Every finding on record at Weskota Manor Inc

Based on record review, interview, and policy review the provider failed to ensure:*A bed-hold notice information was provided when six of six sampled residents (1, 5, 7, 11, 26, and 33) transferred to the hospital to those residents or their representatives.*The Office of State Long-Term Care Ombudsman was notified when a resident discharged from the facility or was transferred to the hospital for six of six sampled residents (1, 5, 7, 11, 26, and 33) and two of two sampled residents (7 and 34)who were discharged home. Findings include:1. Review of resident 1's electronic medical record (EMR) revealed: *He was transferred to the hospital on 8/11/25. *His representative was notified of the 8/11/25 transfer. *There was no documentation that the bed hold information was given to the resident or his representative for his 8/11/25 transfer to the hospital. *There was no documentation that the Office of State Long-Term Care Ombudsman was notified of resident 1's transfer to the hospital. 2. Review of resident 26's EMR revealed: *She was transferred to the hospital on 9/4/25 and was readmitted to the facility on [DATE]. *Her representative was notified of her transfer to the hospital on 9/4/25. *There was no documentation that the bed hold information was given to resident 26 or her representative for her 9/4/25 transfer to the hospital. *There was no documentation that the Office of State Long-Term Care Ombudsman that resident 26 transferred to the hospital and admitted . 3. Review of resident 5's EMR revealed: *She was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. *Her representative was notified of her transfer to the hospital on [DATE]. *There was no documentation that the bed hold information was given to resident 5 or her representative for her 10/25/25 transfer to the hospital. *There was no documentation that the Office of State Long-Term Care Ombudsman that resident 5 transferred to the hospital and admitted . 4. Review of resident 33's EMR revealed: *She was transferred to the hospital on [DATE] and was readmitted to the facility on [DATE]. *Her representative was notified of her transfer to the hospital on [DATE]. *There was no documentation that the bed hold information was given to resident 33 or her representative for her 11/16/25 transfer to the hospital. *There was no documentation of notification to the Office of State Long-Term Care Ombudsman that resident 33 transferred to the hospital and admitted . 5. Review of resident 11's EMR revealed: *He was transferred to the hospital on [DATE]. *His representative was notified of the 12/13/25 transfer. *There was no documentation that the bed hold information was given to the resident or his representative for the 12/13/25 hospital transfer. *There was no documentation of notification to the Office of State Long-Term Care Ombudsman that resident 11 transferred to the hospital. 6. Review of resident 7's EMR revealed: *She was transferred to the hospital on [DATE] and then transferred to another hospital to receive additional services. *Her representative was notified of her transfer to the hospital on [DATE]. *There was no documentation that the bed hold information was given to resident 7 or her representative for her 12/15/25 transfer to the hospital. *Resident 7 did not return to the facility after her hospital stay and was discharged to home on [DATE]. *There was no documentation that the Office of State Long-Term Care Ombudsman was notified of resident 7's transfer to the hospital or her discharge to home. 7. Review of resident 34's EMR revealed: *She was discharged to her home on [DATE] upon her request. *There was no documentation of notification to the Office of State Long-Term Care Ombudsman of resident 34's discharge to home. 8. Interview on 1/14/26 at 2:58 p.m. with registered nurse (RN) E revealed she: *Stated the nurses did not do anything related to bed holds. *Thought the business office staff was responsible for providing the bed hold information to the resident or the resident's representative when the resident transferred out of the facility. 9. Interview on 1/15/26 at 10:25 a.m. with social service director (SSD) C revealed: *She reviewed the bed hold policy with each resident or the resident's representative on admission to the facility and a copy of the policy was in their admission packet. *She was not responsible providing the written bed hold information to the resident or the resident's representative when a resident was transferred to the hospital. *She was responsible for notifying the Office of State Long-Term Care Ombudsman if a resident was transferred or discharged . *She did not notify the Office of State Long-Term Care Ombudsman when the residents transferred and discharged but verbally reviewed those with the local Ombudsman when she was in the facility during her monthly visits. *She verified there was no documentation that the Office of State Long-Term Care Ombudsman office had been notified of the residents' transfers and discharges. 