Every finding on record at Wakonda Heritage Manor

Based on observation, record review, interview, and policy review, the provider failed to ensure there was documentation to support if one of one sampled resident (6) was a candidate for a restraint (a device, material, or medication used to restrict a resident's movement or access to their body to ensure safety or prevent harmful behavior) reduction, a less restrictive method, or for a restraint elimination. Findings include:1.Observation on 5/5/26 at 1:34 p.m. of resident 6 revealed she was sitting in the lounge area in a manual recliner with her feet elevated, watching a movie on the television. 2. Observation on 5/5/26 at 2:20 p.m. of resident 6 revealed she was sleeping in a manual recliner in the lounge area with her feet elevated and a Tab monitor (alarming device to alert staff of movement) was attached to her clothing. 3. Review of resident 6's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 3/2/26 Brief Interview for Mental Status (BIMS) assessment score was 2, which indicated her cognition was severely impaired. She had a physical restraint consent dated 3/8/26 for a Tabs alarm/pressure mat signed by her family member. She had a 4/8/26 physician's order, which indicated to ensure the resident had her Tabs alarm on everyday and night shift due to her dementia (a group of symptoms affecting memory, thinking, and social abilities). Her 5/6/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) had a focus area of I need help with all activities of daily living [ADLs]. I am frequently incontinent of my bladder. I am unsteady at times. The interventions included may use a recliner without feet up, initiated on 11/5/24. Her 7/6/25 lift chair safety assessment indicated, I am not safe to use a lift chair on my own. I have a manual recliner in my room. She had a 3/9/26 physical restraint assessment that indicated there was continued imminent danger to the resident or others and that she had an unsteady gait, agitated behaviors, forget her ambulation device, had frequent falls, attempted to self-transfer, and climbs out of bed. The alternative methods that were attempted included the alarm devices on her bed, and chair. She had nursing progress notes that indicated she fell in the lounge area on 3/31/26 and 4/5/26. She had a behavior progress note dated 5/1/26, which indicated Resident has been noted to be attempting to stand up out of [her] recliner, leaning forward in her recliner and trying to take her Tabs alarm off this shift. Resident has been repositioned in her recliner with her feet up to relax. 4. Interview on 5/5/26 at 2:49 p.m. with resident 6's family member revealed he visited the resident often, and had no concerns about her care. He was aware she had a tabs monitor, and that she was unable to put the foot of the recliner down herself since, her strength had decreased. He wanted her to be comfortable and pain free. 5. Observation and interview on 5/6/26 at 11:35 a.m. with activity director (AD) F revealed resident 6 was leaning forward in her wheelchair, sitting at the nurse's station waiting for lunch. She was removing her gripper socks; her Tabs monitor was attached to her shirt and wheelchair. AD F stated that resident 6 could be very active at times, and she does self-transfer out of her wheelchair. She did not think resident 6 could manually work the recliner lever when she was sitting in the lounge recliner. 6. Interview on 5/6/26 at 1:47 p.m. with certified nursing assistant (CNA) H revealed that resident 6 could not release the manual recliner herself. She was not supposed to have her feet in the upright position when sitting in the recliner in the lounge. Resident 6's care plan indicated that her feet were to always be down. 7. Interview and EMR review on 5/7/26 at 8:48 a.m. with minimum data set (MDS) Coordinator/registered nurse (RN) D revealed she and director of nursing (DON) B updated the nursing part of the resident's care plans. MDS/RN D did not consider resident 6's feet being elevated in the recliner a restraint because she could put the chair down at times; the staff were elevating it for comfort. The staff were educated regarding following interventions on the resident's care plans, pocket care plans (a document that identifies a resident's care needs and interventions) and referencing the change of shift report (report by nursing when new shift comes on). MDS/RN D completed the quarterly and annual restraint assessments for the residents, and the direct care nurses completed the initial one. Resident 6 had a 3/9/26 restraint assessment completed, and a consent for the Tabs alarm was obtained at that time, there was no documentation on the physical restraint assessment form to support why it was not considered a restraint. 8. Interview on 5/7/26 at 9:10 a.m. with DON B revealed the staff refer to the pocket care plans for resident information. She was aware of the care plan intervention to not elevate resident 6's feet in the recliner. She agreed it appeared to be a restraint, but felt that the staff did not intend to restrain resident 6 in the recliner. DON B acknowledged that resident 6 was restrained during the surveyor's observations. 9. Review of the provider's revised 12/31/25 Physical Restraint policy revealed Purpose: To standardize the Restraint Policy to provide guidelines for the appropriate use of physical and/or chemical restraints int the [NAME] LTC [long-term care] facility setting. This assures [NAME] restraint procedures are consistent, compliant, and provides reliable communication to all departments and [NAME] LTC facilities. Policy Scope: This policy will apply to all individuals implementing physical and/or chemical restraints at [NAME] LTC Facilities. It is the responsibility of each Director of Nursing to assure the entities do not have policies that conflict with the content of this policy. [NAME] entities are required to adopt [NAME] LTC Governance Committee policy. Physical restraint: any manual or physical or mechanical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom or movement or normal access to one's body. Physical restraints include but are not limited to leg or arm restraints, bolster mattresses, hand mitts, soft ties or vests, leg cushions and lap tray the resident cannot remove, and tucking a sheet around a resident so that resident cannot move. Freedom of movement: means any change in place or position for the body or any part of the body that the person is physically able to control. Removes easily: means the manual method, device, material, equipment can be removed intentionally by the resident in the same manner as it was applied by staff, considering the residents physical condition and ability to accomplish objective.

Based on record review, interview, and Centers for Medicare and Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual Version 1.20.1 October 2025 review, the provider failed to ensure one of one sampled residents' (1) Minimum Data Set (MDS) (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) assessment was accurately coded for the area of active diagnoses. Findings include:1. Review of resident 1's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. On 1/5/26 a post -traumatic stress disorder (PTSD) diagnosis was added to her diagnoses. Her 3/24/26 quarterly MDS Assessment, section I (active diagnoses) under Psychiatric/Mood Disorder did not have the diagnosis I6100 Post Traumatic Stress Disorder marked. 2. Interview and EMR review on 5/7/26 at 8:42 a.m. with MDS Coordinator/ registered nurse (RN) D revealed she acknowledged resident 1 had a diagnosis of PTSD when her 3/24/26 quarterly MDS assessment was completed. MDS/RN D agreed that resident 1's section I under Psychiatric/Mood Disorder should be marked for PTSD and considered PTSD to be an active diagnosis for resident 1. She used user-defined assessments (UDA's) completed by the nurse, physician's orders, the resident diagnoses, progress notes, and staff interviews when completing the MDS assessments for residents. She referenced the CMS Long-Term Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 to complete the residents' MDS assessments. 3. Review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed review of the CMS Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 October 2025 revealed Section I, Page I1 and I2, Steps for Assessment: 1. Indicate the resident's primary medical condition category that best describes the primary reason for the Medicare Part A stay. Medical record sources for physician diagnoses include the most recent history and physical, transfer documents, discharge summaries, progress notes, and other resources as available.

Based on observation, record review, interview, and policy review, the provider failed to ensure infection control practices were followed regarding one of two sampled resident (34) who used a nebulizer (a device that converts liquid medication into an inhalable mist) machine that was not cleaned after each use by the nursing staff.Findings include:1.Observation on 5/5/26 at 9:38 a.m. in resident 34's room revealed she had a handheld nebulizer tube connected to a nebulizer machine that was placed in the holder on the machine. The medication chamber had a clear liquid at the bottom of the chamber.2. Observation on 5/5/26 at 1:22 p.m. in resident 34's room revealed the nebulizer tube remained in the same position as the above observation with clear liquid in the medication chamber.3. Observation and interview on 5/5/26 at 4:13 p.m. with resident 34 revealed she was unsure if registered nurse (RN) C had rinsed out her nebulizer tube after she used it this morning.4. Observation on 5/6/26 at 8:10 a.m. in resident 34's room revealed the handheld nebulizer tube was lying on her bedside table with a small amount of clear liquid in the medication chamber.5. Observation on 5/6/26 at 4:00 p.m. in resident 34's room revealed the handheld nebulizer tube was in the same position as it was at 8:10 a.m. that morning with a clear solution in the medication chamber.6. Review of resident 34's electronic medical record (EMR) revealed she had a 10/10/25 physician's order for Budesonide(a inhalant that reduces airway inflammation) suspension 0.5 milligrams (mg)/2 milliliters (mL) to be administered via nebulizer by mouth two times daily for Chronic Obstructive Pulmonary Disease (COPD) (a group pf lung diseases that block airflow and make it difficult to breathe). She had a 10/10/25 physician's order for Formoterol (a long-acting inhalant that reduces wheezing and shortness of breath) nebulizer 20 microgram (mcg)/2mL to be administered orally two times a day related to COPD.7. Interview on 5/6/26 at 4:05 p.m. with licensed practical nurse (LPN) E revealed she administered nebulizer treatments that morning to resident 34. Resident 34 received Budesonide and Formoterol using her nebulizer, which were administered separately. LPN E would take apart the medication chamber and pieces, rinse them out, and place them on a barrier to air dry after the resident finished her nebulizer treatments. LPN E did not clean the nebulizer attachments that day (5/6/26).8. Interview on 5/7/26 at 9:04 a.m. with director of nursing (DON) B revealed she expected the staff to follow the policy for rinsing out the nebulizer medication chamber and pieces after each administration of medication and to verify the medication was administered. The nebulizer medication chambers, and tubing were changed weekly by the nurses.9. Review of the provider's February 2026 Oxygen Administration and Nebulizer Treatment policy and procedures revealed To ensure safe administration, monitoring, and documentation of oxygen therapy and nebulizer treatments while promoting resident safety, infection control, and compliance with regulatory standards. Nebulizer Equipment: Nebulizer mask or pipe must be cleaned after each use. Disinfected according to manufacturer guidelines and facility infection control procedures- equipment disinfected weekly and clean filters. Change nebulizer mask and pipe weekly (dated and nurses initials). Allowed to air-dry completely before reuse. Single-resident equipment shall not be shared between residents.

