dressings on top of those paper towels and opened the dressings. -Took her gloves off and put clean gloves on without washing her hands or using hand sanitizer. -With those gloved hands she reached into her pocket, removed a pen and dated the new dressings with the pen. *LPN O placed two new dressings on resident 164's buttock. *CNA P had assisted with repositioning the resident, the bedding, clothes, and incontinence brief. -She removed her soiled gloves and without washing her hands she put clean gloves on. *A large bottle of hand sanitizer was on top of the medication cabinet in the room. *LPN O and CNA P confirmed: -There was hand sanitizer available for use in the room. -They should have used hand sanitizer or soap and water each time they changed their gloves. 2. Interview on 5/24/24 at 1:00 p.m. with the RN infection preventionist I and RN staff development coordinator L regarding the above observed lack of hand hygiene revealed the staff had received repeated hand hygiene education. 3. Observation and interview on 5/22/24 at 10:02 a.m. with RN K while providing a nebulizer treatment for resident 115 revealed: *She did not perform hand hygiene before taking the nebulizer equipment out of the packaging. *She did not perform hand hygiene before putting gloves on or after taking them off. *She admitted she did not perform hand hygiene and stated she should have sanitized her hands before touching the equipment. Review of the provider's January 2023 Nebulizer Treatments policy revealed: * Procedure: 1. Wash or sanitize hands. Review of the provider's Handwashing/Hand Hygiene Policy revealed: *All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections. *All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. *Hand hygiene products and supplies (sinks, soap, towels, alcohol-based rub) would be readily accessible and convenient for staff use to encourage compliance with hygiene policies. *Wash hands with soap and water for the following: -When the hands were visibly soiled; and -After contact with a resident with infectious diarrhea. -Before and after coming on duty. -After personal use of the toilet or conducting your hygiene. *Use an alcohol-based hand rub containing at least 62% alcohol or soap and water for the following situations such as: -Before and coming on duty. -Before and after direct contact with residents. -Before preparing or handling medications. -Before and after handling invasive devices such as a catheter and IV access sites. -Before handling used dressings and contaminated equipment. -Before moving from a contaminated body site to a clean body site during resident care. -After contact with blood or bodily fluid. -Before assisting residents with eating. *Hand hygiene is the final step after removing and disposing of protective equipment. *The use of gloves does not replace hand washing or hand hygiene. *Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on interview, observation, record review and policy review, the provider failed to ensure one of one sampled resident (115) was accurately assessed for appropriate and safe self-administration of a nebulized (converted from liquid to mist) medication. Findings include: 1. Interview on 05/21/24 at 09:25 a.m. with resident 115 revealed she: *Had a medication that was given through a nebulizer (neb) machine. *Was left alone by staff during her neb treatments. *Stated she had never been educated on using the neb machine and could not turn it on or off. *Would take the mask off before the neb treatment was done. *Wanted to self-administer her neb treatment. Observation and interview on 5/22/24 at 10:02 a.m. with registered nurse (RN) K while providing a neb treatment for resident 115 revealed: *She placed liquid Ipratropium (a med to open airways in the lungs) and Budesonide (a med to prevent swelling) in the neb reservoir, started the neb machine and placed the mask on resident 115's face. *She stated that she would set a timer on her watch for ten minutes and return to assist the resident and left the room. *She did not know if the resident had an orderto self-administer the neb treatment. *She was not sure of the facility policy on resident self-administration of medications. *Review of the resident 115's electronic medical record (EMR) revealed: *An order on 05/13/24 for Budesonide (one vile via neb two times a day) and on 05/16/24 for Ipratropium (one vile by mouth three times a day). *There was no order for the self-administration of the Ipratropium or Budesonide . *There was no assessment to determine if she was able to self-administer the neb treatment safely. *Her care plan did not include her self-administration of the neb treatment. 2. Interview on 05/23/24 at 11:03 a.m. with RN I revealed: * There was no order for resident 115 to self-administer any medications. *Resident 115 had not been educated on using the nebulizer. *Self-administration was not included in resident 115's care plan. *She would have expected all education to have been conducted and documented in the resident's record. Review of the providers February 2021 Self-Administration of Medication policy revealed: *3. If it is deemed safe and appropriate for a resident to self-administer medications, this is documented in the medical record and their care plan. The decision that a resident can safely self-administer medications is reassessed periodically based on changes in the resident's medical and /or decision-making status.

Based on observation, record review, interview, and policy review, the provider failed to update interventions and follow their policy for two of three sampled residents (3 and 6) who developed pressure ulcers (sores caused by unrelieved pressure that resulted in damage to the tissue) while residing at the facility. Findings include: 1. Review of resident 6's weekly pressure ulcer flow sheets revealed: *On 1/2/15 a stage II pressure ulcer (reddened area with a break in the skin) measuring 0.5 centimeters (cm) by 0.5 cm had developed on her tailbone. *The following measurements: -On 1/6/15 0.5 cm by 0.2 cm. -On 1/13/15 0.4 cm by 0.8 cm. -On 1/20/15 1.0 cm by 0.5 cm. -On 1/26/15 0.7 cm by 1.2 cm. -On 2/3/15 1.1 cm by 2.0 cm. -On 2/10/15 1.0 cm by 1.3 cm. -On 2/17/15 1.0 cm by 0.7 cm. -On 2/24/15 0.8 cm by 0.6 cm. -On 3/2/15 0.3 cm by 0.2 cm. -On 3/9/15 0.4 cm by 0.4 cm. -On 3/16/15 0.1 cm by 0.3 cm. -On 3/23/15 it had been closed. -On 3/30/15 it had been closed. *There had been no measurements for depth of the pressure ulcer. *On 1/20/15 the treatment had changed. *From 1/20/15 through 3/23/15 the pressure ulcer had gotten larger in size before getting smaller again. *During that timeframe: -The treatment had not changed. -There had been no documentation of notification to the physician. Review of resident 6's 1/20/15 fax to the physician revealed: *Staff had requested a change in treatment. *They had asked to start "2x2 foam dressing to pressure area on right buttock with skin prep (preparation) to periwound (tailbone) secured with [MEDICATION NAME] tape - change QD (every day) and PRN (as needed)." Observations on 3/31/15 of resident 6 at the following times revealed: *At 12:05 p.m. she had been taken to her room from the Robinsview dining room. *At 3:00 p.m. she had been lying in bed. *From 4:35 p.m. through 6:35 p.m. she had been sitting at the dining room table in her wheelchair. Review of resident 6's 12/23/14 and 3/17/15 Minimum Data Set (MDS) assessments revealed: *She had short and long term memory problems and could not complete the resident interview. *Her ability to make daily decisions was moderately impaired. *She needed extensive assistance of two staff members to move in bed, transfer, dress, use the bathroom, and complete personal hygiene tasks. *She needed extensive assistance of one staff member to eat. *She was frequently incontinent (inability to control) of bladder and bowel. *She had been at risk for pressure ulcer development. She had a device in her chair, was on a repositioning program, received pressure ulcer care, and had an ointment administered for preventative care. Review of resident 6's 3/19/15 care plan revealed: *She did not walk. *She was at risk for skin breakdown. Interventions for that focus area included the following: -"I have a stage II pressure area to right buttock (bottom), nursing monitor area QD and MDS to measure weekly until healed. See TAR (treatment administration record) for tx (treatment) and wound book for measurements. Date initiated: 3/26/15. -Braden scale with each MDS and PRN. Date initiated: 10/16/13. Revision on 11/4/13. -I am on a turning plan. Date initiated: 10/16/13. Revision on 11/4/13. -I have a body pillow. Date initiated: 10/17/13. Revision on 11/4/13. -I have a cushion in my w/c (wheelchair). Date initiated: 10/16/13. Revision on 11/4/13. -I have new shoes to provide my feet comfort and not cause any areas of breakdown. Date initiated: 10/16/13. Revision on 11/4/13. -I should lay down in the afternoon but would be nice to be up for afternoon activity. Date initiated: 10/16/13. Revision on 11/4/13. -I wear incontinent products to help keep my skin dry. Date initiated: 10/16/13. Revision on 11/4/13. -Nursing staff will follow my repositioning program. Date initiated: 10/16/13. Revision on 11/4/13. -Please see nutrition related focus for further nutrition related interventions. Date initiated: 9/29/14. -Staff will assist me with toileting, complete peri-cares (personal cares), and change my incontinent product when soiled per toileting plan. Date initiated: 10/16/13. Revision on 11/4/13. -Staff will observe my skin with cares and toileting. Date initiated: 10/16/13. Revision on 3/27/15. -Staff will put protective ointment to my bottom/back twice a day for my scratches. Date initiated: 10/16/13. Revision on 11/4/13." *She needed assistance with her activities of daily living. She could use the bathroom but was frequently incontinent and was on a toileting program. That intervention had been revised on 3/26/15. *There had been no nutritional interventions, no pressure relieving mattress, and no interventions from the physician listed. Review of resident 6's Braden Scale for Predicting Pressure Sore Risk assessments revealed: *On 9/23/14 and 12/23/14 she was at moderate risk to develop a pressure ulcer. *On 3/17/15 she was at high risk for developing pressure ulcers. She had already developed a pressure ulcer at that time. 2. Review of resident 3's weekly pressure ulcer flow sheets revealed: *On 3/6/15 a stage II pressure ulcer measuring 0.4 cm by 0.4 cm had developed on his tailbone. -On 3/9/15 it had healed. *On 3/6/15 a stage II pressure ulcer measuring 0.6 cm by 0.5 cm had developed on his left buttock. -On 3/9/15 it had healed. *On 3/24/15 a stage II pressure ulcer measuring 0.2 cm by 0.2 cm had developed on his tailbone. *On 3/30/15 it had measured 0.2 cm by 0.5 cm. Observation and interview on 3/31/15 at 8:55 a.m. with an unidentified certified nursing assistant (CNA) revealed they were assisting resident 3 into the bathroom. Observation on 3/31/15 at 10:30 a.m. of resident 3 revealed he was resting in his recliner in his room. Observation on 3/31/15 at 11:15 a.m. revealed resident 3 was in the dining room eating partially on his own, but staff were cueing him. Observation and interview on 3/31/15 at 11:45 a.m. with CNA E revealed: *She had taken resident 3 back to his room. *She had transferred him into his bed using a stand aid. *She had not gotten help to assist with the transfer. *She had not asked him if he needed to use the bathroom. *She had not assisted him with toileting. *She placed a long pillow under his right side to shift his weight. *She stated he used to walk, but he had become weaker. *He used to do a pivot transfer but that required two staff members, so they used the stand aid to transfer him. Observation on 3/31/15 at 3:00 p.m., 3:30 p.m., and 3:46 p.m. of resident 3 revealed he had been laying in bed in the same position as earlier at 11:45 a.m. The long pillow was still under his right side. Observation on 3/31/14 at 4:35 p.m. of resident 3 revealed he was at the table waiting for supper to be served. At 5:15 p.m. he was served a sandwich, steak fries, corn and peaches. He was eating the steak fries on his own, and staff sat down to assist him. Review of resident 3's 7/8/14 significant change MDS assessment revealed: *His thinking ability was moderately impaired. *He needed extensive assistance from two staff members to move in bed, transfer, walk in his room, dress, and use the toilet. *He needed extensive assistance from one staff member to move in the hallways and bath. *He ate independently. *He was occasionally incontinent of urine. *He was not at risk for pressure ulcers but had a device in his chair. Review of resident 3's quarterly 10/7/14 MDS assessment revealed: *His thinking ability was not impaired. *He needed extensive assistance from one staff member to move in bed, transfer, walk in his room, move in the hallways, dress, use the toilet, complete his personal hygiene and bath. *He needed supervision of one staff member to eat. *He was occasionally incontinent of urine. *He was not at risk for pressure ulcers, but had a device in his chair and used a preventative ointment. *He had improvements since his last MDS on 7/8/14. Review of resident 3's significant change 12/9/14 MDS assessment revealed: *Staff had identified he had long and short term memory problems and could not complete the resident interview. *He needed extensive assistance from two staff members to move in bed, transfer, move in the hallways, dress, use the toilet, and complete personal hygiene. *He needed limited assistance from one staff member to walk in his room. *He had not walked in the hallway. *He needed extensive assistance from one staff member to eat. *He was frequently incontinent. *He was