10. Interview and review of the provider's bed hold policy on 1/15/26 at 10:51 a.m. with director of nursing (DON) B revealed: *She stated bed hold information was to be provided to the resident or resident representative when a resident was transferred to the hospital. *There had been a miscommunication between the departments about who was responsible to give the bed hold information to the resident or the resident's representative upon transfer, and that may have resulted in the information not being given when the residents were transferred to the hospital. *She was aware that the provider's policy indicated that the nurses were responsible for providing the bed hold information. The nurses used to provide that information, but they no longer had access to the bed hold information, so they no longer provided it. 11. Interview on 1/15/26 at 11:00 a.m. with administrator A revealed: *She was unable to find documentation to support the bed hold information was provided to resident 1, or his representative, for the hospital transfer on 8/11/25. *She was unable to find documentation to support the bed hold information was provided to resident 11, or his representative, for the hospital transfer on 12/13/25. *There was no documentation that residents 5, 7, 26, or 33 or their representatives was provided bed hold information at the time of transfer from the facility. *She indicated that she expected the bed hold documentation would have been in the resident's EMR. *The Office of State Long-Term Care Ombudsman's was not formally notified of resident transfers or discharges. 12. Review of the provider's 2004 Bed Hold policy revealed: *To establish a bed-hold policy for all residents prior to admission, following transfer to a hospital or therapeutic leave and an appropriate procedure for notifying a resident and family member or legal representative of the policy. *Prior to or at the time transfer for hospitalization or a therapeutic leave, the resident and family will be issued a copy of the Facility bed-hold policy. In case of an emergency transfer, a copy of the bed-hold will be issued within 24 hours of the transfer, to resident and family. *The Charge Nurse, at the time a resident is transferred to a hospital or therapeutic leave, will document in the resident file that a copy of the bed-hold policy was issued to the resident and family. Review of the provider's 6/2024 Long Term Care Transfer and Discharge-System Standard Policy, South Dakota, revealed: * Emergency Transfers: When a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of notices for emergency transfers must also still be sent to the Ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis.

Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident's (5) 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 Pre-admission Screening and Resident Review (PASRR) and one of one sampled resident's (17) MDS assessment was accurately coded for areas of pressure ulcers. Findings include:1. Review of resident 5's electronic medical record revealed:*She was admitted on [DATE].*Her diagnoses included delusional disorder (a mental illness where a person holds strong, false beliefs despite evidence to the contrary), anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), schizoaffective disorder (a serious mental illness with symptoms of impaired reality perceptions, mood swings, disorganized thinking, and altered behavior), and paranoid personality disorder (a mental health illness with unwarranted distrust and suspicion of others).*Her 1/14/26 care plan had a focus area that stated, 2/1/2024 PASSR [PASRR] review done and accepted for nursing home care no changes at this time. I [the resident] am determined as a Level 1 Positive PASSR for Level 2 with Serious Mental Illness.*She had a level I (1) PASRR completed on 2/1/24 for a potential change in condition that stated.- Your Level I screen was submitted for a potential status change. It shows that you have evidence of serious mental illness or an intellectual/developmental disability (IDD). However, your condition does not require further PASRR evaluation at this time because your serious mental illness or IDD treatment needs have not significantly changed since your previous PASRR Level II evaluation.- The facility should mark yes for question A1500 on the MDS 'Is the resident currently considered by the state level II PASRR process to have a serious mental illness and/or intellectual disability or related condition?'*Item A1500 of her 9/19/24 and 8/21/25 comprehensive MDS assessments were coded No.2. Review of resident 17's EMR revealed:*She was admitted on [DATE].*She had a stage II (2; open wound or blister with partial-thickness skin loss) pressure ulcer (skin and/or underlying tissue injury from prolonged pressure) on her coccyx (tailbone) from 7/4/25 through 10/6/25 that healed.*Item M0100 A of her 8/14/25 MDS assessment was coded No to the question Resident has a pressure ulcer/injury, a scar over bony prominence, or a non-removable dressing/device.3. Interview and review of resident 5's PASRR determination on 1/15/26 at 10:25 a.m. with social services director (SSD) C revealed she:*Was responsible for submitting the PASRR screens to Maximus (the state contracted agency responsible for reviewing, making determinations, and recommendations related to residents' PASRR screening results).*Completed question A1500 on the residents' MDS assessments related to their PASRRs.*Read resident 5's PASRR outcome explanation from Maximus as a positive Level I with no PASRR Level II required.