Based on observation, interview, record review, and policy review, the provider failed to ensure chemicals were stored safely away from the residents in one of two bathing rooms.Findings include:1. Observation on 5/5/26 at 2:51 p.m. of the bathing room revealed the room was unattended and the door was unlocked. The storage cabinet that contained skin care products and chemicals was also unlocked. Contents of the storage cabinet included a spray bottle of Ecolab rapid Multi Surface Disinfectant Cleaner, an aerosol can of Arrid extra dry antiperspirant, a can of UtlraSure deodorant body spray, a bottle of [NAME] ultra healing lotion, a bottle of [NAME] body wash, a bottle of Eucerin itch relief intensive calming lotion, a bottle of Head and Shoulders shampoo, a bottle of Dove ultra care shampoo, two tubes of Remedy clinical skin cream, a stick of Brut deodorant, a bottle of Selsun blue anti-dandruff shampoo with 1% (percent) Selenium Sulfide, a stick of Degree deodorant, a tube of [NAME] skin protection ointment with vitamin A and D, and a stick of Axe antiperspirant. A bottle of Gentell baby shampoo was on top of the storage cabinet. 2. Observation on 5/6/26 at 11:03 a.m. revealed the bathing room door was unlocked and the storage cabinet door was also unlocked, which allowed residents to have access to all the items inside the cabinet. There were several residents who went by the bathing room on their way to the dining room for lunch. 3. Interview on 5/6/26 at 12:06 p.m. with certified nursing assistant (CNA) I regarding the bathing room revealed the door should be locked. They did have one resident who was independent with showers, and she took a shower yesterday (5/5/26). The door must not have gotten locked after she was done. CNA I knew the bathing room door was to be locked since there were chemicals stored there that the residents should not have access to. 4. Interview on 5/7/26 at 10:00 a.m. with administrator A regarding chemical storage in the bathing rooms revealed that she knew there were some cleaning chemicals and resident bathing products stored in the bathing rooms. She expected the bathing rooms to be locked when they were not in use. 5. Review of the provider's CMS 802 matrix for providers (a document used by long-term care facilities to list all residents and note specific care categories for Medicare/Medicaid surveys) revealed 21 residents were marked for having Alzheimer's/Dementia (a progressive neurodegenerative disorder that destroys memory, thinking skills, and the ability to carry out simple tasks). 6. Review of the provider's revised November 2025 Chemical Product Labeling and Storage policy revealed, 1. All chemicals must be kept inaccessible to residents and visitors when not in use.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, observation, interview, and policy review the provider failed to ensure two of two sampled residents (3 and 21) who were assessed and determined unable to safely use electronic lift chairs independently did not have access to the lift chair control or the chairs' power cords were unplugged or removed as directed in their assessments. Findings include: 1. Review of the provider's 11/22/24 SD DOH FRI regarding resident 3 revealed: *On 11/22/24 at 7:45 p.m. resident 3 had fallen out of his lift chair. -The resident was found by registered nurse (RN) I in his room, lying face down on the floor with his head next to his bed -The resident denied having pain. -He was rolled onto his back with staff assistance. -His vitals were as follows: Blood pressure (BP) 122/79, pulse rate (P) 54, respiratory rate (R) 16 breaths per minute, and oxygen saturation (SpO2) (oxygen level in the blood) of 95%. -A hematoma (swollen, bruised area) was noted on the resident's forehead and a small laceration on his nose. -The resident was alert to self only and verbal with confusion. He could not provide information as to why he was found lying on the floor. -His call light remained clipped on to the resident's chest area of his shirt. -The lift chair was found to be in the most upright position. -His catheter bag remained attached to the pocket on the lower right side of the lift chair. -A call was placed to 911 by RN I. -At 8:33 p.m. the resident was evaluated by emergency medical services (EMS). -His blood glucose was tested and found to be 150, BP 120/85, P 61, R 16, and SpO2 98%. -The resident was transferred to the local hospital by EMS at 8:50 p.m. -At 9:03 p.m. his family was notified of the incident. -His primary care provider (PCP) was notified of the incident. 2. Review of resident 3's electronic medical record (EMR) revealed: *A Lift Chair Assessment had been completed on 4/22/24, 9/6/24, 10/16/24, and 11/29/24. -Each individual assessment had indicated that the resident did not meet the criteria to safely operate a lift chair independently. *A physical restraint assessment was completed on 4/4/23 and had indicated staff were to hook the control for the lift chair on the backside of the chair and to reassess quarterly. *He had a history of raising the lift chair in an upright position and falling when he was sitting in it and had access to the control. *His baseline care plan indicated he had Depression, Paranoid Schizophrenia (one's mind doesn't agree with reality such as hallucinations and delusions), Epilepsy (brain disorder that causes seizures), Insomnia, Aphasia (language disorder that affects one's ability to communicate), and Cerebral Infarction (stroke). -He had tremors that were not related to his medications. -He had balance problems and a history of falls. *On 11/12/24 he had a Brief Interview for Mental Status (BIMS) assessment with a score of 6, which indicated he was severely cognitively impaired. *His care plan had been updated on 12/3/24 to include he did not meet the criteria to safely operate his lift chair independently and would utilize his call light and request assistance to get to and from the chair. 3. Observation on 2/11/25 at 2:30 p.m. of resident 3's room revealed: *The lift chair was plugged into an outlet behind the chair with the control inside its side pocket. -The chair raised and lowered with the use of the control. 4. Observation and interview on 2/11/25 at 10:45 a.m. with resident 3 who was seated in his wheelchair with call light attached to his blanket that was draped over his lap was attempted but he was unable to provide adequate information related to the above fall with injury. *There were no observations at any time, of resident 3 sitting in the lift chair. 5. Interview on 2/11/25 at 2:37 p.m. with certified nursing assistant (CNA) G regarding resident 3 revealed: *He rarely used the lift chair in his room, and when he did, he felt they made sure it was unplugged. -The lift chair was used to raise his legs to decrease the edema in his lower legs. 6. Observation on 02/12/25 at 10:13 a.m. revealed: *Power cord remained attached to the lift chair in resident 3's room. 7. Random observations of resident 3 during the survey revealed he had not been in the lift chair and the control was in the lift's side pocket. 8. Interview on 2/12/25 at 3:15 p.m. with RN C revealed: -The lift chair belonged to resident 3 and was to remain in his room, unplugged and without availability for his use of the remote. -He was not sure why the lift chair remained in resident 3's room, other than it belongs to the resident. -Resident 3 no longer sat in his lift chair due to his history of falls with the use of the chair. 9. Observation on 02/13/25 at 9:10 a.m. of resident 3's room revealed the lift chair's electric power cord had been removed. 10. RN I was not available for interview at the time of the survey. 49958 11. Observation and interview on 2/11/25 at 12:44 p.m. with resident 21 in her room revealed: *Her speech was unclear, and she was not able to answer any direct questions. *She walked with an unsteady gait. *There was an electric lift chair and a wheeled, swivel desk chair with a throw blanket draped over it that hung near its wheels. 12. Observation on 2/13/25 at 8:50 a.m. of resident 21 in her room revealed: *She sat herself in the electric lift chair. *The control for that chair was on the right-side armrest. *That control lifted and lowered that chair when the button was pressed. *She then tucked that control between the armrest and the back of the chair. 13. Observation and interview on 2/13/25 at 10:04 a.m. with CNA H in resident 21's room revealed: *Resident 21 often knew what she wanted but had a difficult time communicating with words. *CNA H stated the wheeled swivel desk chair looked like a fall hazard, but resident 21 only sat in her electric lift chair. She had not seen resident 21 sit in the desk chair. *The desk chair was where resident 21 put her dirty clothes at night. 14. Review of resident 21's EMR revealed: *She was admitted to the facility on [DATE]. *Her diagnoses included Alzheimer's disease with late onset and anxiety disorder. *Her BIMS assessment score was 00, which indicated she was severely cognitively impaired. *A 1/3/25 lift chair assessment determined Resident is unsafe. Resident does not meet [the] criteria to operate lift chair independently. *Her care plan indicated: -I will benefit from simple, repetitive, one-step instructions during activities. -Encourage resident to sit in her recliner w/her [with her] feet up. -Per lift chair assessment, I am not safe to use the controls on my own. 15. Interview on 2/13/25 at 1:29 p.m. with director of nursing (DON) B regarding electric lift chairs revealed: *All residents were assessed for the safe use of electric lift chairs on admission, quarterly, and with any significant change. *The care plan should have indicated if a resident was unsafe to use an electric lift chair. *Residents were allowed to have an electric lift chair in their room as long as it had been unplugged. *Staff removed the electric lift chair's power cord from some residents' chairs and some residents were required to call for assistance with using the lift chair. -Staff would plug the electric lift chair in at that time and then unplug it after it had been positioned. *Power cords would be removed from the chair and from the resident's room if a resident could not comprehend the safe use of the lift chair. *She expected resident 3's electric lift chair to have been unplugged because the assessment had determined he was unsafe to use that chair independently. *She expected resident 21's electric lift chair to have been unplugged because the assessment had determined she was unsafe to use that chair independently. *Staff knew which residents required assistance with their lift chairs and which lift chairs were to remain unplugged because it was on the resident's EMR and paper care plan. *She was unaware resident 21 had a wheeled, swivel desk chair with a throw blanket draped over it in her room. *She thought resident 21's family may have brought that desk chair in and stated, We certainly would not have given her a chair with wheels. -She would discuss removing the desk chair with resident 21's family. 16. Review of the provider's Resident Lists of Cares paper care plan revealed: *Resident 3 had a Recliner in [the] room, resident not safe to operate independently. Must remain unplugged. *Resident 21 was Safe to use lift chair independently. 17. Review of the provider's October 2024 LTC (Long Term Care) Lift Chair Safety Assessment policy revealed: *Before a lift chair is used by a resident, a member of the interdisciplinary team will complete a lift chair safety assessment. *If the assessment deems the resident can safely operate [the] lift chair, [the] lift chair will remain in Residents [resident's] room with full power function of lift chair. If the resident is unable to safely operate the lift chair, the power to the chair will be disabled and the chair will remain in the sitting and sedentary position. 18. Review of the provider's 10/1/24 Lift Chair Assessment policy revealed: *Lift chair assessments will be completed in Point Click Care on each resident upon admission to the facility, quarterly and with any significant change. *The purpose of the assessment is to determine whether resident can safely operate the chair independently. Results will be care planned. *Risks associated with lift chairs include but are not limited to the following: -Falling out of the chair which could cause serious injury and potential death. -Cognitive decline may lead to poor judgement related to when and when not to engage the chair. -Individuals who use mobility devices may have an increased risk for falls. -Risk of injury may be higher for those who present with the multiple factors and spend prolonged periods of time using the device unsupervised.

Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene and glove use was performed to prevent contamination of resident foods by two of two dietary staff (dietary manager J and medical secretary K) during one of one observed meal service in the kitchen and dining room. Findings include: 1. Observation on 2/11/25 at 11:31 a.m. in the main dining room during the noon meal service revealed: *At 11:31 a.m. dietary manager (DM) J began to prepare the resident meal plates. *DM J wore gloves while she prepared to plate the resident's food. *While wearing those same gloves, she: -Touched the surface of trays that were being reused to deliver food to the resident's tables. -Repeatedly touched the individual resident's diet cards. -Touched her cap. -Touched plates and serving utensils. -Picked up ready to eat dinner rolls and placed them on plates. -Continued to dish up food and pick up dinner rolls until the meal service was finished, with those same gloved hands. *Medical secretary K delivered meals to the residents. She reused the same two trays to carry the meal items to the tables. -She asked DM J if she needed to wash her hands between meal deliveries and was told she did not. -She set the trays on the tables while serving the residents' meals. -She touched residents on their shoulders while serving the meals. -She did not wash her hands during the meal service. 2. Interview on 2/12/25 at 9:30 a.m. with DM J revealed: *She had worked in the dietary department for more than six years. *She provided the new employee and annual training for the dietary staff. *She did not think she needed to change gloves to serve the rolls. *She had not considered using tongs to serve them. *She thought she could change her gloves three times before she needed to wash her hands. *She did not know they should have used clean trays to deliver residents' meals. *That was the first time medical secretary K had helped with a meal service in the dining room. *She had told medical secretary K that she did not need to wash her hands between delivering resident meals. 3. Interview on 2/12/25 at 3:30 p.m. with director of nursing (DON) B who was the acting infection preventionist revealed: *She expected that kitchen staff would follow the hand hygiene and glove changing practices as stated in their hand hygiene policy. *She did not know why DM J thought she could change her gloves three times without washing her hands between each glove change. 4. Review of DM J's undated food safety staff in-service training on Personal Hygiene and Handwashing from the Association of Nutrition & Food Service professionals revealed to always wash your hands: -Before putting on clean, single-use gloves for working with food and between glove changes. -If you touch anything that may contaminate your hands, wash them. 5. Review of DM J's in-service training material from Horizon US Foodservice dated April 2006 on Proper Handwashing Technique revealed: -If a food handler does not wash their hands before putting on gloves, the outside of the glove becomes contaminated. -The food handler may contaminate the gloves by touching face, hair, equipment, etc. -Gloves should be changed before handling ready-to-eat foods. 6. Review of DM J's undated in-service training material titled Glove Use and Bare-Hand Contact revealed: -Disposable gloves are not a substitute for handwashing, and hands need to be clean before putting gloves on them. -Anything that can contaminate your hands will contaminate gloves as well. -Change gloves after touching your hair, face, or other non-disinfected surfaces. 7. Review of the provider's 11/14/2024 long term care (LTC) Hand Hygiene policy revealed: *HH (hand hygiene) either with soap and water or with alcohol-based hand rub (ABHR): -After removing gloves. *ABHR may be used instead of soap and water except when in a food preparation setting.

Based on observation, interview, record review, and policy review, the provider failed to ensure menu substitutions for special events were reviewed and approved by a registered dietitian. Findings include: 1.Observation on [DATE] at 12:08 p.m. of resident 1 in the dining room revealed: *He was assisted into the dining room in his wheelchair by a staff member. *His juice, water, and soy milk were at the table for him. *Dietary staff brought his meal on a portioned plate which consisted of meatballs, a baked potato, and wax beans. *The meatballs were ground. *All other foods were cut into small pieces. *He used weighted gloves to keep his hands steady. 2. Interview on [DATE] at 1:35 p.m. with resident 1 in his room revealed: *He had an issue with choking a few days ago and went to the hospital. *The meal he was served that day included steak and potatoes for a special Father's Day meal. *He said he had issues with swallowing but that was better now. *The meat was ground up now and his other food was cut into small pieces. *He was ok with his new diet. 3. Interview and record review on [DATE] at 3:00 p.m. with dietary manager C regarding the incident with resident 1 revealed: *The meal on the menu for supper on [DATE] was, a hot dog and a bun, mashed potatoes and gravy, pea salad, and a banana. *They provided a special Father's Day meal of steak and foil packets that contained potatoes, carrots, onions, and butter for the male residents. *She had marinated the steaks in the morning before they were cooked. *She cut up the steaks for residents before they were served. *Resident 1 was originally on an NDD2 diet with regular meat and staff would cut up the meat. -He came back from the hospital with an order for a speech evaluation. -On [DATE] the speech therapist did a speech eval and education to change his diet to NDD2 with ground meat. -He was now on NDD2 diet (moist, soft foods) with ground meat. *The female residents were served what was listed on the menu. *The June menu substitution log revealed staff had not added the steak and vegetable foil packets to the menu substitution log for the registered dietitian to review and approve. *It was her expectation that staff would have added those food items to the substitution log for the dietitian to review and approve. 4. Interview on [DATE] at 3:30 p.m. with director of nursing (DON) B regarding resident choking and emergency response in the dining room revealed: *All the nursing staff are CPR certified which included choking response. *They have an annual training to go over emergency procedures that pertain to the residents and the facility. *Resident 1 was on an NDD2 diet with regular meat at the time of his choking incident. *After that incident they obstained an order for a speech evaluation. *The evaluation was completed on [DATE] and his diet was changed to NDD2 with ground meat. 5. Interview and record review on [DATE] at ,d+[DATE] p.m. with licensed practical nurse (LPN)D regarding resident 1's choking incident on [DATE] revealed: *She worked the day shift on [DATE]. *Resident 1 was in the dining room for breakfast but did not want to eat due to complaints of nausea. *He was taken back to his room where he had some watery emesis (vomit) with bits of egg in it. *She gave him Zofran (medication to pervent nausea per his doctor's orders. *He continued to have emesis issues throughout the day but denied any issues with breathing. *She called an electronic long-term care support service, and they recommended he be sent to the emergency room (ER) for an evaluation. *He was evaluated in the ER and then admitted to the hospital for thevremoval of the steak. *They had removed two ,d+[DATE] inch-sized pieces of steak from his throat from the special Father's Day meal the night before. *He returned to the facility on [DATE] with orders for a clear liquid diet and a speech evaluation. *The speech evaluation changed his diet to NDD2 with soft meats. *He would be moved to a different table in the dining room to allow for increased staff observation for signs of choking. 6. Interview on [DATE] at 4:40 p.m. with administrator A regarding resident 1's choking incident revealed: *They provide special meals for residents on special occasions like Mother's Day, Father's Day, and St. Patrick's Day. *All nursing staff were trained in CPR and to address choking issues. *There was always a member of the nursing department in the dining room. *She was not sure if dietary staff had ever documented the special meal menus on the substitution sheet for the dietitian to review and approve. *She agreed the dietary staff should have followed the policy for menu substitutions. Review of the provider's menu substitutions policy dated 2021 revealed: *Menu substitutions will be made after discussion with the director of food and nutrition services whenever possible. Last minute substitutions may need to be made for uncontrollable situations (ie. inventory emergency when a food item is temporarily unavailable) . *3. All changes to the menu (including the date, menu item substitution, and reason for the substitution) will be recorded. *4. The registered dietitian (RDN) or designee will periodically evaluate menu changes and if needed, an appropriate plan of action will be made to correct any concerns.

Based on observation, interview, and policy review the provider failed to ensure infection control policies were adhered to with the following: *Appropriate hand hygiene and glove use by two of two certified nursing assistants (CNAs) E and F during the provision of personal care for one of one sampled resident (24). *Appropriate sanitization of an EZ stand mechanical lift by CNAs E and F between care for two of two sampled residents ( 24 and 85). Findings include: Observation on 10/18/23 at 8:21 a.m. with CNA E and F assisting resident 24 revealed: *They both entered the room without knocking on the resident's door. *CNA E applied gloves to both hands without performing hand hygiene. *CNA F applied gloves without performing hand hygiene. *CNA E with her gloved hands performed the following tasks she: -Had moistened the personal wipes with water and Aloe Vista cleansing foam. *The bottle of Aloe Vista had fallen into the empty garbage can. -Picked up the bottle of Aloe Vista out the garbage and then placed it on the sink. -Removed resident 24's soiled incontinence brief and performed peri-care. -Assisted CNA F rolling resident 24 from side to side and placed a new incontinence brief. -Continued to assist CNA F and resident 24 with dressing. -Had been touching resident 24's bedding. *They each removed their gloves and then performed hand hygiene. *CNA E applied the EZ lift strap around resident 24's waist. *She then begun to lift the resident up using the mechanical lift and then transferred her to her wheelchair. *CNA E removed her gloves and applied an alcohol hand rub. *She then made the resident's bed. *CNA E wheeled the resident out of her room. *CNA F had moved the EZ stand mechanical lift out into the hallway. -They had not sanitized the lift after using it on resident 24. *CNA F then wheeled the lift into resident 85's room. *CNA E and CNA F attached the sling to resident 85's waist and transferred her to the toilet. Interview with CNA E and CNA F following the above observations revealed: *CNA E had not realized that she used the same gloves to perform peri-care and then assisted resident 24 to dress with those same gloved hands. *CNA F had not realized that CNA E had not sanitized the lift between the use with resident 24 and 85. Interview on 10/19/23 at 3:00 p.m. with registered nurse (RN) D regarding the above observations and interviews revealed: *CNAs have been trained to sanitize the mechanical lifts between each resident use. *She agreed that CNA E should have removed her gloves and performed hand hygiene after performing peri-care and the removal of the resident's soiled brief. Interview on 10/19/23 at 4:04 p.m. with director of nursing (DON) B regarding the above observations and interviews revealed: *She agreed that CNA E should have changed gloves after performing peri-care and removing the resident's soiled brief. *Mechanical lifts were to have been sanitized after each resident use. Review of the provider's April 2023 Hand Hygiene (washing hands with soap and water or using an alcohol hand rub) policy revealed: *Before a clean procedure. *After removing gloves. Review of the provider's October 2023 EZ Stand Operation Lifting/Transferring policy revealed: *Cleaning: -EZ Stand harnesses are for single patient use only to avoid the risk of cross contamination. -EZ stand lift should be thoroughly wiped down with facility approved disinfectant, Allow to dry for a full minute before use.