at risk for developing pressure ulcers. He had a device on his chair and used a preventative ointment. Review of resident 3's significant change 3/10/15 MDS assessment revealed: *His thinking ability was moderately impaired. *He needed extensive assistance from two staff members to move in bed, transfer, move in the hallways, dress, use the toilet, and complete personal hygiene. *He needed extensive assistance from one staff member to eat and bath. *Walking in his room or in the hall had not occurred. *He was frequently incontinent of urine. *He was at risk for developing pressure ulcers. He had a device on his chair and bed and used a preventative ointment. Review of resident 3's 10/7/14, 12/9/14, and 3/10/15 Braden Scale for Predicting Pressure Sore Risk assessments revealed he was at risk for developing pressure ulcers. The 10/7/14 Braden scale assessment did not match the 10/7/14 MDS assessment that indicated he was not at risk. Review of resident 3's 3/19/15 care plan revealed: *He needed assistance with his activities of daily living. -An intervention for that focus area included being on a toileting plan due to being frequently incontinent of bladder and occasionally incontinent of bowel. *He was at risk for skin breakdown (pressure ulcers and or abrasions). Interventions for that focus area included the following: -"Dietary will monitor intakes. Date initiated: 10/17/13. Revision on 11/4/13. -I am encouraged to change positions often to relieve pressure off my bottom. Date initiated: 10/17/13. Revision on 11/4/13. -I am frequently incontinent of bladder and occasionally incontinent of bowel. Staff assist with toileting. Staff assist with changing incontinent product when soiled. Date initiated: 10/17/13. Revision on 12/19/14. -I do have a [DIAGNOSES REDACTED]. Date initiated: 10/17/13. Revision on 11/4/13. -I feel that I get up frequently enough throughout the day. Date initiated: 10/17/13. Revision on 11/4/13. -I had pressure areas to my bottom that occurred on 3/6/15 and resolved on 3/9/15. Monitor area x (times) 30 days and continue preventative tx (treatment). Date initiated: 3/19/15. -I have a pressure relieving cushion in my w/c (wheelchair) along with my recliner. Date initiated: 10/17/13. Revision on 3/19/15. -I have a transfer bar on my bed. My Braden is 17 (at risk for pressure ulcers). Date initiated: 1/24/14. Revision on 3/19/15. -I have diabetes, nursing will monitor lab (laboratory tests) and blood sugars as ordered. Date initiated: 4/17/14. -I will consume protein with each meal. Encourage me to consume 4 ounces milk with my breakfast cereal and offer me PB (peanut butter) if I have toast. I do not want scheduled snacks at this time. Date initiated: 7/13/14. -Labs will be monitored as ordered. Date initiated: 10/17/13. Revision on 11/4/13. -Staff assist with positioning. I am on a re-positioning plan. Date initiated: 12/19/14. -Staff will observe for (skin) breakdown with cares and toileting. Date initiated: 4/17/14. Revision on 7/15/14." Review of resident 3's 3/19/15 repositioning plan revealed he was to be repositioned every two hours during awake hours and on rounds at night. That involved completely lifting him and removing all weight from his bottom and other dependent areas. Two staff members were to be used. The goal was to prevent skin breakdown related to pressure, they indicated they had met that goal. Review of resident 3's 3/19/15 toileting schedule revealed he was to be "offered the toilet at get up, every two hours during awake hours, and offer the toilet on rounds at night." He was to be assisted by two staff members. Interview and document review on 4/1/15 at 11:50 a.m. with MDS coordinator C regarding resident 3 revealed: *They had changed his cushion in his wheelchair from a high ROHO cushion to a low ROHO cushion. *She did not know when that had occurred. *He currently had the low ROHO cushion in his chair. *Physical therapy (PT) had made the change but had not documented it anywhere. *PT had provided her a document with the kind of ROHO cushions they were. *The high ROHO cushion would be used for "those unable to independently shift weight." *The low ROHO cushion would "maximize stability and prevents risk of potential tissue breakdown...It is for those who can independently shift weight and transfer." *According to the above MDS assessments he could not shift his weight or transfer independently. Review of resident 3's interdisciplinary notes revealed a note on 3/9/15 titled "Communication - with physician." The note stated "new chair cushion placed on 3/6/15." That was the date the first pressure ulcer had developed. 3. Interview and document review on 4/1/15 at 10:45 a.m. with director of nursing B and MDS coordinator C regarding residents 3 and 6 revealed: *Neither resident currently had a pressure relieving mattress on their bed. *They only had overlays in the building. There were no pressure relieving mattresses that they were aware of. *Staff had discussed buying all new mattresses for the facility, but that had not happened. *They had asked the supervisor of housekeeping in front of this surveyor if they had pressure relieving mattresses. She said no there were none in the building. *They had attempted the overlay on resident 3's bed, but he would move around so they took it off. *She was unsure of when they had attempted that. *Resident 6 had never had any type of pressure relieving mattress. *Resident 6 had developed her pressure ulcer because of the staffing issue. *She had not been getting assisted to the bathroom which prompted them to initiate the red dot program (a system where a red dot is placed with the individual and once a CNA finds the dot after assisting the resident the CNA reports to the charge nurse and turned in the red dot). *They had started the red dot program back in February 2015. *On 3/19/15 the red dot had been placed with resident 6 at 8:17 a.m. and not found until 12:30 p.m. *They had not contacted resident 6's physician since 1/20/15 to request a change in pressure ulcer treatment. *The care plan revision date would be when the intervention had last been revised. *Nutritional interventions for wound healing had been started after the development of the pressure ulcers. *They had not been following their Skin Assessment and Pressure Ulcer preventative policy. *They did not have an interdisciplinary team (IDT) to address residents at risk for pressure ulcer development. Review of the provider's 4/6/13 Skin Assessment and Pressure Ulcer Prevention and Treatment Policy revealed: *Residents identified to be at risk for skin breakdown or who currently had skin breakdown would have specific interventions care planned by the IDT. *If a resident had a pressure ulcer daily documentation was to be completed by a licensed nurse. *A consultant wound nurse could have been consulted if needed.

Based on observation, record review, interview, and policy review, the provider failed to update interventions and follow their policy for two of three sampled residents (3 and 6) who developed pressure ulcers (sores caused by unrelieved pressure that resulted in damage to the tissue) while residing at the facility. Findings include: 1. Review of resident 6's weekly pressure ulcer flow sheets revealed: *On 1/2/15 a stage II pressure ulcer (reddened area with a break in the skin) measuring 0.5 centimeters (cm) by 0.5 cm had developed on her tailbone. *The following measurements: -On 1/6/15 0.5 cm by 0.2 cm. -On 1/13/15 0.4 cm by 0.8 cm. -On 1/20/15 1.0 cm by 0.5 cm. -On 1/26/15 0.7 cm by 1.2 cm. -On 2/3/15 1.1 cm by 2.0 cm. -On 2/10/15 1.0 cm by 1.3 cm. -On 2/17/15 1.0 cm by 0.7 cm. -On 2/24/15 0.8 cm by 0.6 cm. -On 3/2/15 0.3 cm by 0.2 cm. -On 3/9/15 0.4 cm by 0.4 cm. -On 3/16/15 0.1 cm by 0.3 cm. -On 3/23/15 it had been closed. -On 3/30/15 it had been closed. *There had been no measurements for depth of the pressure ulcer. *On 1/20/15 the treatment had changed. *From 1/20/15 through 3/23/15 the pressure ulcer had gotten larger in size before getting smaller again. *During that timeframe: -The treatment had not changed. -There had been no documentation of notification to the physician. Review of resident 6's 1/20/15 fax to the physician revealed: *Staff had requested a change in treatment. *They had asked to start "2x2 foam dressing to pressure area on right buttock with skin prep (preparation) to periwound (tailbone) secured with [MEDICATION NAME] tape - change QD (every day) and PRN (as needed)." Observations on 3/31/15 of resident 6 at the following times revealed: *At 12:05 p.m. she had been taken to her room from the Robinsview dining room. *At 3:00 p.m. she had been lying in bed. *From 4:35 p.m. through 6:35 p.m. she had been sitting at the dining room table in her wheelchair. Review of resident 6's 12/23/14 and 3/17/15 Minimum Data Set (MDS) assessments revealed: *She had short and long term memory problems and could not complete the resident interview. *Her ability to make daily decisions was moderately impaired. *She needed extensive assistance of two staff members to move in bed, transfer, dress, use the bathroom, and complete personal hygiene tasks. *She needed extensive assistance of one staff member to eat. *She was frequently incontinent (inability to control) of bladder and bowel. *She had been at risk for pressure ulcer development. She had a device in her chair, was on a repositioning program, received pressure ulcer care, and had an ointment administered for preventative care. Review of resident 6's 3/19/15 care plan revealed: *She did not walk. *She was at risk for skin breakdown. Interventions for that focus area included the following: -"I have a stage II pressure area to right buttock (bottom), nursing monitor area QD and MDS to measure weekly until healed. See TAR (treatment administration record) for tx (treatment) and wound book for measurements. Date initiated: 3/26/15. -Braden scale with each MDS and PRN. Date initiated: 10/16/13. Revision on 11/4/13. -I am on a turning plan. Date initiated: 10/16/13. Revision on 11/4/13. -I have a body pillow. Date initiated: 10/17/13. Revision on 11/4/13. -I have a cushion in my w/c (wheelchair). Date initiated: 10/16/13. Revision on 11/4/13. -I have new shoes to provide my feet comfort and not cause any areas of breakdown. Date initiated: 10/16/13. Revision on 11/4/13. -I should lay down in the afternoon but would be nice to be up for afternoon activity. Date initiated: 10/16/13. Revision on 11/4/13. -I wear incontinent products to help keep my skin dry. Date initiated: 10/16/13. Revision on 11/4/13. -Nursing staff will follow my repositioning program. Date initiated: 10/16/13. Revision on 11/4/13. -Please see nutrition related focus for further nutrition related interventions. Date initiated: 9/29/14. -Staff will assist me with toileting, complete peri-cares (personal cares), and change my incontinent product when soiled per toileting plan. Date initiated: 10/16/13. Revision on 11/4/13. -Staff will observe my skin with cares and toileting. Date initiated: 10/16/13. Revision on 3/27/15. -Staff will put protective ointment to my bottom/back twice a day for my scratches. Date initiated: 10/16/13. Revision on 11/4/13." *She needed assistance with her activities of daily living. She could use the bathroom but was frequently incontinent and was on a toileting program. That intervention had been revised on 3/26/15. *There had been no nutritional interventions, no pressure relieving mattress, and no interventions from the physician listed. Review of resident 6's Braden Scale for Predicting Pressure Sore Risk assessments revealed: *On 9/23/14 and 12/23/14 she was at moderate risk to develop a pressure ulcer. *On 3/17/15 she was at high risk for developing pressure ulcers. She had already developed a pressure ulcer at that time. 2. Review of resident 3's weekly pressure ulcer flow sheets revealed: *On 3/6/15 a stage II pressure ulcer measuring 0.4 cm by 0.4 cm had developed on his tailbone. -On 3/9/15 it had healed. *On 3/6/15 a stage II pressure ulcer measuring 0.6 cm by 0.5 cm had developed on his left buttock. -On 3/9/15 it had healed. *On 3/24/15 a stage II pressure ulcer measuring 0.2 cm by 0.2 cm had developed on his tailbone. *On 3/30/15 it had measured 0.2 cm by 0.5 cm. Observation and interview on 3/31/15 at 8:55 a.m. with an unidentified certified nursing assistant (CNA) revealed they were assisting resident 3 into the bathroom. Observation on 3/31/15 at 10:30 a.m. of resident 3 revealed he was resting in his recliner in his room. Observation on 3/31/15 at 11:15 a.m. revealed resident 3 was in the dining room eating partially on his own, but staff were cueing him. Observation and interview on 3/31/15 at 11:45 a.m. with CNA E revealed: *She had taken resident 3 back to his room. *She had transferred him into his bed using a stand aid. *She had not gotten help to assist with the transfer. *She had not asked him if he needed to use the bathroom. *She had not assisted him with toileting. *She placed a long pillow under his right side to shift his weight. *She stated he used to walk, but he had become weaker. *He used to do a pivot transfer but that required two staff members, so they used the stand aid to transfer him. Observation on 3/31/15 at 3:00 p.m., 3:30 p.m., and 3:46 p.m. of resident 3 revealed he had been laying in bed in the same position as earlier at 11:45 a.m. The long pillow was still under his right side. Observation on 3/31/14 at 4:35 p.m. of resident 3 revealed he was at the table waiting for supper to be served. At 5:15 p.m. he was served a sandwich, steak fries, corn and peaches. He was eating the steak fries on his own, and staff sat down to assist him. Review of resident 3's 7/8/14 significant change MDS assessment revealed: *His thinking ability was moderately impaired. *He needed extensive assistance