*Stated she did not read through the entire document when she received it and only looked at the PASRR Level I determination which said, Level I Positive, No Status Change.*After reviewing the document she agreed that if she had read through the entire document, she would have seen that resident 5 had a current Level II PASRR, and the directions on how she was to answer the question related to the Level II PASRR on resident 5's MDS assessment.4. Interview and review of resident 17's EMR and 8/14/25 MDS assessment on 1/15/26 at 10:41 a.m. with registered nurse (RN)/MDS coordinator D revealed:*She was responsible for coding the residents' MDS assessment related to pressure ulcers.*When she coded the MDS assessments related to pressure ulcers, she would review the resident's EMR, risk management documentation, and information provided during daily staff meetings (to inform staff of resident status and care needs updates).*She would attempt to complete a skin check after the resident's bath during the resident's look back period (the time period over which the resident's condition or status is captured by the MDS assessment) to determine how to accurately code the resident's skin information on the MDS.*After review of resident 17's EMR and 8/14/25 MDS assessment RN/MDS coordinator D verified she had coded M0100A inaccurately as resident 17 had a pressure ulcer during the look back period.5. Interview on 1/15/26 at 10:51 a.m. with director of nursing (DON) B revealed she expected the MDS assessments to be completed accurately.6. Review of the provider's November 2025 MDS Completion policy revealed:* To complete the quarterly, annual and significant change MDS by all departments which include Dietary, Activities, Social Services, and Nursing.* Each department enters all data in their section of the MDS into the computer and signs off their area.Review of the provider's December 2025 LTC [Long-Term Care] PASRR -South Dakota- policy revealed:* It is the policy to screen all potential admissions on an individualized basis. As part of the preadmission process, the facility participates in the Preadmission Screening and Resident Review (PASRR) screening process (pre-screening and Level I) for all new and readmissions per requirement to determine if the individual meets the criterion for mental disorder (SMI/SMD), intellectual disability (ID) or related condition.* The objective of the PASRR policy is to ensure that individuals with mental illness and intellectual disabilities receive the care and services that they need in the most appropriate setting. The PASRR will be evaluated as needed upon any significant change for those individuals identified.

Based on observation, interview, and policy review, the provider failed to monitor the room temperature to ensure medications were stored within safe temperature ranges in one of one medication room. Findings include:1. Observation and interview on 1/14/26 at 12:44 p.m. with registered nurse (RN) E in the medication room revealed:*She stated the facility had one medication room.*She stated the medication room often felt significantly warmer than the rest of the facility.*There were logs to document the temperatures of the medication and food refrigerators stored in the medication room in a three-ringed binder.*There were no documented medication room temperatures.*RN E stated that the temperature of the medication room was not monitored or documented.*She stated she did not know how the temperature of the medication room could be adjusted because there was no thermostat for that room.*A box of resident 19's ipratropium bromide and albuterol sulfate (a medication to open airways and make breathing easier) indicated it was to be stored between 68- and 77-degrees Fahrenheit (F) was stored in the upper cabinet in the medication room.2. Interview on 1/15/26 at 8:49 a.m. with administrator A revealed there were no medication room temperature documentation logs.3. Interview on 1/15/26 at 10:07 a.m. with RN F revealed she:*Stated the temperature of the medication room was not monitored or documented.*Stated the temperature of the medication room fluctuated by the seasons, sometimes it felt hot in there and other times it felt cool.*Stated that the monitoring of the temperature of the medication room had been discussed before but she was not sure why it was not monitored.*Agreed that if the temperature of the medication room was not monitored it would not be possible to verify that the medications stored in the medication room were maintained within the manufacturers' recommended storage temperatures.4. Interview on 1/15/26 at 10:51 a.m. with director of nursing (DON) B revealed she:*Verified the temperature of the medication room was not monitored.*Was not aware the temperature of the medication room was required to be monitored.*Had verified that the provider's policy addressed the temperatures in which medications were to be stored.5. Review of the provider's January 2026 Medication Storage policy revealed:* Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.* Medication storage areas are kept clean, well-lit, and free of clutter and extreme temperatures and humidity.* All medications are maintained within the temperature ranges noted in the USP [US Pharmacopeia (a legally recognized collection of publicly accessible quality standards for drugs and their components)] and by the CDC [Center for Disease Control].