A. Based on observation, interview, and South Dakota Food Service Code review, the provider failed to ensure proper storage of raw and ready-to-eat meats in one of one walk-in cooler. Findings include: 1. Observation on 8/16/22 at 8:58 a.m. of the bottom shelf of the righthand side food rack in the walk-in cooler revealed: *An unopened log of ready-to-eat uncut deli ham meat and part of a 10-pound (lb.) tube of raw ground beef were on the middle tray. -Red liquid was leaking from the tube of raw ground beef onto the middle tray and onto the floor. The red liquid was touching the unopened log of ready-to-eat uncut deli ham. *The remainder of the 10lb. tube of raw ground beef was on the right tray. Interview on 8/16/22 at 9:41 a.m. with dietary manager C regarding the above observation revealed: *She was able to list how to properly store raw and ready-to-eat meats and agreed the tube of raw ground beef should not have been on the tray with the unopened log of ready-to-eat uncut deli ham. *They recently started receiving raw ground beef in the 10lb. tubes and were trying to figure out how best to thaw it. Review of the Administrative Rule of South Dakota (ARSD) Food Service Code 44:02:07:23, Preventing contamination of packaged and unpackaged food revealed, Packaged and unpackaged food must be protected from cross-contamination by the following methods .Separating raw animal foods during storage, preparation, holding, and display from raw ready-to-eat food, including other raw animal food such as fish for sushi or molluscan shellfish; other raw ready-to-eat food, such as vegetables; and cooked ready-to-eat food. B. Based on observation, interview, and weekly cleaning schedule review, the provider failed to ensure adequate sanitation practices for the floors in one of one kitchen and one of one dish room. Findings include: 1. Observation on 8/16/22 at 8:38 a.m. in the dish room revealed: *The floor drain in the dish room was caked with pieces of colored plastic, chunks of unidentified food, and an unidentifiable gray substance. *The floor drain was halfway plugged with the above-mentioned refuse, which potentially compromised the draining ability. *The floor underneath the handwashing sink in the dish room was caked with an unknown black and greasy-looking substance. 2. Observation on 8/16/22 at 10:57 a.m. in the main kitchen/service area revealed: *The floors underneath the flattop grill, the food prep counters, the three-door cooler, and the hot-holding table were covered with dust, dirt, and food crumbs. *The area of the floors that bordered the black safety mats was covered in an unknown black, greasy substance. Interview on 8/16/22 at 4:07 p.m. with dietary cook E regarding kitchen sanitation activities revealed: *The end-of-day closing procedures included sweeping and mopping. *She mopped every other day. *There was neither a daily cleaning task list nor deep-cleaning task list. *The only cleaning task list they had was the weekly cleaning schedule posted on the kitchen's bulletin board that was located outside the dish room. *She confirmed the cleaning task list did not include cleaning the floors in-between, underneath, or behind equipment. Interview on 8/16/22 at 4:15 p.m. with dietary manager C regarding kitchen sanitation activities revealed: *The black safety mats were cleaned monthly. *Staff were supposed to sweep and mop each day. *They used to have a deep cleaning schedule, but they had not used it for some time. *She thought their weekly cleaning schedule covered everything that needed to be cleaned in the kitchen. *The floors in-between, underneath, and behind equipment should have been cleaned more thoroughly. Review of the dietary department's 8/1-8/18/22 weekly cleaning schedule revealed there was no task on the list indicating to clean the floors underneath, in-between, or behind food service equipment such as the three-door cooler, the flattop grill, or the hot-holding table. C. Based on observation, interview, and policy review, the provider failed to ensure one of five dietary staff wore appropriate hair restraints. Findings include: 1. Observation on 8/16/22 at 11:32 a.m. in the kitchen during lunch service revealed: *Dietary aide D was wearing a hair net, a plastic face shield, and a surgical face mask. *Black beard hairs were seen sticking out of the sides and underneath his face mask. *He was placing beverage cups on resident meal trays. *He had poured the beverages earlier in the day in preparation for lunch service. *There was a short black hair floating in a cup of milk. Interview on 8/17/22 at 8:19 a.m. with dietary aide D regarding beard restraints revealed: *He confirmed he had access to proper beard restraints, like beard nets. *He said that beard nets were discussed at a meeting previously, and it was decided that a surgical face mask was sufficient to act as a beard restraint. -He did not indicate who was involved in the above-mentioned meeting. Interview on 8/17/22 at 8:21 a.m. with dietary manager C regarding beard restraints revealed: *She confirmed they had proper beard restraints, like beard nets. *She assumed a surgical face mask was sufficient to act as a beard restraint. *She was not aware dietary aide D's hair had not been completely restrained within the surgical face mask, or that a hair had been found in a cup of milk that was supposed to have been used for lunch service. *She agreed he should have worn a proper beard restraint, like a beard net. Interview on 8/17/22 at 8:35 a.m. with administrator A regarding the above observations revealed she agreed improvements were needed for food safety, kitchen cleanliness, and the use of proper beard restraints. Review of provider's policy titled Employee Sanitary Practices revealed: *The policy was part of the 2019 [NAME] & Associates, Inc. policy and procedure manual, section 4-4. *Procedure number one stated, All employees will .Wear hair restraints (hairnet, hat, and/or beard restraint) to prevent hair from contacting exposed food.