from two staff members to move in bed, transfer, walk in his room, dress, and use the toilet. *He needed extensive assistance from one staff member to move in the hallways and bath. *He ate independently. *He was occasionally incontinent of urine. *He was not at risk for pressure ulcers but had a device in his chair. Review of resident 3's quarterly 10/7/14 MDS assessment revealed: *His thinking ability was not impaired. *He needed extensive assistance from one staff member to move in bed, transfer, walk in his room, move in the hallways, dress, use the toilet, complete his personal hygiene and bath. *He needed supervision of one staff member to eat. *He was occasionally incontinent of urine. *He was not at risk for pressure ulcers, but had a device in his chair and used a preventative ointment. *He had improvements since his last MDS on 7/8/14. Review of resident 3's significant change 12/9/14 MDS assessment revealed: *Staff had identified he had long and short term memory problems and could not complete the resident interview. *He needed extensive assistance from two staff members to move in bed, transfer, move in the hallways, dress, use the toilet, and complete personal hygiene. *He needed limited assistance from one staff member to walk in his room. *He had not walked in the hallway. *He needed extensive assistance from one staff member to eat. *He was frequently incontinent. *He was at risk for developing pressure ulcers. He had a device on his chair and used a preventative ointment. Review of resident 3's significant change 3/10/15 MDS assessment revealed: *His thinking ability was moderately impaired. *He needed extensive assistance from two staff members to move in bed, transfer, move in the hallways, dress, use the toilet, and complete personal hygiene. *He needed extensive assistance from one staff member to eat and bath. *Walking in his room or in the hall had not occurred. *He was frequently incontinent of urine. *He was at risk for developing pressure ulcers. He had a device on his chair and bed and used a preventative ointment. Review of resident 3's 10/7/14, 12/9/14, and 3/10/15 Braden Scale for Predicting Pressure Sore Risk assessments revealed he was at risk for developing pressure ulcers. The 10/7/14 Braden scale assessment did not match the 10/7/14 MDS assessment that indicated he was not at risk. Review of resident 3's 3/19/15 care plan revealed: *He needed assistance with his activities of daily living. -An intervention for that focus area included being on a toileting plan due to being frequently incontinent of bladder and occasionally incontinent of bowel. *He was at risk for skin breakdown (pressure ulcers and or abrasions). Interventions for that focus area included the following: -"Dietary will monitor intakes. Date initiated: 10/17/13. Revision on 11/4/13. -I am encouraged to change positions often to relieve pressure off my bottom. Date initiated: 10/17/13. Revision on 11/4/13. -I am frequently incontinent of bladder and occasionally incontinent of bowel. Staff assist with toileting. Staff assist with changing incontinent product when soiled. Date initiated: 10/17/13. Revision on 12/19/14. -I do have a [DIAGNOSES REDACTED]. Date initiated: 10/17/13. Revision on 11/4/13. -I feel that I get up frequently enough throughout the day. Date initiated: 10/17/13. Revision on 11/4/13. -I had pressure areas to my bottom that occurred on 3/6/15 and resolved on 3/9/15. Monitor area x (times) 30 days and continue preventative tx (treatment). Date initiated: 3/19/15. -I have a pressure relieving cushion in my w/c (wheelchair) along with my recliner. Date initiated: 10/17/13. Revision on 3/19/15. -I have a transfer bar on my bed. My Braden is 17 (at risk for pressure ulcers). Date initiated: 1/24/14. Revision on 3/19/15. -I have diabetes, nursing will monitor lab (laboratory tests) and blood sugars as ordered. Date initiated: 4/17/14. -I will consume protein with each meal. Encourage me to consume 4 ounces milk with my breakfast cereal and offer me PB (peanut butter) if I have toast. I do not want scheduled snacks at this time. Date initiated: 7/13/14. -Labs will be monitored as ordered. Date initiated: 10/17/13. Revision on 11/4/13. -Staff assist with positioning. I am on a re-positioning plan. Date initiated: 12/19/14. -Staff will observe for (skin) breakdown with cares and toileting. Date initiated: 4/17/14. Revision on 7/15/14." Review of resident 3's 3/19/15 repositioning plan revealed he was to be repositioned every two hours during awake hours and on rounds at night. That involved completely lifting him and removing all weight from his bottom and other dependent areas. Two staff members were to be used. The goal was to prevent skin breakdown related to pressure, they indicated they had met that goal. Review of resident 3's 3/19/15 toileting schedule revealed he was to be "offered the toilet at get up, every two hours during awake hours, and offer the toilet on rounds at night." He was to be assisted by two staff members. Interview and document review on 4/1/15 at 11:50 a.m. with MDS coordinator C regarding resident 3 revealed: *They had changed his cushion in his wheelchair from a high ROHO cushion to a low ROHO cushion. *She did not know when that had occurred. *He currently had the low ROHO cushion in his chair. *Physical therapy (PT) had made the change but had not documented it anywhere. *PT had provided her a document with the kind of ROHO cushions they were. *The high ROHO cushion would be used for "those unable to independently shift weight." *The low ROHO cushion would "maximize stability and prevents risk of potential tissue breakdown...It is for those who can independently shift weight and transfer." *According to the above MDS assessments he could not shift his weight or transfer independently. Review of resident 3's interdisciplinary notes revealed a note on 3/9/15 titled "Communication - with physician." The note stated "new chair cushion placed on 3/6/15." That was the date the first pressure ulcer had developed. 3. Interview and document review on 4/1/15 at 10:45 a.m. with director of nursing B and MDS coordinator C regarding residents 3 and 6 revealed: *Neither resident currently had a pressure relieving mattress on their bed. *They only had overlays in the building. There were no pressure relieving mattresses that they were aware of. *Staff had discussed buying all new mattresses for the facility, but that had not happened. *They had asked the supervisor of housekeeping in front of this surveyor if they had pressure relieving mattresses. She said no there were none in the building. *They had attempted the overlay on resident 3's bed, but he would move around so they took it off. *She was unsure of when they had attempted that. *Resident 6 had never had any type of pressure relieving mattress. *Resident 6 had developed her pressure ulcer because of the staffing issue. *She had not been getting assisted to the bathroom which prompted them to initiate the red dot program (a system where a red dot is placed with the individual and once a CNA finds the dot after assisting the resident the CNA reports to the charge nurse and turned in the red dot). *They had started the red dot program back in February 2015. *On 3/19/15 the red dot had been placed with resident 6 at 8:17 a.m. and not found until 12:30 p.m. *They had not contacted resident 6's physician since 1/20/15 to request a change in pressure ulcer treatment. *The care plan revision date would be when the intervention had last been revised. *Nutritional interventions for wound healing had been started after the development of the pressure ulcers. *They had not been following their Skin Assessment and Pressure Ulcer preventative policy. *They did not have an interdisciplinary team (IDT) to address residents at risk for pressure ulcer development. Review of the provider's 4/6/13 Skin Assessment and Pressure Ulcer Prevention and Treatment Policy revealed: *Residents identified to be at risk for skin breakdown or who currently had skin breakdown would have specific interventions care planned by the IDT. *If a resident had a pressure ulcer daily documentation was to be completed by a licensed nurse. *A consultant wound nurse could have been consulted if needed.

Based on observation, record review, and interview, the provider failed to maintain adequate staff to prevent care issues and meet basic care needs for: *Two of four sampled residents (3 and 6) who had developed pressure ulcers (sores caused by unrelieved pressure that resulted in damage to the tissue) after admission into the facility. *Two of two random observed residents (18 and 19) who needed assistance with eating. *Two of four sampled residents (2 and 5) in the memory support unit who had declines in their activities of daily living. Findings include: 1. Review of resident 3 and 6's medical record revealed they had developed pressure ulcers after admission into the facility. Refer to F314, findings 1, 2, 3 and 4. 2. Random observations and interview on 3/31/14 regarding residents 18 and 19 revealed they had to wait for staff to be available before they could eat. Refer to F241, finding 1. Preceptor: Surveyor: 3. Observation on 3/31/15 from 9:05 a.m. through 12:09 p.m. of resident 2 in the Memory Care Unit (MCU) lounge revealed at: *9:05 a.m. she was asleep in a recliner with her feet elevated on the foot rest. *11:10 a.m. she had remained asleep in the recliner in the same position. *11:12 a.m. a licensed practical nurse had awoken her and administered her medications to her. *11:38 a.m. she had remained awake in the recliner in the same position. *11:42 a.m. she had fallen asleep in the recliner in the same position. *1153 a.m. she had awoken. *11:58 a.m.: -She asked CNA N to take her to the dining room table. -CNA N asked her to "wait a few minutes." -CNA N assisted another resident to the bath room. *12:07 p.m. CNA N assisted her to the dining room table. Interview on 3/31/15 at 10:30 a.m. with CNA N revealed she stated: *Resident 5 had been on a walking program but was no longer walking. *Six residents had been on a walking program. *Six residents now required the assistance of two staff members. *They (staff): -No longer performed the walking program because they "don't have time to do much more than the basic care." -"I have to choose between helping a resident go to the bathroom or walking another one. I need to help the one who needs to use the bathroom first." -"We are short (not working with full staff) a lot." *A worker had called in and they "begged" her co-worker who was to leave at 10:00 a.m. to stay. *She would be working alone on Sunshine today from around 2:15 p.m. through 4:30 p.m. *Her schedule reflected she was to be in Morningview unit for her whole shift. *Staffing issues had been a problem starting back in October 2014. 4. Observation on 3/3/15 from 11:35 a.m. through 12:12 p.m. of resident 5 in the MCU revealed: *11:35 a.m. he was at the dining room table in his wheelchair with his eyes closed. *11:50 a.m. his food was sat in front of him. *12:12 p.m. CNA N had begun assisting him with eating. Surveyor: 5. Confidential interview on 3/31/15 at 10:30 a.m. with a small group of residents revealed: *A few of the residents felt the staff had not answered their call lights at night. One resident had waited forty minutes and finally shut the call light off him/herself. *One resident felt there had been a problem with call lights being answered in the late afternoon and after the evening meal. *One resident felt the staff would place dependent (required staff assistance) residents in the dining room at 5:00 p.m. and make them wait until 7:00 p.m. before taking them back to their rooms. *A few residents felt the evening shift needed more help. *One resident felt there had been "a big turnover in staff at the end of each semester." *One resident felt there was not enough staff on the night shift or on the weekend shift to help the residents. *One resident felt the staff "brush off" what we ask for." Preceptor: Surveyor: 6. Interview on 3/30/15 at 4:50 p.m. with RN J revealed: *The provider had been having staffing issues that affected resident care. *The decreased staffing was more evident in the late afternoon, at evening, and at night. *She felt administration was trying to work on the problem, but they could do a better job. *Sometimes there were only three CNAs for the whole building. -She felt that was not enough for seventy-eight residents. Interview on 4/1/15 at 10:30 a.m. with activity coordinator K revealed: *The activity department had recently been down one staff member. *The provider had been using the remaining activities staff as CNAs at times because of the shortage of CNAs. *That sometimes the activity documentation would not get done, because activities was working on the floor. Surveyor: Multiple random interviews on 3/31/15 and on 4/1/15 with the interim administrator, the director of finance, director of nursing A, and director of nursing B revealed they had been experiencing staffing issues. They had a 2 percent unemployment rate in the city and were finding it difficult to find new employees. They had attempted an incentive program in February 2014. They had began using a temporary service today. Interview on 3/31/15 at 2:30 p.m. with human resources generalist Q revealed: *It could not be determined who was working on which unit on any given day based on the staffing calendar and twenty-four hour staff sheets. *This surveyor had requested who had been working in the memory support unit on 3/27/15, but she had not provided that information by the end of the survey. *If someone was scheduled on one unit and pulled to work a few hours on a different unit that was not put on the calendar. *Time cards would not have reflected what unit they had worked on.