Based on observation, interview, policy review, and manufacturer's instructions review the provider failed to ensure food items for resident consumption were appropriately labeled, stored, and served in a safe and sanitary manner for the following: *Three of three commercial and one of one resident refrigerators that contained food items that were not labeled, dated, or discarded by the use-by date. *Two of two dry food storage areas that contained dry food items that were not labeled or dated. *One of one commercial freezer that contained food items that were not labeled, dated, or appropriately stored. *One of one food service manager (C) did not properly sanitize the food thermometer while temping the food items before serving them to the residents. *The kitchen and food service equipment was not maintained in a clean condition. Findings include: 1. Observation during the initial tour of the kitchen and food storage areas on [DATE] at 12:40 p.m. revealed: *In the reach-in refrigerator: -There were two out of five Activia yogurts with a use-by date of [DATE]. -There was a can of V8 juice dated [DATE]. -There was a [NAME] jar containing an unidentified red liquid dated [DATE]. -There was an opened tube of whipped topping that did not have an opened date or use-by date. *Another refrigerator which staff referred to as the salad fridge contained: -An opened bag of mozzarella cheese dated ,d+[DATE]. -A container of sour cream with an opened date of ,d+[DATE] and a use-by date of [DATE]. -An egg carton contained ten eggs with a use-by date of [DATE]. -An opened package of deli fresh roast beef that did not have an opened date. -A container of beef paste that did not have an opened date or a use by date. -An unopened package of oven roasted turkey with a use-by date of [DATE]. -An opened package of oven roasted turkey that did not have an opened date and had a use-by date of [DATE]. -An opened jug of creamer that did not have an opened date. -A jug of orchard splash juice with an opened date of [DATE] and a use by date of [DATE]. *In the dry baking goods storage room: -A clothing jacket was on the metal wire shelf that had oyster crackers stored on it. -An opened bag of marshmallows that did not have an opened date on it. -A container of pink lemonade powder with an expiration date of [DATE] with an opened date of ,d+[DATE]. -An unsealed bag of Oreo cookie pieces that had a use-by date [DATE]. -An opened container of white vanilla frosting that did not have an opened date. *The freezer in the dry baking goods storage room contained: -A light weight zipped bag of brats that appeared to have freezer burn dated ,d+[DATE]. -An opened bag of sausage dated ,d+[DATE]. -An opened bag of rhubarb with best by date of [DATE]. -An opened bag of potatoes that did not have a use-by date. -A light weight zipped bag of French fries that did not have a use-by date. -A light weight zipped bag of ham which appeared to be freezer burnt that did not have an opened by date. -A ripped open brown paper sack with French fries that did not have an opened by date. -An opened ice cream container that was labeled, ,d+[DATE] chicken pot pie. -Three bags of opened chicken patties that did not have an opened by date. *The weekly cleaning schedule hung up on a cabinet revealed: -Two out of 19 tasks were marked as completed for week 1. -One out of 19 tasks were marked as completed for week 2. *The cabinet above the sink contained: -A cottage cheese tub that contained lemon jello dated ,d+[DATE]. -A bag open to air that contained vanilla pudding and pie mix that had not open or best by date. -A box of orange gelatin mix that was labeled, ,d+[DATE]. *The top of the oven appeared dusty with food particles and had a baking rack set on it. *The canned dry storage area contained: -Cleaning supplies including Comet, Dawn [NAME] Sanitizer, and Stera Sheen on the bottom rack of a food shelving unit. *In the walk-in freezer: -There were three unopened boxes on the floor. -An opened bag of sausage patties that did not