Based on observation, interview, and policy review, the provider failed to ensure infection control procedures were done appropriately to ensure sanitary conditions were maintained for: *Two of two dressing changes by two of two registered nurses (RN) (C and D) for one of one sampled resident (20). *One of one catheter bag emptying by one of one certified nurse assistant (CNA) (E) for one of one sampled resident (27) with a catheter. *Personal care for one of one sampled resident (13) by one of one CNA (B). Findings include: 1. Observation on 2/11/20 at 4:06 p.m. with RN C during a dressing change for resident 20 revealed: *RN C: -Gathered supplies for a dressing change from the treatment cart which included: --A package with two cotton swabs in it. --Four individual packages of gauze bandage rolls. --A tube of santyl ointment in a plastic bag. --A jar of [MEDICATION NAME] cream in a plastic bag. --A package with a large gauze dressing in it, and a roll of tape. -Entered resident 20's room and placed the treatment supplies on the resident's soiled seat of her walker without a clean barrier. -Performed hand hygiene and put on gloves. *Resident had: -A small open area on the top, inner aspect of her right foot and a small open area on the bottom of her right heal that had scant green drainage noted on the removed dressing. *RN C: -Noticed the package with the large gauze dressing had fallen off the seat and onto the floor, so she picked it up and put it back on the soiled walker seat. *With those same soiled gloves she: -Opened the tube of santyl and squeezed some out onto a cotton swab. -Applied santyl to an open area on the top of her right foot with that cotton swab. -Did the same with another cotton swab and applied it to an open area on her right heal. -Closed the tube and placed it back on the soiled seat. -Picked up the soiled package of the large gauze dressing. -Opened the soiled package and removed the dressing. -Placed, the now soiled dressing, on her right heal over the open sore. -Took the [MEDICATION NAME] jar out of it's plastic bag and put the bag back on the soiled seat. -Opened the jar and dipped her glove into the [MEDICATION NAME] then placed the jar back onto the soiled seat. -Rubbed the [MEDICATION NAME] onto her right foot. -Opened a package of gauze bandage roll and wrapped it around her right foot. -Picked up the tape, that had fallen onto the floor, and taped the roll. -Removed her gloves, did hand hygiene and put on new gloves. -Picked up the [MEDICATION NAME] jar and dipped her gloved hand into it and rubbed it onto her left foot. -Placed the jar back onto the resident's soiled walker seat. -Took off her gloves, did hand hygiene and put on clean gloves. -Wrapped her left foot with a gauze bandage roll. -Took off her gloves, did hand hygiene and put on clean gloves. -Put the tube of santyl back into the soiled plastic bag. -Put the jar of [MEDICATION NAME] back into the soiled plastic bag. -Picked up the two soiled unused packages of gauze bandage rolls and the two soiled plastic bags with medication in them and left the room. -Placed these soiled items back into the treatment cart in a common drawer with supplies used for other residents. -Removed her gloves and performed hand hygiene. Interview on 2/11/20 at 4:35 p.m. with RN C regarding the above observation confirmed and agreed she should have: *Used a clean barrier to put her treatment supplies on when doing the dressing change. *Done hand hygiene and changed her gloves after she picked up the items from the floor. *Not placed the soiled large gauze dressing over the open area on the resident's heal. *Not brought soiled treatment supplies from the resident's room and put them back into the cart with other resident care items. 2. Observation on 2/13/20 at 9:44 a.m. with RN D near the end of a dressing change for resident 20 revealed: *She had been: -Sitting on the floor in front of the resident's feet. -Wrapping the resident's left foot with a gauze bandage roll. *There had been -Empty and opened packages on the floor in front of RN D. -Tape and a jar of medicated cream sat on the floor. -No barrier between the floor and the supplies. *RN D: -Picked up the jar and tape off the floor and put it on the resident's dresser. -Took off her gloves, did hand hygiene, and put a clean glove on her right hand. -Picked up the jar with her right gloved hand and left the room. -Placed the jar on a barrier on the treatment cart. -Removed her glove and did hand hygiene. -Got a disposable germicidal wipe and wiped down the jar. -Placed the jar in the treatment cart and did hand hygiene. Interview immediately after the above observation with RN D confirmed she had put the treatment supplies on the resident's soiled seat of her walker without a barrier. She stated she did not have a clean barrier for her treatment supplies. She agreed she should have placed her treatment supplies on a clean surface to maintain a clean procedure. 3. Observation on 2/11/20 at 11:01 a.m. with CNA [NAME] during the emptying of a urinary catheter bag for resident 27 who was on isolation precautions and in a shared room revealed: *CNA E: -Walked with the resident to his room and assisted him to sit down. -Did hand hygiene. -Put on a gown, gloves, and a mask. -Obtained two alcohol pads from a basin in the resident's room. -Had put a paper towel on the floor and placed a non-sterile collecting container on it. -Opened the spigot of the catheter bag and wiped it with an alcohol pad. -Drained the urine from the bag into the container. -Lifted up his catheter tubing so the urine would drain from the tubing into the bag then into the container. -Had done this for approximate two minutes. -Had allowed the spigot of the catheter bag to touch the inside and top of the non-sterile collecting container and to dip inside the urine on-and-off for the entire two minutes. -Cleaned the spigot with an alcohol pad. -Closed the spigot and replaced it into it's holder. -Picked up the container and threw away the paper towel. -Emptied the urine from the container into a shared toilet. -Turned on a shared sink with the back of her gloved hand and put water into the cylinder to rinse out the urine. -Turned off the water with the back of her gloved hand. -Poured the water into a shared toilet. -Flushed the shared toilet with her soiled gloved hand. -Took off her gown, gloves, and mask and placed them in the isolation garbage. -Performed hand hygiene and left the room. Interview on 2/11/20 at 11:25 a.m. with CNA [NAME] regarding the above care revealed she: *Did not realize she should have not let the spigot touch the non-sterile collecting container or let it dip into the urine. *Agreed the toilet handle was contaminated and should have been disinfected. 4. Interview on 2/13/20 at 3:04 p.m. with director of nursing (DON) A regarding the above observations of dressing changes and the emptying of a catheter confirmed: *There was an infection control breech with the dressing changes. -A barrier should have been used. -No contaminated treatment supplies should be put back into the treatment cart. *The spigot of the catheter bag should not have touched the non-sterile collecting container. *The toilet handle should have been disinfected after it was contaminated with the CNA's soiled glove. Review of the provider's (MONTH) 2019 Urinary Catheter System Maintenance policy revealed: Emptying the collecting bag regularly, avoiding splashing and preventing contact of the drainage spigot with the non-sterile collecting container'' Review of the provider's non-dated competency of Urinary Emptying Drainage Bag revealed: Avoid touching the tip of the tubing to the graduate (a non-sterile collecting container). The DON was unable to provide a policy or competency for a dressing change. They used the Potter and Perry Fundamentals of Nursing as a resource on proper dressing technique and infection control. 5. Observation on 2/11/20 at 8:35 a.m. revealed CNA B: *Washed her hands in the sink and placed the dry perineal wipes in the sink to wet them. *She then put on gloves and picked up the wipes from the sink and sprayed perineal wash on them. *She used those wipes to perform perineal care for resident 13. Interview on 2/13/20 at 9:59 a.m. with DON A revealed: *She confirmed CNA B had contaminated the perineal wipes by placing them in the sink after she had just washed her hands. *She confirmed there was no policy concerning use of the perineal wipes. They use the Potter and Perry Fundamentals of Nursing as a resource on infection control. Potter and Perry Fundamentals of Nursing states in Chapter 29, page 445, Box 29-1: Vehicles of contamination include contaminated items and water among others.

Based on observation, interview, and policy review, the provider failed to ensure appropriate hand hygiene during one of one meal services. Findings include: 1. Observations on 1/8/19 from 11:14 a.m. to noon revealed: *Cook E wore gloves and opened the serving window, opened cracker container to obtain unwrapped crackers from inside and placed on tray, opened and closed cupboards, got serving bowls, and served garlic toast. She removed her gloves and had not washed her hands before putting on new gloves. She then continued to serve food. *Dietary aide D wore gloves while passing drinks to residents and returned to the kitchen to get coffee and cups, touched his face repeatedly, threw garbage away, opened doors, wrote with sharpie on paperwork, and continued to serve trays. *Cook F opened refrigerator, retrieved bag of lettuce and cheese container, opened lettuce bag and placed lettuce into bowl, opened cheese container and placed cheese on salad, and put lettuce and cheese container back in refrigerator. *Activities Director wore the same gloves while passing food trays to all residents, removed unwrapped crackers out of container and placed them on salad bowls, and touched various surfaces with the same gloves. Interview on 1/9/19 at 12:10 p.m. with the Activities Director, cook E, dietary aide D, and cook F revealed: *They agreed hand hygiene should have been completed prior to working in the kitchen and dining room areas. *They agreed they had used the same gloves while performing tasks without changing or performing hand hygiene. *They agreed during the above meal service, hand hygiene had not been done after gloves were removed. *They agreed if gloves were used, they should have been changed when they became contaminated. Review of the provider's 2013 Bare Hand Contact with Food and Use of Plastic Gloves policy revealed Gloved hands are considered a food contact surface that can get contaminated or soiled. If used, single use gloves shall be used for only one task (such as working with ready-to-eat food or with raw animal food), used for no other purpose, and discarded when damaged or soiled, or when interruptions occur in the operation.

Based on observation, record review, interview, and policy review, the provider failed to ensure steps had been completed to support appropriate self-administration of medication for one of one randomly observed resident (4) who self-administered her nebulizer medication. Findings include: 1. Observation on 1/8/19 at 8:45 a.m. of registered nurse (RN) A during a nebulizer medication administration for resident 4 revealed she: *Poured the [MEDICATION NAME] inhalation medication into the chamber of the nebulizer machine. *Handed the medication chamber to resident 4 and turned the machine on. *Instructed resident 4 she would return to her room in twelve to fifteen minutes to shut the machine off. *Left the resident's room. *Returned to resident 4's room after twelve minutes and turned the machine off. Interview with RN A at the above time regarding resident 4 self-administering the nebulized medication revealed: *Resident 4 did not have a physician's order to self-administer her nebulizer medication. *She had reviewed the self-administration of medication policy that morning. *That policy had stated that if residents were alert and oriented they did not need a physician's order to self-administer their medications. *Resident 4: -Had been admitted on [DATE]. -Was alert and oriented. Review of resident 4's medical record revealed:*No physician's order for self-administration of medications. *No documentation a self-administration of medications assessment had been completed. *Nothing on the Medication Administration Record [REDACTED]. *Her 12/31/18 care plan had not included self-administration of medication. Interview on 1/8/19 at 2:30 p.m. with the RN resident care coordinator/Minimum Data Set coordinator regarding self-administration of medications revealed:*All residents who self-administered their medications required: -An assessment to monitor their ability to self-administer medications. -A physician's order to self-administer their medications. -The assessment and physician's order were to have been approved by the interdisciplinary team and the physician prior to allowing the resident to do so. *Resident 4 had not been approved to self-administer her medication. Interview on 1/9/19 at 3:30 p.m. with the director of nursing regarding the above interview confirmed resident 4 had not been assessed for her ability to self-administer her medication. Review of the provider's revised (MONTH) (YEAR) Self-Administration of Medication(s) by Resident policy revealed: *Residents have the right to self-administer their own medications with nursing supervision, but only after evaluation by the Registered Nurse determines that the resident may safely and effectively administer the medication(s) and a physician order is secured that allows the resident to self-administer medication(s). *If a resident chose to self-administer medications the following was to have been in place prior to self-administration: -A self-administration of medication screen tool was to have been completed by an RN to ensure the resident could safely administer the correct dose at the right time in the frequency ordered by the physician. -The resident was to have been capable of adhering to any safety precautions. -A physician's order must be obtained that allows the resident to self-administer medication(s). *If the resident was deemed capable of self-administration of medication: -The medication order was to have included the physician's approval to self-administer that medication. -The resident was to have been reevaluated quarterly or with any significant change to ensure the resident was safe to continue self-administer the medication. -The care plan was to have included the self-administration of medications. *If the resident failed to display competency with self-administration of the medication the doctor was to have been notified, and the order to self-administer was to have been discontinued.