Based on observation, record review, and interview, the provider failed to maintain adequate staff to prevent care issues and meet basic care needs for: *Two of four sampled residents (3 and 6) who had developed pressure ulcers (sores caused by unrelieved pressure that resulted in damage to the tissue) after admission into the facility. *Two of two randomly observed residents (2 and 4) who needed assistance with eating. *Two of four sampled residents (1 and 5) in the memory support unit who had declines in their activities of daily living. Findings include: 1. Review of resident 3 and 6's medical records revealed they had developed pressure ulcers after admission into the facility. Refer to F314, findings 1, 2, 3, and 4. 2. Random observations and interview on 3/31/14 regarding residents 2 and 4 revealed they had to wait for staff to be available before they could eat. Refer to F241, finding 1. Surveyor: 3. Observation on 3/31/15 from 9:05 a.m. through 12:09 p.m. of resident 1 in the Memory Care Unit (MCU) lounge revealed at: *9:05 a.m. she was asleep in a recliner with her feet elevated on the foot rest. *11:10 a.m. she had remained asleep in the recliner in the same position. *11:12 a.m. a licensed practical nurse had awoken her and administered her medications to her. *11:38 a.m. she had remained awake in the recliner in the same position. *11:42 a.m. she had fallen asleep in the recliner in the same position. *1153 a.m. she had awoken. *11:58 a.m.: -She asked CNA H to take her to the dining room table. -CNA H asked her to "wait a few minutes." -CNA H assisted another resident to the bath room. *12:07 p.m. CNA H assisted her to the dining room table. Interview on 3/31/15 at 10:30 a.m. with CNA H revealed she stated: *Resident 5 had been on a walking program but was no longer walking. *Six residents had been on a walking program. *Six residents now required the assistance of two staff members. *They (staff): -No longer performed the walking program, because they "don't have time to do much more than the basic care." -"I have to choose between helping a resident go to the bathroom or walking another one. I need to help the one who needs to use the bathroom first." -"We are short (not working with full staff) a lot." *A worker had called in and they "begged" her co-worker who was to leave at 10:00 a.m. to stay. *She would be working alone on the Sunshine wing today from around 2:15 p.m. through 4:30 p.m. *Her schedule reflected she was to be in Morningview unit for her whole shift. *Staffing issues had been a problem starting back in October 2014. 4. Observation on 3/3/15 from 11:35 a.m. through 12:12 p.m. of resident 5 in the MCU revealed at: *11:35 a.m. he was at the dining room table in his wheelchair with his eyes closed. *11:50 a.m. his food was sat in front of him. *12:12 p.m. CNA N had begun assisting him with eating. Surveyor: 5. Confidential interview on 3/31/15 at 10:30 a.m. with a small group of residents revealed: *A few of the residents felt the staff had not answered their call lights at night. One resident had waited forty minutes and finally shut the call light off him/herself. *One resident felt there had been a problem with call lights being answered in the late afternoon and after the evening meal. *One resident felt the staff would place dependent (required staff assistance) residents in the dining room at 5:00 p.m. and make them wait until 7:00 p.m. before taking them back to their rooms. *A few residents felt the evening shift needed more help. *One resident felt there had been "a big turnover in staff at the end of each semester." *One resident felt there was not enough staff on the night shift or on the weekend shift to help the residents. *One resident felt the staff "brush off" what we ask for." Surveyor: 6. Interview on 3/30/15 at 4:50 p.m. with RN F revealed: *The provider had been having staffing issues that affected resident care. *The decreased staffing was more evident in the late afternoon, at evening, and at night. *She felt administration was trying to work on the problem, but they could do a better job. *Sometimes there were only three CNAs for the whole building. -She felt that was not enough for seventy-eight residents. Interview on 4/1/15 at 10:30 a.m. with activity coordinator G revealed: *The activity department had recently been down one staff member. *The provider had been using the remaining activities staff as CNAs at times because of the shortage of CNAs. *That sometimes the activity documentation would not get done, because activities was working on the floor. Surveyor: Multiple random interviews on 3/31/15 and on 4/1/15 with the interim administrator, the director of finance, director of nursing A, and director of nursing B revealed they had been experiencing staffing issues. They had a 2 percent unemployment rate in the city and were finding it difficult to find new employees. They had attempted an incentive program in February 2014. They had began using a temporary service today. Interview on 3/31/15 at 2:30 p.m. with human resources generalist I revealed: *It could not be determined who was working on which unit on any given day based on the staffing calendar and twenty-four hour staff sheets. *This surveyor had requested who had been working in the memory support unit on 3/27/15, but she had not provided that information by the end of the survey. *If someone was scheduled on one unit and pulled to work a few hours on a different unit that was not put on the calendar. *Time cards would not have reflected what unit they had worked on.

Based on record review, interview, policy review, and job description review, the provider failed to ensure: *Five of five sampled nurses (D, K, L, M, and N) had initial orientation provided and documented that included emergency services. *One of one sampled resident (1) who had an acute change in condition was transported to the emergency room (ER) as directed by the physician. *Ten of eighteen licensed nurses (C, D, J, K, L, M, N, O, P, and Q) were currently trained in cardiopulmonary resuscitation (CPR). NOTICE: Notice of immediate jeopardy was given verbally to the administrator and the director of nursing (DON) on [DATE] at 4:35 p.m. They were asked for a plan of correction to be given to the surveyors on [DATE] at 9:00 a.m. They were asked that the plan of correction include: *The completion of the initial orientation including emergency services for the above five nurses prior to their next shift assignment. *The action plan to ensure the newly hired staff completed their initial orientation prior to actively working in the facility. *The training and updating of all nursing staff on the procedure of cardiopulmonary resuscitation (CPR) (a life-saving technique used to help restore a stopped heartbeat or breathing). *The action plan to ensure all the nursing staff had CPR certifications that were current. PLAN: A plan of correction for the initial orientation of newly hired staff that included emergency services, suctioning, and training for all the nursing staff on CPR was accepted on [DATE] at 1:30 p.m. The plan of correction included the training for both hardline and portable phone use. It also included a system set in place to ensure all staff had pagers, a check-in/out process, and a maintenance program to ensure proper functioning of that system. A policy and procedure was created for Emergency Ambulance Transfers. The plan implemented to achieve the above compliance was as follows: *The certification of CPR for all licensed nurses would be completed by [DATE]. All other nursing staff would be certified in CPR no later than [DATE]. Human resource director I would be responsible to ensure all CPR certifications were kept current and newly hired staff would be trained prior to actively working for the provider. *On [DATE] and 29, 2014, the DON held a training for thirteen of the eighteen licenses nurses. That training and education was on the procedures for: -Suctioning. -Admissions, discharges, transfers, and death. -The new policy and procedure for Emergency Ambulance Transfer. -Those trainings would all be completed by [DATE]. *The DON would be responsible to ensure all licensed nurses had completed the orientation process and check-list prior to actively working for the provider. *A count on all the pagers would be done by [DATE]. The provider would ensure all staff had access to a pager with two extra purchased by [DATE]. A policy and procedure for the use and maintenance of those pagers would be implemented no later than [DATE]. The DON and human resource director would be responsible for the training on this policy for any newly hired staff. *The vendor for the hardline and cordless phones would be contacted on [DATE] to set a date for training on the use of those phones. A policy and procedure for the use and maintenance of those phones would be implemented by [DATE]. The DON and human resource director would be responsible for the proper use of the phones. The director of maintenance would be responsible for compliance and quality assurance. Additional findings include: 1a. Review of licensed practical nurse (LPN) D's personnel file revealed: *A [DATE] hired date. *Review of her registered nurse (RN)/LPN skill orientation checklist revealed portions had been documented as completed on [DATE] and [DATE]. *There was no documentation admission/discharge/transfer/death orientation had been completed that included: -Transfer forms if transported to the ER. -Transportation using ambulance or private vehicle. -Needing orders from the physician prior to transferring to the emergency room . b. Review of RN J's personnel record revealed: *A [DATE] hired date. *Review of her RN/LPN skill orientation checklist revealed portions had documentation "self" and no date. *There was no documentation admission/discharge/transfer/death orientation had been completed. c. Review of RN K's personnel file revealed: *A [DATE] hired date. *There was not an orientation checklist in her file that any orientation training had been completed. d. Review of RN L's personnel file revealed: *A [DATE] hired date. *There was not an orientation checklist in her file that any orientation training had been completed. e. Review of RN M's personnel file revealed: *A [DATE] hired date. *There was not an orientation checklist in her file that any orientation training had been completed. f. Interview on [DATE] at 10:30 a.m. with the administrator regarding the above revealed: *It was the responsibility of the director of nursing (DON) to start the orientation checklist. *The checklist was dated and initialed by the nurse on the floor who went over each orientation area with the new employee. *It was the responsibility of the new employee to make sure the completed orientation checklists were returned to the DON or human resources. *She confirmed LPN D and RN J had no orientation training documented regarding emergency services and they should have had that prior to working on the nursing floor. *She confirmed RNs K, L, and M had no documentation of orientation training, and they should have had that prior to working on the nursing floor. Interview on [DATE] at 10:45 a.m. with the DON regarding the above staff revealed she: *Had only been the DON since [DATE]. *Was unaware the above licensed nurses orientation training was incomplete or not done at all. *Confirmed orientation training should have been completed prior to the nurses having been scheduled on their own on the nursing floors. *Stated they were in the process of redoing their orientation program and had just hired two nurses in a new position. 2. Review of resident 1's medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. -[MEDICAL CONDITION] (no oxygen) [MEDICAL CONDITION] on [DATE]. -Spastic [MEDICAL CONDITION] (paralysis arms and legs). -Depression. Review of resident 1's [DATE] care plan revealed: *"I have [MEDICAL CONDITION]." *"I have impaired memory related to my [MEDICAL CONDITION]." *"My wheelchair is my independence. I have a new power chair." *"I require two assistance with bed mobility." *"I will require two staff with transfers and gait belt for transferring, unless I am being toileted or bathing I require two assist with the PAL lift (mechanical lift)." *"I sometimes just yell for assistance instead of using my call light if I drop items." *"I have been taught that I should let my frustration out by hitting things such as my pillow or mattress instead of yelling. I am going to get frustrated as it is part of my [MEDICAL CONDITION]." Review of resident 1's CPR policy and declaration signed by his physician on [DATE] revealed: *"I do want to have CPR administered." *"I understand the difference in policy between a witnessed event and an unwitnessed event." Review of resident 1's [DATE] progress notes by LPN D revealed: *8:10 a.m.- "Resident had emesis (vomiting) this morning at breakfast. Was given as needed (PRN) [MEDICATION NAME] (medication for vomiting) around 7:30 a.m. Resident wanted to go back to his room and be layed down. Waited about a half hour before he was helped to bed. Resident had put on his call light many times this morning. Resident has also been calling out for many different things. A few times for TV adjustment and a drink of water. Temperature was taken and was elevated at 104.6 (normal 98.6). Called ER and received telephone order to be transferred to the ER." *9:30 a.m.- "After receiving order to be transferred to the hospital, went in to check on the resident. Resident was in his room in bed at that time 8:50 a.m. Resident had foam around his mouth and was not breathing. Checked heart rate, no heart rate noted. Checked heart rate again with stethoscope (external device used to listen to the heart or lungs) and again no heart rate noted. Resident was cold to the touch. Called another nurse down to resident's room to confirm. Time of death is 8:50 a.m. Resident was dead upon nurse entering room. CPR not initiated due to no heart rate." *9:35 a.m.- "From the time nurse received order to transfer to the ER to the time of death nurse had gotten called away to another neighborhood and was taking care of another resident that needed a catheter (tube in the bladder to drain urine) change. Nurse was also looking for some guidance from LPN E as to how to transfer resident from facility to ER. Was not sure if ambulance needed to be called or if beta bus (non-emergency bus used by hospital) could be used. Did not get a chance to talk with LPN E as she was busy. When nurse returned to sunshine neighborhood certified nursing assistant (CNA) F had told nurse the resident was sleeping. Went in to check on resident as he had been calling out for different things during the morning and was not sure he would be sleeping. Went into resident's room and found not breathing. Necessary steps then taken per facility policy." Review of resident 1's [DATE] progress notes by LPN E revealed: *11:22 a.m.