have an opened by date. -A light weight zipped bag of blueberry muffins that did not have an opened or use-by date. *In the walk-in fridge: -There were six unopened packages of roasted turkey that was dated use or freeze by ,d+[DATE]. -A case of cottage cheese that had a use-by date of ,d+[DATE]. -Three activia yogurts that had a use-by date of ,d+[DATE]. -A case of lite and fit yogurt that had a use-by date of ,d+[DATE]. -There were four cucumbers that were uncovered on the shelving unit and visibly spoiled with mold spots. -There were six 4-packs of lemon lime jello that had a use-by date of ,d+[DATE]. -There were two 4-packs of strawberry jello that had a use-by date of ,d+[DATE]. -A case of unpasteurized eggs. *In the dining room fridge/freezer: -There was an undated, zipped bag in freezer with pumpkin bread labeled, a resident's name on it. -There were two undated jars of pickles labeled, a resident's name on it. -An undated Walmart bag with strawberries, melon, and tomatoes labeled, a resident's name on it. -A tub with blue lid with watermelon in it labeled, ,d+[DATE] a resident's name on it. -An undated container with a blue lid with grapes in it labeled, a resident's name on it. -An opened, unfinished can of root beer with resident's initials that was not dated. 2. Observation and interview on [DATE] at 11:38 a.m. through 12:10 p.m. with food service manager C during the noon meal prep revealed: *The desserts (carrot cake and pudding) for the noon meal in the reach-in fridge were not covered. *Food service manager C: -Dipped the thermometer in a red bucket which she stated was filled with sanitizer. -Inserted that thermometer in a chicken breast, waited a few seconds, and read the temperature of 165 degrees Fahrenheit (F). -Placed the thermometer in a green bucket which she stated was detergent. -Wiped off the food particles into the green bucket and then dipped the thermometer into the red bucket. -Continued to obtain the temperatures of the food items and used this cleaning process ten additional times. *She stated the sanitizer is the same that is used for the dishes. 3. Observation on [DATE] at 12:15 p.m. in the dishwasher room revealed: *Expired hydron chlorine test strips dated [DATE]. *There were rusty cans that staff put leftover food in after meals and would then wash them in the dishwasher. 4. Interview on [DATE] at 3:36 p.m. with food services manager C about the above observations revealed: *She was not aware there were expired items in any of the fridges. *It was her expectation that staff throw away expired food times and label them correctly when opened. *The staff were supposed to keep personal items in their locker and not with food items. *She stated things in the freezer should be wrapped in saran wrap and put in gallon zipped bags. *She was not aware that her zipped bags were not freezer bags, and the food was getting freezer burnt. *If food was brought in for residents, it needed to be labeled correctly with their name, date, and could be kept for seven days. *She confirmed that the eggs were not pasteurized. *She stated the egg container in the kitchen fridge has been refilled since she has been there but should have the correct date from the original egg container marked on it. *She agreed that the cleaning schedule was not complete and that everything on that list should be cleaned weekly and marked when done. *Staff were supposed to put the hydron chlorine test strips on the silverwear before every meal to test the chlorine level. *She stated she was not aware the test strips were expired. *She explained dishes must completely air dry after they were removed from the dishwasher per the sanitizer instructions. *When asked if she allowed the thermometer to dry before temping foods, she stated she had not and that it was a problem. 5. Interview on [DATE] at 4:34 p.m. with administrator A revealed there was no policy on the cleaning schedule, and she expected staff to fill the cleaning schedule out accordingly. 