Based on record review, observation, interview, and policy review, the provider failed to assess restraints for one of one sampled resident (27) who used a personal alarm. Findings include: Review of resident 27's complete medical record revealed: *Her 4/10/18 Care Conference Summary stated she was: -Confused. -Difficulty finding words. -Wanders at times. -Staff would anticipate her activity and interests. -She gets restless and tries to stand up and walk. *On 10/23/18 a fax to her physician revealed behaviors had improved. *Her Brief Interview for Mental Status (BIMS) was 99, indicated moderately cognitively impaired. Observation on 1/7/19 at 2:24 p.m. of resident 27 revealed: *She was sitting in a recliner in the lounge area. *She did not have a call light. *She had a person alarm attached to her shirt under her left arm/waist area. Observation on 1/7/19 at 3:06 p.m. revealed: *She was still sitting in the lounge area with the personal alarm on. *She stood up and the alarm went off. *She did not startle when the alarm went off. *Several unidentified staff from the surrounding area rushed to her and sat her back down in the chair. *No mention to her why she got up or where she was going. Observation on 1/7/19 at 3:42 p.m. through 4:35 p.m. revealed she was sitting in a group activity with the personal alarm on. Random observations on 1/8/19 from 7:30 a.m. through 4:30 p.m. revealed that she had her personal alarm on either on her back or under her arms. Interview on 1/9/19 1:25 p.m. with the director of nursing (DON) revealed: *She does not consider an alarm a restraint. *She used the alarm to know when she was up because she can be physically abusive to other residents. *She was abusive to another resident a couple years ago. *She has not had a restraint assessment completed since the alarm had been in place. *The facility does not have an assessment for a personal alarm. Interview on 1/9/19 at 1:38 p.m. with the Minimal Data Set (MDS) coordinator revealed: *She does not consider an alarm a restraint because it did not restrict movement. *It tells staff when she was up walking by herself. *She was able to remove the alarm herself. *A long time ago she had an altercation with another resident. *She had four non-injury falls in (YEAR). -January, April, (MONTH) and July. -When she falls she had usually had taken off the alarm. *Her alarm was usually attached on her back so she can not reach it. *The facility does not have an assessment for the alarm. *Therapy had recommended that she did not walk by herself so the alarm lets the staff know when she was up. -No one was available for interview in therapy. Observation on 1/09/19 at 1:51 p.m. of resident 27 revealed: *She had been sitting at the dining room table with other residents. *She stood up and proceeded to walk out of the dining room with her walker. *The alarm had not went off. -It was connected to her side under her left arm and the alarm device was on her walker. Review of the resident's care plan and interview on 1/09/19 at 2:20 p.m. with the MDS coordinator revealed: *There would have been no documentation of the personal alarm except for care plan. -The care plans goal was I will leave my tabs monitor on at all times and wait for staff to assist me to activities and meals. -This was the only mention of the alarm on the care plan. *It had not been mentioned at care conference. *No physician order. *No monitoring or evaluation for the continued use of the alarm. *No interventions for reducing or discontinuing the use of the alarm when no longer needed. *No documentation that family were aware of this alarm. Interview on 1/9/19 at 2:30 p.m. with certified nurses aide (CNA) B revealed: *He had been working with her the last three to four months months, and she had not been abusive to other residents. *She had the alarm on because she wanders into other residents room at night. *She was to have the alarm on at all times and to connect it to her back so she could not reach it to take it off. Interview on 1/9/19 at 2:35 p.m. with registered nurse (RN) C revealed: *She wears the alarm for staff to know when she is up. *She might fall. *She was not aware of any assessment or documentation that was done concerning the alarm. *The alarm was placed on her back so she could not reach it to take it off. Interview on 1/9/19 at 2:48 p.m. with the administrator revealed: *They did not have assessed her for the alarm. *She understood how the alarm should have been considered a restraint. Review of the provider's 8/18/18 Physical Restraint policy revealed: *It did not mention personal alarms as restraints. *Restraints must not have been used for the convenience of staff or for a substitute of supervision.

Based on interview, and admission packet review, the provider failed to ensure one of nine sampled residents (8) and a confidentially interviewed group of three residents had their mail delivered consistently to them on Saturdays. Findings include: 1. On 10/24/17 from 10:00 a.m. through 11:00 a.m. during the group interview revealed, three residents were in attendance. The residents brought up the concern about not getting their mail delivered on Saturdays. The residents reported the mail was brought by postal staff to the facility and was kept at the desk, but the staff members did not deliver it to them until Mondays. That had upset them, because they had known the mail was at the facility. Mondays through Fridays staff delivered their mail to them. Interview on 10/24/17 at 2:00 p.m. with medical secretary G regarding mail delivery to the residents revealed:*She worked Monday through Friday every week and was responsible for mail delivery those days. *On Saturdays the mail was delivered to the facility by postal staff and kept at the desk until Monday. -When she got to work on Monday she sorted that mail, and then delivered it to the residents at that time. *There was no staff designated or responsible for Saturday mail delivery to the residents. *She liked to sort through the residents' mail before delivering it to them in case some of the mail needed to be forwarded to their responsible parties. -Staff working on Saturdays would not have known what mail to sort out. Therefore they had not had staff deliver the mail on those days. *She stated the residents could have gone to the nurse's desk to ask for their mail if they wanted it though. *She confirmed access to their mail was a residents' right, and they should have had access to that on Saturdays. Interview on 10/24/17 at 2:00 p.m. with the director of nursing confirmed mail delivery had not occurred on Saturdays, and it should have. The medical secretary was responsible for mail delivery, and she only worked Monday through Friday. Interview on 10/24/17 at 5:15 p.m. with the director of senior services confirmed it was the residents' right to have their mail delivered to them on Saturdays. Surveyor: 2. Interview on 10/25/17 at 9:05 a.m. with resident 8 revealed: *She had not received her daily newspaper. *She had not regularly or consistently received her mail on Saturdays. *Her mail including her newspaper was delivered to her room each Monday through Friday. *She needed to go to the nurses station to get her daily newspaper from the nurse on duty on Saturdays. *Receiving her mail including her daily newspaper was very important to her. Surveyor: 3. Review of the provider's undated resident admission packet revealed mail should have been delivered daily to the residents.

Based on observation, interview, record review, and policy review, the provider failed to ensure control and accountability of medications (med) for:*One of one emergency med kit (E-kit) in one of one med room. *One of one container of controlled medication for emergency use in one of one med room. *One of one randomly observed discharged resident's (14) controlled med and emergency use controlled meds in one of one refrigerator (frig) in the med room. *One of one randomly observed resident's (13) controlled meds in one of two (Pine) treatment carts. Findings include: 1. Observation, interview, and record review on 10/15/17 at 11:20 a.m. with the director of nursing (DON) during med room and med cart audit revealed: *In the med frig there were:-Two sealed vials of lorazepam for resident 14 who had been discharged over a year ago. -Two sealed vials of lorazepam for emergency use that had been sent with the E-kit. --Those medications were not being counted or monitored during the controlled med inventories by nursing staff. *In a locked drawer there was a plastic container secured with a plastic zip tie that had an identification (ID) number on it. It contained the following emergency use controlled meds:-Tramadol tablets. -Liquid morphine in syringes for oral administration. -Injectable morphine. -Hydrocodone/acetaminophen tablets. -Lorazepam tablets. --No one was monitoring those medications or that tag to ensure control and accountability of those meds. *The E-kit container sitting on the counter of the med room had a padlock on it and no plastic zip tie. *The E-kit med list revealed it contained several antibiotics, psychoactive meds, cardiovascular meds, gastrointestinal meds, analgesics, and respiratory meds. -No one had been monitoring the security of those meds for control and accountability. *A binder near the E-kit contained forms to send to the pharmacy to replace a med that was used from it. *A 10/22/17 form indicated a nurse had taken out two tablets of furosemide for a resident. -During that process they had removed the plastic ID zip tie and replaced it with a new zip tie. -That new ID zip tie was no longer on the E-kit box. -The DON had no explanation as to where that zip tie would have gone. -There were no other completed forms in the binder. *Upon opening the E-kit container several more plastic ID zip ties were found inside for staff to use to seal the container. *The DON was unsure what the process for the E-kit was supposed to be, since they had recently changed to a different pharmacy. -She thought this new E-kit had been in the facility for about a week. -The nurses had some training from the new pharmacy staff prior to the change. -She could not remember if the training had addressed the process for the E-kit including the control and accountability of those meds. *She agreed there was no control and accountability monitoring in place for the E-kit currently, and there should have been. -They should have been using the plastic ID zip ties and monitoring those numbers routinely. -As it was now there was no way to know who would have accessed the E-kit and when. *In the Pine treatment cart there was a box of Androgel controlled med packets for resident 13. -That box was not: --Locked up with the other controlled meds. --Being monitored or counted during the controlled med inventories by nursing staff. --The DON was not aware it was a controlled med, but she agreed it had a pharmacy sticker indicating it as such. *The DON indicated all meds including controlled meds should have had a system in place to ensure control and accountability, and the above medications had not. *She was unsure where the pharmacy policies and procedures for the facility were located. Interview on 10/25/17 at 2:50 p.m. with registered nurse F regarding the above findings revealed:*She confirmed there was a lack of control and accountability for those meds. *The controlled substances should have been counted and verified with the controlled med inventories at each change of shift. *The new pharmacy had implemented the new E-kit and controlled meds in the refrigerator and drawer recently. *Pharmacy staff had done some training for the nurses. -That training had not included anything related to those ID zip ties on the E-kit itself, the controlled meds in the refrigerator or in the drawer, or the forms used related to the E-kit replacments. Review of the provider's reviewed March 2017 Narcotic - Counting and Destruction policy revealed: *To provide accurate regulation and maintenance of controlled substances. All schedule 1 through 4 controlled substances are to be counted and use monitored.*b. Controlled substance count verification should be done every shift by two (2) nurses (one from previous shift and one from oncoming shift).*i. Count what is in the narcotic drawer/cabinet/refrigerator against amount shown on the narcotic book page. Review of the provider's 2/1/17 pharmacy Accountable Medication System reference that was used for the nurse's training revealed:*No mention of how the facility should have ensured control and accountability of meds. *For the E-kit: -A detailed list of controlled substances contained in the emergency kit will be maintained for nursing staff reference as well as on the product within the kit.-When medications are removed and used immediately, the 'Request for Emergency Kit Replacement' will need to be filled out. This will be faxed to pharmacy along with the copy of the order. -There was no mention of the plastic ID tag use or how to monitor the security, control, and accountability of those meds. Review of the provider's copy of the Long-Term Care Pharmacy policies revealed for: *Controlled Substance Storage revised in November 2011:-D. A controlled substance accountability record is prepared by the pharmacy/facility for all Schedule II, III, IV, and V medications . -E. At each shift change, or when keys are transferred, a physical inventory of all controlled substances, including refrigerated items is conducted by two licensed nurses and is documented .The emergency supply may be verified by assuring that the seal on the supply has not been broken . *Emergency Kits reviewed in September 2015: -1. The pharmacist shall retain control of all medications provided in the emergency kits.-4. Each E-kit will contain a separate control case, insulin case, and a lorazepam case outside of the E-kit that will be stored in designated locations within the facility. All E-kits/IV E-kits will be sealed with a red numbered zip tie, including each control case, insulin case, and lorazepam case.-1. A Control E-Kit Shift Count will be used by the facility staff to keep track and use for counting controlled case medications shift to shift on a monthly basis. -4. Emergency Kit Replacement Slips and Emergency IV Kit Replacement Slips will be used to send to pharmacy once use of drug has been used from Emergency Kits.