- "Upon arrival to resident room at about 8:55 a.m., resident was cold to touch and no heart rate or respirations. ER called for time of death at 8:50 a.m. Sister called right after and informed of resident death. While she was upset, she did ask details of his death and events of the morning were explained to her as outlined in charting. Administration called. DON called. Doctor faxed. Pastor was called and notified of death. Family to arrive for viewing and will give funeral home direction at that time." *11:28 a.m.-"Resident mother called to inquire about hotel rooms and condolences were given. She went on and asked about events surrounding resident's death. These were explained to her as outlined in charting." *2:58 p.m.- "Sister arrived and was greeted at the door. After seeing her brother, she had questions about funeral home and cleaning room. She also wondered about CPR being performed and was surprised to know that resident was full code (CPR should be started if no heart beat) as documented in the paper chart. Witnessed event and unwitnessed event was explained to her. She had no further questions at this time. She went on to say that she does not want information shared with resident's ex-wife." Review of resident 1's [DATE] physician's verbal telephone orders revealed: *8:10 a.m.- "Okay to transfer to ER for temperature 104.6" written by LPN D. *9:00 a.m.- "Time of death 8:50 a.m. Okay to release body to funeral home" written by LPN E. Review of resident 1's [DATE] medication and PRN record revealed documentation he received the following medications: [REDACTED] *At breakfast (no time documented)- -Aspirin. -[MEDICATION NAME] (antidepressant medication). -[MEDICATION NAME] ([MEDICAL CONDITION] medication). -[MEDICATION NAME] sodium (stool softner). -[MEDICATION NAME] (medication for [MEDICAL CONDITION] (retaining fluid)). -[MEDICATION NAME] (medication for rash). -[MEDICATION NAME] (stool softner). -Tamsulosin (prostate medication). -[MEDICATION NAME] (medication for muscle spasms). -Vitamin C. *[MEDICATION NAME] at 8:10 a.m. for temperature of 104.6. *[MEDICATION NAME] at 8:10 a.m. for nausea (upset stomach). Review of the [DATE] event report (monitoring of when a resident's call light was activated and the time elapsed before it was answered) provided by the administrator revealed the following for resident 1: *12:45 a.m. was activated and time elapsed before staff response was 8 minutes and 47 seconds. *3:10 a.m. was activated and time elapsed before staff response was 3 minutes and 26 seconds. *4:49 a.m. was activated and time elapsed before staff response was 1 minute. *6:14 a.m. was activated and time elapsed before staff response was 14 minutes and 54 seconds. *7:22 a.m. was activated and time elapsed before staff response was 11 minutes and 22 seconds. *7:47 a.m. was activated and time elapsed before staff response was 1 minute. *7:55 a.m. was activated and time elapsed before staff response was 1 minute. *8:02 a.m. was activated and time elapsed before staff response was 2 minutes and 27 seconds. *8:45 a.m. was activated and time elapsed before staff response was 7 minutes and 48 seconds. *8:53 a.m. was activated and time elapsed before staff response was 18 minutes and 3 seconds. (There was handwriting by the elapsed time "Bumped.") Review of the typed interview notes for the morning of [DATE] provided by the DON revealed: *CNA F who worked 6:00 a.m. to 9:00 a.m.: "Resident 1 was acting like resident 1. He does not like working with new people. I do not think he was acting unusual. He was dressed and put in his chair. At breakfast he ate a little bit. His arms and legs were flailing (moving rapidly), which caused him to spill his glass. His legs kept coming off the foot rests. He kept asking to have his feet put back on the foot pedals. He had an emesis in the dining room, went to his room, and threw up again. He has his shirt changed by CNA B and CNA F who then left the room. He kept calling CNA B back and wanted to drink water. He asked to lie down and LPN D and unlicensed assistive personnel (UAP) G laid him down. CNA B and F went into the dining room. LPN D stated he wanted up again and to get another temperature since his temperature was high. A cold cloth was placed on his forehead. CNA F assisted another resident in getting dressed and toileted, and when finished, she saw his call light was on. CNA F went into his room, turned his call light off at that time. She asked him a question if he was okay with no response. CNA F said the head of the bed was flat, and she did not see any vomit around his mouth. He was a natural color and had color in his face. CNA F then left the floor. CNA F told CNA B and UAP G, who later told LPN D that he was sleeping." *CNA B who worked 6:00 a.m. to 2:30 p.m.: "At 6:30 a.m. his call light was on. He was angry and frustrated due to new staff getting him ready for the day. He was coughing and gagging and he threw up. The dietary aide said he was feeding himself an egg sandwich and told CNA B he was not acting right. His arms were jerking and flailing more than usual and he knocked over his cup at breakfast. LPN D was around and saw that he was throwing up. He was taken to his room, they changed his shirt and cleaned his face. He was not hot at this time. He said he wanted to stay in his wheelchair in his room. He called out for me many times for small things, to move his phone charger and to move his call light. He continued yelling out but not asking for help. He said he was fine and was no longer nauseated. He put on his call light again asking to go back to bed. LPN D and UAP G put him in bed. They took his temperature, and he was really hot. LPN D said at that time he wanted to get up. At 8:40 a.m. he was still hollering. Around 9:00 a.m. he stopped yelling. I saw LPN D and told her that he was sleeping, and that they would wait to get him up. LPN D rushed into his room. LPN D told me he was dead. His face was bright purple, he had foam around his mouth, and there was yellow liquid coming out of his nose running down his neck, and yellow and chunks of emesis spilled out of his mouth when he was turned. He was still warm at this time." *UAP G who worked 6:00 a.m. to 2:30 p.m.: "He was hollering loudly and his yells were heard by staff members out in the hallway. His typically easily agitated, but his yells were worse than usual. Staff members thought he was more easily irritable this day because there were different staff members working than usual. He was louder than normal. He ate some breakfast and threw up. His pills were given between 7:30 a.m. and 8:00 a.m. in his room. At 8:10 a.m. [MEDICATION NAME] and Tylenol were given. He was driving his wheelchair into the trash can, door, and walls which was unusual. He cornered himself in his room. He sat in his wheelchair for 30 minutes waiting to go to bed. He laid down flat in bed with brief on and no sheet. He had a red face and you could feel the heat coming off his body. He was sweaty. A cold washcloth was placed on his forehead. His fan was on. He continued to yell and LPN D helped him. I remember LPN D going in the room quite often after he was lying down. CNA F was leaving around 9:10 a.m. She checked on him prior to leaving and said he was sleeping. When found his mouth was foamy and he turned purple." *LPN E who worked 6:00 a.m. to 6:30 p.m.: "There was nothing in report about him being ill. Five minutes to 9:00 a.m. LPN D called my phone and asked if I could come to the Sunshine wing right now. LPN D said the resident was dead. We went into his room and took his apical (chest) pulse with no pulse. He was cool, discolored, and had no respirations (breathing). His face had some dried substance on his beard. He had grey foam around his mouth. The sheet by his head was wet she thought maybe was from sweating. The sheet was wet right behind his neck and shoulder. He was lying flat. When LPN D was asked if he had a pulse or respirations when she had found him LPN D said no. I told her to document that. I explained the policy of witness/unwitnessed events for starting CPR. I started the resident death checklist. I told the CNAs to clean up the resident. CNAs said there was a large amount of foam coming out of his mouth. I reviewed the call light times for him. At 8:45 a.m. his call light was on. At 8:53 a.m. his call light was turned off." *LPN D who worked 6:00 a.m. to 6:30 p.m.: "There was nothing said in report about any abnormalities with him on the night shift. 6:30 a.m. I was on the floor. First thing he was calling to get him up. He was more needy than typical. He was the first one at breakfast. He was the first one they took care of, and he took a bit longer to get up. Maybe around 7:00 a.m. he was out to breakfast. He threw up at breakfast. He was gagging and threw up in a bag. He was taken back to his room right away. He was saying he was very hot. It was a half hour before LPN D and UAP G put him back in bed. I took his temperature and immediately gave Tylenol and [MEDICATION NAME] (medication for muscle spasms). He was insisting on drinking and I gave him one and one-half cup full of water. He was asked if he wanted to go to the hospital to which he responded that he did not want to go to the hospital (a CNA heard this in the hallway). I called the ER anyway and received a verbal order to transfer him to the ER. I did not write down the order immediately. I wrote it later in the morning. The actual time of the order is unknown. The ER staff member on the phone said that the Bata bus sometimes transfers residents to the ER. I went back into his room and said that he needed to be changed. I told CNA B to change him. I was not sure if I should call the ambulance or use the Bata bus so I needed to ask the other nurse LPN E. I did not know how to use the overhead paging system in the Sunshine wing and I chose not to use the one in the Riverview wing. I then went to look for LPN E in the Southridge wing. When I was in the Southridge wing, another resident was in the tub and her Foley (catheter) tubing came unconnected. I went to find tubing and a leg bag. I helped transfer this resident into the tub chair. This took about a half hour. I could not find LPN E, but I got LPN E's portable phone number when I went through Morningview wing. When back in the Sunshine wing, I asked if he had been changed, it was quiet, and they said he was sleeping. I rushed into his room. He was cool when found. I checked his wrist and used a stethoscope. He did not anything after emesis at breakfast. After I got order, I went back into his room and he was still hollering. I went in there and he was drinking water and watching TV. He was very thirsty. He was cool when found, cyanotic (without color), and foam on his mouth. I should have called the ambulance right away." Interview on [DATE] at 9:45 a.m. with LPN E regarding resident 1 revealed: *She had been there about fifteen years. *She was working on another nursing unit on [DATE]. During the course of a day there was little interaction between nurses the way the building was designed and each area having its own dining room. *She thought LPN D had been employed by the facility about a year. *The first time she had been made aware the resident was sick was after he had died . *They had a policy in place for do not resuscitate or full code. If an event was witnessed for a resident with a full code CPR was then initiated. If an event was not witnessed for a no code resident then no CPR was initiated. *She had reviewed his call light log as "It was bothering me later in the day." *The last time his call light was on was at 8:45 a.m. and had been turned off at 8:53 a.m. He was already likely dead. *CNA had told CNA B and UAP G he was sleeping when she had answered his call light. *LPN D did not have a portable phone on her, and she was unsure why. *The Bata bus was used to transport non-emergent resident situations, and the ambulance was called if they needed the ER. Interview on [DATE] at 10:00 a.m. with CNA F regarding resident 1 revealed: *She had been employed at the facility about a year. *She had come in extra to help with staffing on [DATE] from 6:00 a.m. to 9:00 a.m. *She very seldom ever worked on the Sunshine wing where he resided. *She had been working primarily in the restorative area. *CNA B who was working with her that day also rarely ever worked on the Sunshine wing. *CNA B and I got him up out of bed about 6:45 a.m. when he turned his call light on. *He was very upset that staff he was not familiar with were caring for him. *He was not happy with CNA B and myself, and he hollered loudly the whole time we were getting him up. We were giving him the care he should have received but not to his satisfaction. *He used his motorized wheelchair to go independently to breakfast about 7:00 a.m. *The dietary aide (not sure of her name) asked us what we had done to make him so upset as he was so crabby when he came to the dining room. *The dietary aide told us she thought he was going to get sick, and I got him some bags. *We took him to his room, and he had another emesis. *CNA B and I changed his shirt. We thought the emesis was breakfast. *I never talked to LPN D. She talked to CNA B more. *I do not believe I ever informed LPN D he was sick. *I was supposed to be done at 9:00 a.m., and his call light was on. *She had been told LPN D had given him Tylenol and put a washcloth on his forehead which he had taken off right away. *CNA B had told her LPN D wanted them to take his temperature again prior to her answering his light. She thought the Tylenol had relaxed him, and he had fallen asleep. *The room was dark when I answered his call light. His eyes were closed, and I could not see his mouth. *I told CNA B and UAP G that he had fallen asleep before I left the floor after answering his light. I then went down to the restorative room. *I was surprised when I heard a little after 10:00 a.m. he had passed away. Interview on [DATE] at 10:15 a.m. with CNA B regarding resident 1 revealed: *She had been employed by the facility since [DATE]. *There were issues in report that morning about what CNAs should work on the Sunshine unit. *The other CNAs decided where they were going to work, and it was left up to CNA F and herself to work on the Sunshine