6. Review of the providers [DATE] reviewed General Food Preparation and Handling policy revealed: *Procedure: -The kitchen and equipment are clean. -Foods are received, checked, and stored properly as soon as they are delivered. -Food is covered for storage. 7. Review of the providers [DATE] Dry Food Storage policy revealed: * Food is stored, prepared, and transported at appropriate temperatures and by methods designed to prevent contamination. *Procedure: -All containers must be legible and accurately labeled. -Chemicals must be clearly labeled, kept in original containers when possible, and kept in a locked area away from food. -All stock must be rotated with each new order received. 8. Review of the provider's [DATE] reviewed Temperatures of Hot and Cold Food policy revealed: *Procedure: -To take temperatures, a clean, sanitized and air-dried thermometer is needed . -The thermometer must be sanitized between uses in different foods. Thermometers can be sanitized using alcohol swabs in between taking the temperature of the food. 9. Review of the provider's [DATE] reviewed Food from Outside Sources policy revealed: *Procedure: -It must be placed in a plastic container with tight fitting lid. -Food brought in should be labeled with the individuals name. If the item is to be stored, it must be dated and placed in the resident's refrigerator. After 3 days the perishable item will be discarded. 10. Review of the [NAME] Sanitizer manufacturer's instructions for use revealed: *For sanitizing food contact surfaces: - .must be sanitized by emersion. -Thoroughly wet all surfaces. -Drain thoroughly and air dry. -Do not rinse.

Based on interview, and policy review, the provider failed to ensure fourteen of fifteen sampled residents (1,2,5,7,10,11,16,17,19,21,23,26 and 33) had been screened for post-traumatic stress disorder (PTSD) upon admission. Finding include: 1. Interview on [DATE] at 12:58 p.m. with resident 10 while seated in her recliner revealed: *She did not know why she was there. She had been a good girl. *She had thought she was living there because her mother died . Interview on [DATE] at 4:00 p.m. with licensed practical nurse (LPN) E regarding the above interview with resident 10 revealed: *She knew that resident 10 had been sent to a juvenile detention center when she was a teenager because she had a boyfriend. *Resident 10 would often tell staff she had been a good girl and did not know why she was there. Interview on [DATE] at 4:44 p.m. with social service manager (SSM) D regarding PTSD screening of residents revealed: *She did not screen all new residents for PTSD. *She had screened resident 34 for PTSD due to her having a diagnosis of the disorder upon admission. *She had contacted her social services consultant G regarding screening new residents for PTSD. -She had been informed a screening needed to be completed upon admission and annually on all residents. Interview on [DATE] at 10:07 a.m. with SSM D regarding PTSD screening on resident 10 revealed: *She had screened resident 10 today ([DATE]) and had spoken to the resident's son. -The resident's son had verified that resident 10 had been in a juvenile detention center when she was a teenager. --He added that resident 10 would reference she had been a good girl and did not know why she was there. *SSM D had offered counseling to resident 10 but she declined and her family also declined. Interview on [DATE] at 9:55 a.m. with social services consultant G regarding screening residents for PTSD revealed she had informed SSM D all residents needed a screening upon admission and then annually. Interview on [DATE] at 10:30 a.m. with director of nursing B regarding screening residents for PTSD revealed she had not been aware that all residents required a screening upon admission and annually. Review of the provider's [DATE] PTSD Screening policy revealed: *Nursing assess the day of admit with clinical assessment. *Social Services to evaluate each resident at admit and then during the annual assessment using the PTSD screening tool for DSM-5.