Based on observation, interview, policy review, and manufacturers' instructions review, the provider failed to ensure appropriate infection control practices were followed related to: *Maintaining four of five containers of expired disinfectant wipes for use on two of two medication carts and two of two treatment carts. *Proper cleaning and disinfection of shared glucose meters during three of three observations for two of two random residents (15 and 16) by one of one registered nurse (RN) (F). *Cleaning the rubber seal on the insulin pen device prior to attaching the needle during two of two observations for one of one random resident (15) by one of one RN (F). *Proper hand hygiene and glove use during one of one room cleaning observation by one of one housekeeper (E) and one of two observed whirlpool tub cleanings by one of two certified nursing assistants (CNA) (D). Findings include: 1. Observations and interviews on [DATE] from 7:30 a.m. through 6:30 p.m. and on [DATE] from 7:30 a.m. through 5:45 p.m. with RN F during medication (med) administration and med cart audits revealed:*The container of Super Sani cloth disinfectant wipes on the Pine med treatment cart she was using for disinfection of the glucose meter had expired in [DATE]. *The container of wipes on the Maple treatment cart had expired in [DATE]. *The container of wipes on the Pine medication cart had expired in [DATE]. *The container of wipes on the Maple medication cart had expired in [DATE]. *She confirmed those expired wipes should not have been kept for use. -The expired wipes might not have been effective against microorganisms. *For appropriate infection control practices wipes should have been used before the expiration date. Interview on [DATE] at 11:20 a.m. with the director of nursing (DON) regarding the above expired disinfectant wipes revealed:*Those wipes should not have been kept for use or used to clean and disinfectant the glucose meter. *Expired disinfectants were not effective against microorganisms which was an infection control concern. 2a. Observation on [DATE] at 8:50 a.m. of RN F during resident 15's glucose check using the shared glucose meter revealed:*She used a Super Sani cloth wipe that had expired in [DATE] to clean and disinfect the surface of it. *She wiped the surface of the machine for about three seconds and put it back in the drawer of the treatment cart. b. Observation on [DATE] at 4:52 p.m. of RN F during resident 16's glucose check using the shared glucose meter revealed she wiped the surface of the meter with a Super Sani cloth for about two seconds, then she put it back onto a paper towel on the cart. c. Observation on [DATE] at 4:55 p.m. of RN F during resident 15's glucose check using the shared glucose meter again revealed she only wiped the surface of the meter with the Super Sani cloth wipe for about two seconds. Then she put it back into the treatment cart drawer. Interview and review of the Super Sani cloth instructions for use on the label following the above observation with RN F revealed: *She was unsure how long the disinfectant should have remained on the surface of the meter. *No one had told her the disinfectant had to remain wet on the surface for two minutes to be effective. *She confirmed: -The label indicated two minutes for it to have been effective. -The glucose meter had not been cleaned and disinfected properly which was a concern for infection control. 3. Interview on [DATE] at 11:20 a.m. with the DON regarding the above glucose meter cleaning and disinfection practices revealed:*If the disinfectant wipes had not been used according to the instructions they were not effective against microorganisms. -That was an infection control concern. *She had been aware of the Super Sani cloth instructions to have the disinfectant remain wet for two minutes on the surface. *She expected the staff to follow the manufacturer's recommendations for use. Review of the provider's revised [DATE] Glucose testing meters, Finger Stick blood sugars testing and Disinfection policy revealed 8. Wipe down meter with super Sani cloth disinfectant wipes, use according to manufacturer's directions, dispose of wipe. 3. Observations on [DATE] at 8:50 a.m. and again at 4:55 p.m. with RN F during resident 15's [MEDICATION NAME]administration revealed she had not used an alcohol wipe to clean the surface of the rubber seal on the insulin pen device prior to attaching the needle. Interview with RN F following the 4:55 p.m. administration revealed she never used an alcohol wipe to the rubber seal on the insulin pen prior to attaching the needle. She was not aware she should have done so. Interview on [DATE] at 11:20 a.m. with the DON regarding the above concern revealed:*An alcohol prep pad should have been used to clean the surface of the rubber seal prior to attaching the needle to the pen device. *The manufacturer's instructions for use had not been followed which was an infection control concern. Review of the [MEDICATION NAME] Instructions for Use printed off the internet on [DATE] by the DON revealed the rubber seal should have been wiped with an alcohol prep prior to attaching the needle. 4. Observation and interview on [DATE] from 9:43 a.m. through 9:57 a.m. in room nineteen with housekeeper E revealed she: *Did not perform hand hygiene before she had put on gloves and began cleaning the room. *Removed her gloves once and put on a new pair of gloves while cleaning the room. -No handwashing was observed during that time. *Washed her hands after she cleaned the room. *Agreed she should have washed her hands before putting on and after removing a pair of gloves. 5. Observation and interview on [DATE] from 8:20 a.m. through 8:40 a.m. in the residents' bathing room with CNA D revealed she: *Did not perform hand hygiene before and after she had disinfected the whirlpool tub. *Disinfected the whirlpool tub per policy and procedure steps. *No glove usage was observed. *Agreed she should have washed her hands before and after disinfecting the whirlpool tub. Interview on [DATE] at 9:50 a.m. with the director of nursing revealed she: *Would have expected all personnel to do appropriate hand hygiene to prevent the spread of infection. Review of the provider's [DATE] Hand Washing policy and procedure revealed: *Hand washing is the single most important procedure for the control of infection. *Although everyone's hands carry bacteria as normal flora, the purpose of hand washing is to remove the transient bacteria picked up while working with patients and equipment. *All personnel must wash their hands: -After handling soiled equipment or utensils. -After removing gloves or aprons.

Based on record review and interview, the provider failed to give appropriate timely notification of the liability and/or appeal notice for two of four randomly reviewed residents (11 and 12). Findings include: 1. Interview and review of resident 11's Notice of Medicare Non-Coverage form with the Minimum Data Set (MDS) assessment nurse revealed:*Medicare skilled services had ended on 8/4/17 for the resident. *Notice to the authorized representative was signed on 8/7/17. -That was not completed in a timely manner. 2. Interview and review of resident 12's Notice of Medicare Non-Coverage form with the MDS nurse revealed:*Medicare skilled services had ended on 9/12/17 for the resident. *Notice to the authorized representative was signed on 9/12/17. *A 9/8/17 progress note from the social services staff member indicated it was mailed to the authorized representative. -That note had not indicated the authorized representative was made aware at that time though. *The MDS nurse stated the representative should have been notified two days prior to the end of coverage for appropriate notice. *Normally the social services staff completed the notifications, but she was out of the facility on leave and unable to be contacted for further information. 3. Interview on 10/24/17 at 5:50 p.m. and on 10/25/17 at 8:00 a.m. with the director of nursing revealed appropriate timely notice of non-coverage had not been provided to residents 11 and 12's authorized representatives. Notices should have been given two days before the services ended. The provider had no policy related to those notices.