wing. *She usually never worked on the Sunshine wing and neither did CNA F. *LPN D was not in the dining room when he vomited, but she was in the hallway and had seen me grab the emesis pan. *The UAP usually focused on passing the medications in the morning, and the nurse worked on treatments. *UAP G and LPN D put him to bed about 8:00 a.m. *At about 8:40 a.m. LPN D told me to get him back up and take his temperature. CNA F and I were just going to get another resident up and did that first which took us until about 9:00 a.m. *Between about 8:40 a.m. and 9:00 a.m. we did not hear him hollering anymore when we were getting the other resident up for the day. *The whole morning he had been constantly hollering which could be heard in the hallway and when in other residents' rooms. *CNA F peeked in on him before she left at 9:00 a.m. and told myself and UAP G he was sleeping. *I told LPN D he was sleeping. When I told her he was sleeping LPN D rushed into his room. I guess she felt something was not right. *There was a shortage of pagers that weekend to alert staff when call lights were on. There was only one pager down the Sunshine wing, and I did not have one. Interview on [DATE] at 11:00 a.m. with UAP G regarding resident 1 revealed: *The morning started out unusual with the CNAs not communicating who was going to work where. *Since she was more familiar with the Sunshine wing than CNAs B and F, she had asked CNA B if she wanted to pass the medications. She did not. *He had thrown up before his pills. She had asked LPN D if she should go ahead and give him his pills, and LPN D had told her to go ahead. *She went back later and gave him [MEDICATION NAME]. *She knew he had vomited shortly after he had gotten up between 6:45 a.m. and 7:00 a.m. *She heard about 8:00 a.m. his temperature was 104.7. *LPN D gave him Tylenol for his temperature. *He wanted to go to bed between 7:30 a.m. and 8:00 a.m. after she had given him his medications. *He was laid down in bed after she had given him the [MEDICATION NAME] but was unsure of the time. *He had started initially to holler when CNA B and CNA F went to get him up for the day. *She thought he had been hollering "Bed" a lot. *He usually had a lot of tantrums, but "they were beyond different" on that day. *LPN was the one that found him dead. Interview on [DATE] at 1:20 p.m. with LPN D regarding resident 1 revealed: *She had worked at the facility about one month "maybe a little more." *She thought she had been hired in [DATE]. *She had "shadowed" a couple nurses on the day and night shift once or twice. She thought about four shifts before she was on her own. *When you shadow another nurse you follow that nurse and ask a lot of questions. *She was unsure how many times she had worked with resident 1 prior to [DATE]. *She knew he was pretty vocal but felt comfortable working with him. *She knew CNA B and CNA F usually never worked with him, and UAP G was more familiar with him. *It was the nurse who decided where the CNAs worked, and it had been decided UAP G would administer medications that day. *The nurse was usually busy doing treatments and did not have a lot of time to help the CNAs on the floor. *There was nothing in report about any abnormalities with him during the night shift. *His hollering was not alarming to her as "he could be like that." Interview on [DATE] at 2:00 p.m. with the DON and administrator regarding resident 1 revealed: *They were in the process of rebuilding their orientation program. *The assistant DON and education director had left before the DON started three months ago. *They were starting a new position. An operations nurse that would bridge the gap in direct care staff education. *They had made some cuts due to financial reasons in all departments but nursing the past year. *Nursing had only been restructured, but the nursing staff were having difficulty adjusting to the changes. *LPN D had received orientation when she had started on [DATE] how to use the phone and paging system. *They confirmed there was no documentation on her orientation checklist she had received emergency service training. *Their expectation would have been basic emergency care would have been taught in nursing school. *LPN D should have transported him to the ER when she had received the verbal order from the physician at 8:10 a.m. *They had offered to LPN D more education on their policies and procedures prior to [DATE], but she had declined. *Since [DATE] LPN D had been reassigned to CNA duties. Review of the provider's undated Charge Nurse job description revealed: *A charge nurse's duties included accessing residents' records, monitoring residents, and informing physicians of changes to residents' conditions. *Additional duties included communicating with supervising nurses about residents' conditions when needed. *Provided appropriate interventions or recommended interventions based on interpretations of changes in residents' conditions. 3a. Review of RN C and M's personnel files revealed their CPR certifications had both expired. b. Review of LPN D and O's personnel files revealed no documentation of any CPR certifications. c. Review of RN J, K, L, N, P, and Q's personnel files revealed no documentation of any CPR certifications. d. Review of the provider's undated CPR Status policy and declaration revealed: *"If you choose to CPR administered, the following will occur: -CPR will be initiated by the staff in the event the resident stops breathing and has no pulse in the presence of staff. In other words, if this event is witnessed CPR will be initiated. -911 will be called. -Hospital field emergency care providers will continue with the resuscitation process and transport the resident to the hospital. -In the event the resident is found without a pulse and is not breathing, CPR will not be initiated, 911 will not be called, and hospital field emergency care providers will not arrive to provide continued medical care. The family and physician will be notified of the death." *"If you choose you do no want CPR administered, the following will occur: -CPR will not be initiated in the event you become pulseless and not breathing. -The resident will be maintained as comfortable as possible including the administering of pain medication as ordered by the doctor." Interview on [DATE] at 4:00 p.m. with the DON and administrator regarding the above revealed: *All licensed nurses should have been currently certified in CPR. *Their personnel files should have had current CPR certification cards.

Based on observation, interview, record review, and policy review, the provider failed to ensure the appropriate monitoring, assessment, and treatment for [REDACTED]. Findings include: 1. Observation and interview on 3/18/13 at 5:00 p.m. with resident 3 revealed she: *Was lying on her back in bed with the head of her bed elevated. *Had been admitted on [DATE]. *Had fallen at home and had fractured her right hip. *Had spent the majority of her time in bed. *Was unable to bear any weight on her right leg. *Ate most of her meals in bed. *Had therapy twice a day. Observation and interview on 3/19/13 at 8:45 a.m. with resident 3 revealed she: *Was lying in bed on her back with the head of her bed elevated. *Was waiting for breakfast. *Required total assistance with repositioning. *Had informed this surveyor the staff had never repositioned her on her sides. *Had never been repositioned throughout the night. *Had stated staff would come in and assist her to scoot up in bed at times and would assist her with activities of daily living. *Had open areas on her thigh, right side of her back, and now on her bottom. Interview on 3/19/13 at 9:00 a.m. with Minimum Data Set (MDS) coordinator B regarding resident 3 revealed the certified nursing assistants (CNA) used repositioning logs (a piece of paper with the resident's name and time to be repositioned).Those logs were used for residents who required repositioning assistance. Interview on 3/19/13 at 9:09 a.m. with CNA C regarding repositioning of resident 3 revealed: *She had assisted her with using the bedpan. *She had not assisted her with any repositioning from side-to-side in bed. Interview on 3/19/13 at 9:15 a.m. with RN E regarding repositioning of resident 3 revealed the staff were to reposition her every two hours. Interview on 3/19/13 at 9:25 a.m. with CNA D regarding repositioning of resident 3 revealed: *The resident had a trapeze on her bed to assist with repositioning. *She had never repositioned the resident from side-to-side. *She had only assisted resident 3 with repositioning her bottom in bed for comfort with the use of the trapeze. *Therapy had assisted resident 3 with dressing. Observation on 3/19/13 at 9:30 a.m. of the occupational therapist and CNA D as they provided care to resident 3 revealed: *The resident needed total assistance of two staff with repositioning. *There was a brownish dressing noted to the resident's coccyx (tailbone). *There also was a pink abduction pillow (to prevent criss-crossing of legs) placed between the resident's legs. Review of resident 3's 2/22/13 MDS revealed: *She was alert and orientated to person, place, and time. *She was totally dependent on staff for bed mobility, transferring, and dressing. *She was at risk for developing a pressure ulcer. *She was on a turning and repositioning program. Review of resident 3's 2/27/13 care area assessment (CAA) summary revealed: *She was at risk for skin breakdown due to: -Total assistance with bed mobility. -Incontinence. -Pain. -Functional limitation in range of motion. *She had very restricted mobility and was non-weight bearing. *Staff assisted her with bed mobility, toileting, and personal care. Review of resident 3's March 2013 treatment administration record (TAR) revealed: *On 3/16/13 there was a handwritten instruction to monitor a stage two pressure ulcer to her left coccyx twice daily. *On 3/19/13 there was a handwritten order to "monitor stage 2 to sacrum (L (left) coccyx) QD (everyday) and change every seven days or as needed if soiled or rolled." There were no specific instructions on the type of dressing that should have been applied. Review of resident 3's turning and repositioning program dated 3/5/13 revealed: *She needed to be repositioned at least every two hours. *She was to be repositioned at night during rounds. *She had required physical assistance of two or three staff with bed mobility and transfers to make sure no weight was applied to the right leg. *Staff were to make sure the repositioning was completed without causing friction or a shearing force. *The goal was to have zero pressure areas. *Skin was observed closely twice daily during care and as needed especially heels, elbow, and coccyx for any other actual or potential pressure areas or alteration in skin. Review of resident 3's Braden scale (measurement for predicting pressure ulcer risk revealed: *On 2/17/13 she had scored sixteen that placed her at a mild risk. *On 2/22/13 and 3/5/13 she had scored eighteen that had placed her at a mild risk. * On 3/5/13 under the mobility risk factor that indicated the ability and control of body position she had been scored a three (slightly limited movement that meant she could make frequent though slight changes in body or extremity position independently). *She was totally dependent on staff for repositioning. Review of resident 3's 3/16/13 comprehensive care plan revealed: *There was a stage two (partial thickness loss of the skin presenting as a shallow open ulcer with a red or pink wound bed) pressure ulcer to her coccyx. *The intervention was to "Enc. (encourage) staff to reposition often." *There was no goal addressed. *The current treatment had not been addressed. Review of resident 3's Progress Notes Listing revealed: *On 3/16/13 at 1:30 p.m. the left side of the sacrum/coccyx there was a wound identified that had been caused by pressure. -The area measured 1.2 centimeters (cm) by 0.4 cm. *On 3/16/13 at 1:42 p.m. the physician had been notified of the open area. *Treatment per protocol included repositioning at least every two hours. *The preventative measures: "Resident is on a repositioning schedule every 2 hours." *Physician had noted and signed the Progress Notes Listing form which had not been dated by the physician. Review of the repositioning and toileting sheets for resident 3 from 3/7/13 through 3/18/13 revealed: *During the night shift there were entries made at 11:00 p.m. and 3:00 a.m. There was no indication the resident had been repositioned. It had just been initialed and handwritten "OK." *On 3/16/13 it had been handwritten "pressure ulcer bottom stage 2." *On 3/17/13 the night shift charting revealed a handwritten entry "dressing on bottom." There had been initials entered at 11:00 p.m. and 3:00 a.m. and handwritten "OK". *On 3/18/13 on the night shift there had been entries at 11:00 p.m. and 3:00 a.m. with initials and handwritten "OK". *On 3/18/13 on the evening shift it had been handwritten "pressure areas repo (reposition) every 2 hrs. (hours)". It was marked "OK" at 4:00 p.m., after supper, and 8:30 p.m. *Throughout the review of those sheets there had been no indication the resident had been repositioned or toileted with the initialed entries. Interview on 3/19/13 at 10:00 a.m. with MDS coordinator A regarding resident 3's current pressure ulcer, repositioning schedule, and the interviews with CNA C and D revealed: *She was being repositioned every two hours except for the night shift. *There was a concern with inconsistent staffing. *Staff had not followed the resident's plan of care. *She agreed the resident should have been repositioned every two hours. *CNA C and D should have been assisting resident 3 with repositioning. *The current pressure ulcer treatment was being performed by a protocol from a wound supply company without notification of the physician prior to initiating the treatment. *The provider had been following guidelines from the topical wound management company regarding pressure ulcers. *The resident's physician had been notified regarding the pressure ulcer but not the current treatment being provided. Interview on 3/20/13 at 9:35 a.m. with MDS coordinator A regarding resident 3 revealed: *Staff should have been educated regarding the importance of repositioning and prevention of pressure ulcers. *The direct care staff should have followed through with the repositioning of the resident to prevent pressure ulcers. *The care plan had not been updated to reflect the resident's current treatment and need for repositioning every two hours. 