A. Based on observation, interview, record review, manufacturer's instructions, and policy review, the provider failed to ensure one of one nurse aide (NA) B in training had the appropriate supervision during a mechanical lift transfer for one of two sampled residents (5). Findings include: 1. Observation on 9/14/16 at 11:00 a.m. with resident 5 and NA B revealed: *NA B stated was she ready to transfer resident 5 with the EZ way smart stand lift from her bed to the toilet seat. *She assisted the resident up in the bed. *The resident did not appear to be assisting NA B with movement. *She did not close the door or window. *She maneuvered the resident to place her feet on the standing lift, put the harness around her back, and then under her arms. *The resident was unable to hang on to the grab bars with her hands when instructed by the NA. NA B placed the resident's hands around the grab bars. *The leg safety strap on the stand aide was not secured. *When the stand aide started to lift the resident up from the edge of her bed, the harness was pulling at her arms. Her shirt had pulled up revealing her breast. *She was moaning and stated Tuck my shirt in my side. *NA B continued to move the resident in the lift, her arms were pulled up around her head, and she was not able to hang on to the grab bars herself. -At that point, this surveyor intervened and asked NA B to return the resident her bed and sought assistance from certified nurse assistant (CNA) A. *CNA A came in, closed the curtain and then attached the safety strap to resident 5's legs. *Together they proceeded to move the resident in the lift to the restroom. *She was not able to hold on to grab bars herself and the harness pulled underneath her arms as before. *She was transferred to toilet with assistance of CNA A. -Following the transfer, this surveyor sought assistance from licensed practical nurse (LPN) C. *At 11:35 a.m. LPN C requested assistance from therapy staff I. Therapy staff were able to pivot her into wheelchair with the use of a gait belt. -Therapy staff I instructed them to use a commode, and transfer using the pivot method that she had just shown NA B and CNA A. -Therapy staff I instructed that if she was not able to hang on to the grab bars herself she would not be able to use the EZ Way Smart Stand lift safely. Interview on 9/14/16 at 2:00 p.m. with NA B revealed: *CNA A had asked her to go into resident 5's room and assist her. *That was her first transfer independently, and she was not comfortable. Interview per phone on 9/14/16 at 4:30 p.m. with registered nurse J revealed: *She had trained NA B for eight hours. -Training was verbally walking through skills, No hands on. *She had instructed NA B not to use any lifts, because no training had been done on lifts. *NA B was not able to work alone until she had taken her test and was certified. Interview on 9/14/16 at 4:45 p.m. with the director of nursing (DON) and the administrator both agreed: *Nursing assistants were allowed to work independently. *NA B had the training to work independently. *CNA A would have evaluated NA B and would have determined if she could transfer residents using a lift independently. *The DON revealed the MDS coordinator had not been able to train NA B during her first three days of training. Interview on 9/15/16 at 9:00 a.m. with the Minimum Data Set (MDS) coordinator revealed: *She also trained the new employees and aides. *NA B had her eight hours of training and was able to work alone on the floor. *She had not been able to train NA B due to her busy schedule. *She had been trained by CNA A. *She had not checked the skill level on CNA A when he had been hired, and she did not routinely check competencies for resident skills for new hires. Review of CNA's inservice training revealed NA B and CNA A had not received any training on mechanical lifts. Review of the DON job description revealed she Coordinates the continuing education program for nursing service. The NA job description had been requested from the DON but was not provided by the end of the survey. B. Based on interview, record review, manufacturer's instructions review, and policy review, the provider failed to ensure there had been two staff assisting with mechanical lift transfer for one of one sampled discharged resident (10) who had fallen during the transfer with major injury. Findings include: 1. Review of resident 10's medical record revealed: *An admission date of [DATE]. *She had been hospitalized from [DATE] through 1/4/16. *A 1/4/16 physician's orders [REDACTED].>-Admit to SNF with Hospice. -Activity as tolerated, use assistance as needed. *She had difficulty with walking and balance. *[DIAGNOSES REDACTED]. *She had a fall with major injury that had required hospitalization on [DATE]. Review of the provider's 12/29/16 PT-Therapist Progress & Discharge Summary revealed resident 10's treatment [DIAGNOSES REDACTED].>-Muscle weakness. -Other abnormalities of gait and mobility. -Unspecified lack of coordination. *Her goal Patient will safely transfer sit to stand and chair/chair with MOD (I) (modified improvement). Review of the nurses' notes from 1/4/16 through 1/5/16 regarding resident 10 revealed: *On 1/4/16 at 4:11 p.m. RN E's nurse's note revealed: -She had been readmitted to the facility. -She is very weak, needs 2 assist and staff did use the EZ stand on her to transfer her. *On 1/5/16 at 5:31 a.m. RN K's nurse's note revealed: -Tried to use sit to stand to get her to bathroom -Resident chicken wings et holds breath. *On 1/5/16 at 4:05 p.m. director of nursing (DON) nurse's note revealed: *She had been alerted to come to resident 10's room. *Upon arrival in the above room: -She found the resident sitting on the floor in front of recliner with EZ stand present. -There was a large amount of blood under the resident. -She had fallen while transferred with EZ stand. -Injury to her right lower extremities was determined to have been the cause of the bleeding. -The DON had called 911 due to the nature of injury and bleeding. *On 1/5/16 at 4:39 p.m. RN D's nurse's note revealed: *She had been called to the resident's room: -Certified nurse assistant (CNA) G had stated the resident had fallen. -(Resident's name) stated she passed out during the final stage of transfer to her recliner. *A Hoyer lift had been used when the ambulance arrived to transfer the resident. -The ambulance had left with the resident at 5:35 p.m. Review of the provider's 1/5/16 Required Healthcare Facility Event report for resident 10 revealed: *She had been transferred with the EZ stand lift with staff assistance from CNA G. *CNA G had reported the resident had lost consciousness during the transfer. *She had attempted to maneuver the resident to the chair. *She had fallen to the floor onto her bottom with her leg striking the EZ stand causing an open area to her right leg. *She had come to after the fall and had verbalized she was passing out while being transferred. *The ambulance had been notified, and she had been transferred to the hospital for treatment. Review of the provider's 1/8/16 Required Healthcare Facility Event report for resident 10 revealed: *She had been transferred for toileting by CNA G. *Resident had lost consciousness and was no longer being able to assist with support in stand lift. Review of resident 10's 1/4/16 Fall Risk Assessment revealed she: *Was chair bound. *Had not been able to perform gait and balance function. *Had: -Intermittent confusion. -Her total score was twelve, and that had put her at risk for falls. -A score of ten or higher represented a high risk for falls. Review of resident 10's 10/12/15 quarterly Minimum Data Set (MDS) assessment, sections C and G, revealed she: *Had a Brief Interview for Mental Status test score of 15 that indicated she was cognitively intact. *She had needed extensive assistance (staff providing weight-bearing support with two plus persons) for bathing. Review of resident 10's revised 12/29/15 care plan revealed: *She had been at risk for falls related to balance problems. *The goal was to have had no fall related injuries over the next MDS quarter. *Approaches had included toilet resident on a regular basis. *No EZ stand had been added to the care plan on 1/8/16. *There had been no documentation prior to 1/8/16 regarding the usage of the EZ stand. *There had been no documentation prior to the fall regarding the usage of the EZ stand lift and the number of staff needed for assistance. Interview on 9/15/16 at 9:35 a.m. with RN E regarding resident 10 revealed: *When the resident had returned from the hospital she had been physically weaker. *She had assessed the resident, and she had needed two staff assistance with the EZ stand lift. *The decision to have used one or two staff for a transfer was based on how she was doing at that exact time. Interview on 9/15/16 at 10:55 a.m. by telephone with physical therapy assistant H regarding resident 10 revealed: *She had been on physical therapy prior to her hospitalization before she had fallen. *She had been discontinued from therapy on 12/29/15. *Therapy was not usually consulted regarding what lift to have used when not on therapy. Interview on 9/14/16 at 10:55 a.m., 9/14/16 at 1:50 p.m., and at 9/15/16 at 11:45 a.m. with the DON regarding resident 10 revealed: *She had been physically weaker after her hospitalization . *RN E had documented the resident had needed two staff assistance with the EZ stand lift. *The fall risk assessment was used for assessing what lift to have used. *The provider had not used any formal lift assessment form. *The decision on a lift usually involved therapy as needed and the nurses and CNA input. *She stated any changes with residents requiring assistance with transfers would have been communicated at report that was held three times per day at 6:00 a.m., 2:00 p.m., and at 5:00 p.m. *She confirmed the communication regarding the above need for assistance had not been communicated as well as it should have. *Her care plan had needed to have been updated regarding her care for transfers. *She agreed the resident's need for a two person assist with the EZ stand had not been communicated to all staff providing care to her. *She confirmed there needed to have been two staff assist with the EZ stand on 1/5/16 before she had fallen. An interview with CNA G regarding resident 10 had not been possible during this survey. Review of the provider's 6/17/14 EZ Way Smart Stand Lift Operator's Instructions for use revealed: *The EZ stand lift was designed to lift residents from a sitting position to a standing position, then transfer to a bed, chair, or toilet. *The lift was to be used for residents who: -Were able to bear some weight. -Had upper body strength. -Were able to follow simple commands. *The lift was designed to be operated safely by one person, however, -Depending on the situation. -Facility policy. -Resident's condition. -Two staff might have been necessary. Review of the provider's December 2014 Transferring/Lifting policy revealed: *Safety was the responsibility of every employee. *The mechanical stand might have been one or two staff depending on resident needs. *To be used for residents including those: -Who because of their medical condition were difficult to control during a transfer. -Who required more than assist of one to ambulate or to transfer from sitting to stand to ambulate.

Based on observation, record review, interview, and policy review, the provider failed to ensure two of two sampled residents (11 and 12) had been assessed and evaluated to safely self-administer their medications (med). Findings include: 1. Observation on 9/13/16 at 11:40 a.m. of registered nurse (RN) D administering medications in the dining room (DR) to resident 12 revealed: *She set the med cup in front of the resident and returned to the med cart. *The resident placed the meds on a napkin and took each pill one at a time. *The nurse had been in and out of the dining room twice while the resident took his meds. Observation on 9/14/16 at 9:15 a.m. of RN F who was administering meds in the DR to resident 11 revealed: *She set the med cup in front of the resident, and she returned to her cart to continue passing medications. *The resident placed meds on a napkin and took each pill one at a time. *The nurse had left the dining room while the resident took her meds and had not been observing the resident. Review of resident's 11 and 12's complete medical records revealed: *There was no documentation an assessment for self-administration of medications had been completed. *There was no physician's order to self-administer medication. Interview on 9/14/16 at 4:00 p.m. with the director of nursing regarding residents 11 and 12 confirmed: *Those residents should not have been self-administering their meds without an appropriate assessment. *She expected an assessment and a physician's order for the residents to safely self-administer their medications. Review of the provider's December 2009 Medication Administration policy revealed: *Administer the medication and observe swallowing. *Do not leave medications at the table unless the resident has a physicians order to do so. Review of the provider's December 2009 Medication Control policy revealed All residents expressing a desire to self-administer medications would have been evaluated and assessed by the care team to determine competency.

Based on observation, interview, and policy review, the provider failed to ensure dignity was maintained for one of one sampled resident (13) who had her abdomen exposed during an insulin injection. Findings include: 1. Observation at the nurses station from 9/14/16 at 10:00 a.m. to 10:40 a.m. of registered nurse (RN) (F) regarding resident 13 revealed: *She pulled down the resident's pants and pulled up her shirt exposing her abdomen and her pink underwear. *The door remained open at the nurses station. *Staff were going in and out of the nurses station. *Two large window blinds were open to the hallway where staff, residents, and the public could view resident 13 receiving her injections. *RN continued to look for the resident's Medication Administration Record [REDACTED]. *At 10:40 a.m. at the nurses station the nurse gave the resident a second injection of the blood thinner. Interview on 9/14/16 at 11:00 a.m. with RN F revealed: *It was routine to have given injections to the residents at the nurses station. *She agreed she should have closed the door and the blinds to ensured privacy of the resident. Interview on 9/15/16 at 9:10 a.m. with the Minimum Data Set (MDS) assessment coordinator regarding insulin administration to residents at the nurses station revealed: *Blinds and door should have been closed when exposing a resident's abdomen. *Resident's injections were routinely given at the nurses station. Review of the provider's undated Dignity policy revealed the staff would interact with residents in a hospitable manner to maintain and enhance self-worth and dignity. An Injection Administration policy was requested but was not provided by the end of the survey.