2. Review of resident 11's current medical history revealed he: *had a history of [REDACTED]. *Currently had a pressure ulcer on his left buttock (bottom). That pressure ulcer had been identified on 3/3/13. *Had multiple medical [DIAGNOSES REDACTED]. Review of resident 11's physician's orders and nursing notes from 3/4/13 revealed: *Staff had identified a scabbed over pressure ulcer on his left buttock on 3/3/13 at 9:00 p.m. and his right buttock was reddened. *The physician had been notified via fax on 3/4/13 and had ordered Zinc Oxide to be applied to the area. *Prevention measures to have been implemented by nursing at that time were to place a cushion in the resident's chair at meal times. Observations on 3/20/13 of resident 11 during the breakfast and lunch meals revealed he had not had an additional cushion placed in his dining room chair during either meal service. Observation and interview on 3/20/13 at 10:00 a.m. with licensed practical nurse (LPN) P during resident 11's left buttock dressing change revealed: *No dressing was present on the resident's buttock from the prior documented dressing change. *The resident had a large reddened area that encompassed both his inner left and right upper buttock folds and tail bone area. That area did not blanch when LPN J was asked to test it. The left buttock also had a small scabbed over area. *The resident stated his buttock was very painful especially when he tried to slide up and down in his bed. *LPN P cleansed the area with sterile water saturated gauze pads and then proceeded to apply a pressure ulcer dressing the size of a quarter to just the small area located on the left buttock. *LPN P confirmed after the dressing change the resident had both stage 1 and possible stage 2 pressure ulcers to his buttock and tail bone areas. Interview and record review on 3/20/13 at 8:30 a.m. and at 10:30 a.m. with RN case manager G regarding resident 11's pressure ulcer revealed: *She was currently in charge of the care and monitoring of the resident's pressure ulcer with the assistance of the provider's consulting wound care nurse. Refer to F281, finding 1 regarding the provider's consulting wound care nurse. *Nursing staff had delegated both the application of the Zinc Oxide and the assessment of the pressure ulcer to CNAs from 3/4/13 through 3/14/13. During that time the pressure measurements had changed from 0.5 cm by 0.5 cm to 3 cm by 1 cm. *No daily nursing information related to his pressure ulcer was documented other than initialing the resident's treatment record indicating the dressing change had been completed. *Staff had stopped applying the physician ordered Zinc Oxide on 3/14/13 and had now started applying a [MEDICATION NAME] dressing with no Zinc Oxide. No physician order existed for that change. The change had been made based upon a manual given to the provider by a pressure sore dressing company. *The provider considered the above mentioned manual the pressure sore "protocol." However none of the interventions had been approved by the medical director or any of the other physicians [MEDICATION NAME] in the facility. The front page of the above manual stated; "It is for the readers' general knowledge and is not a substitute for legal or medical advice." *No physician order existed for the dressing change observed above or for the method of cleansing the wound. *The resident's 3/5/13 care plan had not been updated with the most current interventions including the dressing change and pressure relieving cushion. *No Braden scale pressure ulcer risk assessment tool had been completed on the resident since 2/26/13. Preceptor: 3. Record review of resident 2's 3/5/13 care plan revealed: *Pressure ulcers to her left and right heels. *The nursing staff were to monitor the heels daily. *The MDS nurse was to measure the pressure ulcers weekly. Review of resident 2's weekly pressure ulcer flow sheets from 11/27/12 through 3/20/13 revealed: *There were no measurements documented for nine of sixteen weeks for the stage three pressure ulcer to the right heel. *There were no measurements documented for ten of sixteen weeks for the stage two pressure ulcer to the left heel. A pressure blister to the right heel had been discovered and measured on 3/8/13. There was no documentation of measurements for that blister for the week of 3/10/13 through 3/16/13. Interview on 3/20/13 at 9:40 a.m. with MDS coordinator A revealed: *Her expectation for resident 2's pressure ulcer assessment and measuring was it should have been done weekly. *The assessment and measuring had not always been done weekly due to time constraints and resident activity. Review of the provider's wound care policy dated July 2012 revealed: *The charge nurse was required to document daily on the wound. *The charge nurse was to document on the treatment record with each dressing change or observation. *The MDS nurse was to reassess the resident's skin including the wound weekly and document findings on the weekly pressure ulcer flow sheet or weekly nonpressure ulcer flow sheet. *The MDS nurse would create a weekly progress note addressing the wound. Review of the provider's 2005 care plan policy revealed: *"Purpose: Our facility develops a comprehensive care plan for each resident that includes measurable objectives and timetables to meet the resident's medical, nursing and psychological needs". *"Care plans are revised as changes in the resident's condition dictate." Review of the South Dakota Board of Nursing Administrative Rules for nursing delegation revealed: *20:48:04.01:07. Nursing tasks that may not be delegated. The following are nursing tasks that a licensed nurse may not delegate to unlicensed assistive personnel: -Assessments which require professional nursing judgment, intervention, referral, or follow-up. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th Ed., St Louis, Mo., 2005, revealed: *Page 419: "The physician is responsible for directing medical treatment. Nurses are obligated to follow physicians' orders unless they believe the orders are in error or would harm clients. Nurses must be certain to document that the physician was notified and document his or her response, the nurse's follow-up, and the client's response." *Page 481: "High-quality documentation and reporting are necessary to enhance efficient, individualized client care. Quality documentation and reporting have five important characteristics: they are factual, accurate, complete, current and organized."

Based on observation, interview, record review, and policy review, the provider failed to ensure adequate supervision and monitoring related to Wanderguard and door alarms to prevent accidents or potential for accidents for five of five sampled residents (2, 3, 8, 10, and 12) with Wanderguards. Findings include: 1. Observation from 6/18/12 through 6/19/12 of resident 2 revealed: *On 6/18/12 at: - 3:35 p.m. she was sitting in her wheel chair (w/c) in the Southridge day room. -4:55 p.m. she was sitting in her w/c and leaned forward sounding the Tabs alarms attached to her shirt. A certified nursing assistant (CNA) responded by assisting with repositioning her in the w/c and reattaching the Tabs alarm. -5:30 p.m. she was sitting in her w/c in the Southridge dining room. After she was assisted with meal tray set-up and cueing she ate independently. -6:00 p.m. she propelled her w/c independently away from the table and began to go up and down the Southridge hallway. There was no attempt by any staff to redirect her. *On 6/19/12 at: -11:30 a.m. she was sitting in her w/c in the Southridge dining room eating independently. -1:35 p.m. she ambulated (walked) independently out of her room. The Tabs alarm could be heard ringing from her room. She had part of the alarm attached to her shirt. She had ambulated approximately 60 feet from her room when two staff members noticed her and assisted her back to her room. -2:00 p.m. she was in her w/c propelling independently down the "east hallway." Two staff members walked by her and made no attempts to redirect her. -5:00 p.m. she was in her w/c propelling independently up and down hallways. There was no attempt by any staff to redirect her. Review of resident 2's complete medical record revealed: *An initial admission date of [DATE]. *A readmission date of [DATE]. *A [DIAGNOSES REDACTED]. *The most recent physician's orders [REDACTED]. *A progress note dated 4/16/12 at 5:37 p.m. revealed: -On 4/16/12 at 5:30 p.m. "CNA had stated to this nurse that resident was seen outside. CNA and nurse went out to get resident. Resident found with no harm down in park next to facility. Resident was known to cut Wanderguard off per self. New one had been applied. Had also been taken off by resident found by resident's kleenex box in room." *Progress note dated 5/16/12 at 3:35 p.m. revealed: -"At 2:25 p.m. a Brookings city police officer entered the building and asked if we had a resident by the name of (resident's name). Informed there is someone by that name in this facility. Police officer states that they found a lady on 3rd and 4th who had fallen in the street with abrasions to her face and the only thing she could tell them was that her name was (resident's name). He states the ambulance is taking her to the ER to be evaluated. Facility search completed and staff looked outside for resident. She was not found. (Resident's name) has been noted to take and/or cut off her wanderguard several times in the past. Family have stated this as well. She had taken it off again just last evening and the nurse reapplied it at that time. Searched facility for wanderguard. None found. (Resident's name) does have advancing dementia and does wander about the facility. (Resident's name) was out with family before noon and son states she was upset with them when they left here today. Resident did attempt to elope at 11:51 when the door alarm went off as she had gotten to close. Resident was noted sitting in the lobby at 2:00 p.m. in the rocker glider. During the search of facility for (resident's name), another resident was sitting by the front door with her family members who visit here on a daily basis. These family members state they saw her leave and walk towards the park." Review of the South Dakota EMS (emergency medical response) Report dated 5/6/12 revealed: *The ambulance arrived at 2:14 p.m. at the scene. *The narrative revealed "Called by dispatch for a female pt (patient) lying on the road with an unknown problem. Upon arrival pt found lying prone (face down) on the side of the roadway with bystanders attending to her. Pt is awake but confused c/o (complain of) pain to her jaw, mouth and nose. Also pain to left elbow and bilateral (both) hips and lower back. Pt is able to follow commands but answers inappropriately at times. Bystanders saw pt trip after stepping off the curb and falling face first onto the roadway. Possible loc (level of consciousness) initially as bystanders report pt not verbalizing when they first tried to talk to pt. It is noted that the pt has a nursing home alert bracelet to her ankle and the pt does now recall that she lives at (facility name)." Review of resident 2's hospital discharge summary dated 5/9/12 revealed: *She had a bilateral condyle (jawbone) fracture. *"That bilateral condyle fractures were nonoperable. He (physician) noted that the surgery to reposition the condyles was difficult and has poor longevity thus had excessive risk and very little benefit." Review of the most recent care plan revealed: *Cognitive function: oriented to person, forgetful, and confused. *Restraints: Wanderguard. *Date - 5/9/12: -Problem: "I wander around the facility. I have eloped twice, with the second time resulting in injuries and a hospitalization . I do get upset and agitated when my family leaves after visiting me or returning me from an outing." -Goals: "I will not leave the facility unattended. I will remain safe." -Approaches: "Wanderguard to be worn at all times. I do take it off at times so you need to check it frequently throughout the day to make sure it is still in place. My family does not want me walking alone at this time. When my family leaves know that I will be more upset and anxious. Spend one to one time with me when I am very anxious an looking for them. Offer me activities to distract me when I am anxious and restless." *Date - 5/10/12: -Problem: "I have been lowered to the floor after I got up by myself." -Goals; "I want to stay safe and my family does not want me walking by myself." -Approaches: "Staff will check on me every 15 minutes. With these checks I will be offered the restroom, offered snacks, drinks, etc., asked if I am comfortable, and invited to any activities that are occurring." *Date - 5/14/12: -Problem: "I sat down on the floor in another resident's room." -Goal: "I will have not more falls this month." -Approaches: "I will wear a tabs monitor at all times. I will continue my 15 minute checks." Review of resident 2's physician's progress note dated 4/10/12 revealed "She had episodes of agitation and threatening behavior" and was referred to (name of mental health agency). Review of resident 2's psychological services progress note dated 4/27/12 revealed: *Presenting behavior/target symptoms: depression, helplessness, nervousness/worried/stresses, wandering, anxiety, confusion, memory loss. *Intervention: "Thought process good, however pt increasingly confused with where she is. Pt observed wandering more frequently. Mood sad, depressed. Anxiety r/t (related to) not knowing where she is at." Review of resident 2's elopement assessment forms dated 11/10/11 and 2/9/12 revealed a score of four. A four plus score "Indicates that resident may have potential for elopement." Review of resident 2's May and June 2012 treatment administration record (TAR) revealed: *The Wanderguard placement was to be checked every shift for placement. *Nineteen out of forty-eight checks were not documented as completed in May 2012. *Six out of thirty-six checks were not documented as completed in June 2012. Review of the provider's computerized log form for the front door revealed the alarm had not sounded when resident 2 had left the faciity on [DATE] sometime after 2:00 p.m. Review of the provider's daily alarm check flow sheets provided by the director of nursing (DON) on 6/20/12 at 11:15 a.m. for January 2012 through May 2012 revealed: *There were two separate door alarm check flow sheets for each month. *The door alarm check flow sheets revealed: -There was no identification on the flow sheets as to what door alarm was being monitored. -The identified times for the checks to be done were midnight, 6:00 a.m., noon, 1600 (4:00) p.m., and 2000 (8:00) p.m. -Instructions on the sheets revealed: "Check to make sure that all the alarms are on. Simply check the box and initial when alarm was checked." *The daily alarm check flow sheets revealed: -January 2012: ? Sheet One: 70 out of 155 checks were not documented as completed. ? Sheet Two: 108 out of 155 checks were not documented as completed. -February 2012: ? Sheet One: 68 out of 145 checks were not documented as completed. ? Sheet Two: 84 out of 145 checks were not documented as completed. -March 2012: ? Sheet One: 65 out of 155 checks were not documented as completed. ? Sheet Two: 60 out of 155 checks were not documented as completed. -April 2012: ? Sheet One: 62 out of 150 checks were not documented as completed. ? Sheet Two: 78 out of 150 checks were not documented as completed. -May 2012: ? Sheet One: 30 out of 155 checks were not documented as completed. ? Sheet Two: 68 out of 155 checks were not documented as completed. Interview on 6/19/12 at 3:30 p.m. with the DON revealed: *She was not sure if the provider had a Wanderguard policy. *The interdisciplinary team (IDT) determined who wore a Wanderguard. *If a resident had an elopement attempt then a charge nurse could put a Wanderguard on the resident until the IDT met. *The provider required a physician's orders [REDACTED]. Interview on 6/19/12 at 4:20 p.m. with the licensed social worker revealed: *A family member and a resident had seen resident 2 go through the front door on 5/6/12. *The front door alarm had not sounded as resident 2 went through the doorway on 5/6/12 Interview on 6/20/12 at 10:30 a.m. with the director of environmental services revealed: *As of 5/6/12 the alarm system was outdated. It was an old "code alert system." *The provider had not followed the policy for alarms and outside doors for daily documentation. Interview and policy review on 6/20/12 at 10:50 a.m. with the DON revealed: *She was not sure when the Wanderguard was initiated for resident 2. *Her expectations were for the nurse or unlicensed asssistive personnel (UAP) to sign off the TAR. If it was not signed than it was not done. *The flow sheets had not been completed according to the provider's revised June 2001 policy for Alarms and Outside Doors. *She had not documented the daily alarm checks according to the provider's undated policy for Resident Elopement Protocol which stated: "Daily alarm check will be completed by the DON or designee." Interview on 6/20/12 at 11:10 a.m. with registered nurse/Minimum Data Set (RN/MDS) coordinator D regarding resident 2 revealed: *She was not sure when a Wanderguard had been placed on the resident. *The resident had a Wanderguard on prior to the elopement on 5/6/12. *The resident had a Wanderguard on when she eloped on 5/6/12. *She agreed if the TAR was not signed off then the treatment or assessment had not been done. Interview on 6/20/12 at 11:30 a.m. with the administrator revealed: *An all staff in-service regarding elopement had not been conducted. *The staff had been educated on 6/8/12 through a memo placed in their pay check envelopes in regards to "Door alarms and Door Security as of June 8th, 2012." *She was not able to confirm if all the staff had read the memo. *She did not have a system/audit in place to confirm if all the staff had been educated to the alarm system. Interview on 6/20/12 at 12:35 p.m. with the DON revealed: *There were several open slots on the daily alarm flow sheet. *If the document had not been signed off then the door alarms had not been checked. *The staff had been re-educated to door alarms and elopement practices. *There had not been any further follow-up regarding door alarms or elopement. Review of the provider's April 2012 Elopement policy revealed: *"As preventative measures for residents at risk of eloping, the following steps will be taken: -a.) Residents with wanderguards will have their wanderguard checked monthly to make sure it is working. -b.) Residents with wanderguards will have their bracelet placement checked daily. -c.) Residents at risk for elopement will have an elopement assessment completed on all shifts." Review of the provider's revised October 2005 policy Alarms and Outside Doors revealed: *"The alarms connected to the doors that lead to the outside must be periodically inspected to ensure that they are in operational order. These doors include only the east door by the Sunshine Lounge, the east door in the 100 wing and the south door in the 500 wing. All other facility doors either open to a fenced area or are provided with other alarm devices." *"Four times every 24 hours, these three alarms will be visually inspected by facility staff to ensure that the alarms are active. -At 0400, 1000, 1600, and 2200 the alarms will be visually inspected. -A sign-off method will be used daily. -A separate record will be kept at each control panel." Review of the provider's undated Resident Elopement Protocol revealed: *"An elopement assessment is completed with each MDS (minimum data set) assessment: it is through this assessment that it will be determined what course of action to take depending on the amount of risk the resident displays. *If a resident scores greater than 3 on the MDS elopement risk assessment, the following will follow: -Monthly bracelet checks will be recorded on the TAR (treatment assessment record). -Every shift visual bracelet placement checks will be recorded on the TAR. -Daily alarm check will be completed by the director of nursing or designee. *At any time when the nurse believes intense visual observation should be completed, it should be implemented." 2. Review of resident 3's May and June 2012 TAR revealed: *In May and June the Wanderguard: -Was to be checked for placement every shift. -Was to be checked monthly to ensure proper working order. *Nineteen out of fifty checks were not documented as completed in May 2012. *Six out of thirty-six checks were not documented as completed in June 2012. *There was no documentation in May 2012 the Wanderguard had been checked for proper working order. 3. Review of resident 12's medical record revealed: *The May 2012 and June 2012 TAR stated to check Wanderguard placement every shift. *Eleven out of fifty checks were not documented as completed in May 2012. *Ten out of thirty-eight checks were not documented as completed in June 2012. 4. Review of resident 8's medical record revealed: *The May 2012 TAR stated to check Wanderguard monthly for placement and function. There was no documentation the check had been completed. *The May 2012 and June 2012 TAR stated to check Wanderguard placement every shift. *Sixteen out of forty-eight checks were not documented as completed in May 2012. *Eight out of thirty-eight checks were not documented as completed in June 2012. 5. Review of resident 10's April, May, and June 2012 treament administration record (TAR) revealed: *In April and May the Wanderguard was to be checked monthly to make sure it was in good working condition. *There was no documentation that had been done. *In May and June there had been an order to check Wanderguard placement every shift. There were multiple times when there was no documentation this had been done.

Based on observation, interview, record review, and policy review, the provider failed to: *Prevent pressure ulcers from developing for two of five sampled residents (1 and 6) with pressure ulcers. *Appropriately care plan current treatments and needs for two of five sampled residents (1 and 6) with pressure ulcers. *Ensure the current pressure ulcer treatment had been placed in the treatment administration record (TAR) for one of five sampled resident's (1) with pressure ulcers. Findings include: 1. Observation on 6/19/12 at 7:45 a.m. with registered nurse/Minimum Data Set (RN/MDS) A coordinator of resident 6's room during a dressing change revealed: *The resident was totally dependent on two staff members to be transferred from her wheel chair (w/c) to the bed and to be positioned in bed for the dressing change. *There was a pressure ulcer to the resident's left ischium (the area between the bottom of the buttock and the upper leg) measuring 1.4 centimeters (cm) by 0.9 cm. *The treatment consisted of an application of wound gel and covering the area with a foam dressing daily. *The resident was transferred back to the w/c with the assistance of two staff members and was taken to the dining room for breakfast. Interview with RN/MDS coordinator A during the dressing changed revealed: *The pressure ulcer was first noted on 6/6/12. *The resident had declined in activities of daily living and had required more assistance. Observation on 6/19/12 of resident 6 revealed: *From 8:05 a.m. through 11:40 a.m. she was sitting in her w/c. *At 11:45 a.m. she was sitting in her w/c in the dining room eating dinner with staff assistance. *From 2:30 p.m. through 3:30 p.m. she was in her bed lying on her left side. *At 4:20 p.m. she continued to be lying in her on her left side in her bed. *From 4:50 p.m. through 5:05 p.m. she continued to lie in bed on her left side. Observation on 6/20/12 from 8:00 a.m. through 10:30 a.m. of resident 6 revealed she was sitting in her w/c in the dining room and in the front TV room. Random observations on 6/20/12 from 10:30 a.m. through 3:00 p.m. of resident 6 revealed she had not been placed in bed during that time. Review of resident 6's certified nursing aide (CNA) care sheets revealed there was no consistent information regarding repositioning. Review of resident 6's Pressure Ulcer Healing Chart for the left ischium revealed: *On 6/6/12 the measurement was 2 cm by 1.9 cm. *On 6/13/12 the measurement was 1 cm by 1 cm. *On 6/19/12 the measurement was 1.4 cm by 0.9 cm. Review of the provider's Pressure/Venous/Arterial Weekly Wound report revealed on 6/6/12 resident 6's left ischium pressure ulcer was stage 3 (full thickness loss, subcutaneous fat may be visible). Review of resident 6's progress notes revealed: *On 6/6/12 at 9:41 a.m. the doctor was notified. -The cause of the wound was pressure. -Preventive measures included frequent repositioning and laying the resident down in bed at least twice daily. -Resident was w/c bound and had declining mental and physical status. Review of resident 6's MDS dated [DATE] revealed she: *Had a [DIAGNOSES REDACTED]. *Required extensive assist with transfers, toileting, and bed mobility. *Had impairment in her upper and lower extremities (arms and legs). Review of resident 6's Care Area assessment dated [DATE] regarding the pressure ulcer revealed: *She was at high risk for obtaining a pressure ulcer. *She currently had a pressure ulcer on her left ischium. *The wound nurse had observed the area and treatment had been started. *The resident had a turning schedule before but time to lie down had been increased from once to twice daily. *A dietary supplement had been started. *"She had a pressure relieving device in her chair, but if wound did not heal or other areas were noted, will check into pressure relieving device for the bed also since she is not moving as well as she used to. No further referrals needed." Review of resident 6's current care plan dated 6/6/12 revealed: *She needed one person's assistance. *She was on a turn and position program every two hours. *Her Braden score was fifteen on 5/29/12, that meant she was at mild risk to develop a pressure ulcer. *On 6/6/12 Problem/Need revealed she was at high risk of skin breakdown. Interview on 6/19/12 at 11:30 a.m. with the registered dietitian (RD) regarding resident 6's pressure ulcer revealed: *She was unaware the resident had a pressure ulcer. *The dietary manager (DM) was to notify her of any skin issues. *To her knowledge she had not been notified of the resident's pressure ulcer. Interview on 6/19/12 at 11:40 a.m. with the DM regarding resident 6's pressure ulcer revealed: *The nurses would notify her of skin issues and then she would notify the RD. *She was unsure whether she had been notified of the resident's pressure ulcer and needed to check her notes. *After she had checked her notes she stated she had not been notified of resident 6's pressure ulcer. *She believed resident 6 was already on a health shake twice daily. Interview on 6/19/12 at 3:45 p.m. with the director of nursing (DON) regarding resident 6's pressure ulcer and interventions revealed: *The resident care sheets used by staff showed when the resident was repositioned. *Each shift received a care sheet for their current assignments and initialed after toileting or repositioning residents. *She stated " You would need to talk to RN/ MDS coordinator A regarding resident 6's pressure ulcer and interventions." Interview on 6/19/12 at 4:00 p.m. with RN/MDS coordinator A regarding resident 6's pressure ulcer and interventions revealed: *The resident had not been placed on a pressure relieving device for her bed. *She had felt the pressure ulcer was improving with repositioning. *She had not felt resident 6 needed the device for her bed. *The resident had a pressure reducing device for her w/c. Review of the provider's October 2009 policy for Prevention of Pressure Ulcers revealed: *"Assessment of risk on admission to the facility and at regularly scheduled intervals." *"Appropriate skin and incontinence care." *"Adequate nutrition and the addition of supplements as needed." *"Relief/reduction of pressure as needed. *"Continued education of residents, families, and staff relative to the prevention of injury to the skin." *Nursing care shall include: -"Turning and repositioning at a minimum of every 2 hours with inspection of bony prominences." -"Incontinence care every 2 hours and as needed." -"Assessment of nutrition and hydration with referrals as needed." -"Institution of measure to reduce the effects of pressure, friction, and shear." 2. Review of resident 1's complete medical record revealed: *On 6/14/12 at 6:10 a.m. the nurses progress note revealed a stage 2, 1.5 cm by 2.5 cm by 0.1 cm reddened area to resident's left inner buttock. *On 6/19/12 at 3:18 p.m. the RD had sent a fax to resident 1's physician that addressed "a stage 2 ulcer to her left inner buttocks." *The 4/24/12 MDS stated the resident was at risk for developing a pressure ulcer. *There was no documentation on the TAR and the care plan that identified the open area. Interview on 6/20/12 at 8:15 a.m. with RN/MDS coordinator D revealed: *The open area had not been documented on the TAR or in the care plan. *The nurse who found the open area was responsible for putting the information on the TAR. *Any nurse who was working would not know if resident 1 had an open area.