Based on observation, interview, record review, and policy review, the provider failed to ensure that 17 of 17 expired Influenza vaccine injections were removed from the medication refrigerator prior to the expiration date. Findings include: 1. Observation and interview on [DATE] at 5:00 p.m. with licensed practical nurse (LPN) E in the medication storage room revealed: *There were two boxes of Influenza vaccines totaling 17 doses with an expiration date of ,d+[DATE] found in the medication refrigerator. *LPN E agreed that these influenza vaccines were expired and should not have been in the medication refrigerator. *The vaccines were removed from the refrigerator and LPN E said she would find out what needed to be done with them. 2. Interview on [DATE] at 07:54 a.m. with director of nursing (DON) B revealed: *DON B agreed that the 17 influenza vaccines were expired. *When asked what happened to the vaccines and she said, we got rid of them. She later said that they were destroyed the previous night after the vaccines were discovered. *I asked if she knew what the expiration date was on the vaccines, and she said ,d+[DATE]. 3. Interview and record review on [DATE] at 1105 a.m. with DON B regarding the provider's Pharmaceutical Supplies Inspection Guide revealed: *The Pharmaceutical Supplies Inspection Guide was a tool used to check for outdated medications and pharmaceutical supplies. *This guide was to be completed monthly. *The last time this guide was documented as completed was on [DATE] by LPN E. *That guide was not completed during the month of July, 2024. 4. Review of the provider's Medication Destruction policy revealed: * When medications are discontinued by the physician order, expired or in the of patient's death or discharge, the medications are destroyed in the facility.

Based on observation, interview, record review, and policy review, the provider failed to ensure two of two sampled residents (2, 28) with a facility acquired pressure ulcer received ongoing assessments and interventions to have prevented the pressure ulcer. Findings include: 1. Observation on 3/21/22 at 3:00 p.m. of resident 2 revealed she had been seated in her wheelchair in the hall way. Observation on 3/22/22 at 8:30 a.m. of resident 2 revealed she had been seated in her wheelchair in the dining room. Interview on 3/21/22 at 5:00 p.m. with licensed practical nurse O regarding skin treatment for [MEDICAL RECORD OR PHYSICIAN ORDER] *She received normal saline dressing change twice a day to the affected area. *While staff had already completed treatment prior to the surveyor arrival, request was made to observe other skin treatments. Review of resident 2's electronic medical record revealed inconsistencies in documentation between different portions of the record that included: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) of 6 indicating very severe impairment. *She had refused to be repositioned and other cares. *She had been incontinent of bowel and bladder. *Registered nurse (RN) M had a skin observations entry on 11/12/21 at 1:26 p.m. that revealed: -Open areas to bilateral gluteal folds measuring 4 centimeters (cm) by 1 cm to the left side and 2 cm by 1 cm to the right side. -Barrier cream was applied. *On 12/9/21 at 2:36 p.m., RN M's skin/wound note revealed: -The upper buttock crease was pink and the skin was fragile. -The right inner buttock measured a 2 cm by 2 cm bruise. Light purple area. Skin was intact. *On 1/3/22 at 6:27 p.m., RN I's Communicated to physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Open L shaped area to right buttock that measured 0.6 cm by 0.8 cm. -Resident 2 had a cushion in her wheelchair and recliner. -She had an air mattress on her bed. -Barrier cream was applied. -No response or orders were noted in the progress note from the physician. *On 1/11/22 at 1:26 p.m., RN M's Communicated to physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Open area measured 1 cm by 1.5 cm stage 2 pressure ulcer to her right buttock. -Order received from physician to apply duoderm to right buttock every three days and as needed. *On 1/25/22 at 2:14 p.m., RN N's Communicated to physician progress notes [MEDICAL RECORD OR PHYSICIAN ORDER] -Duoderm not effective to open area on buttock. -Order received from physician to discontinue the duoderm. -Barrier cream applied to affected area and encouraged resident to lay on her side. -She refused to lay on her side. *On 1/25/22 at 2:51 p.m., RN M documented a skin/wound note that revealed: -A stage 2 pressure ulcer to inner left buttock measured 5 cm by 4 cm and right buttock measured 4.5 cm by 4.0 cm. -The skin area around the wound was red and wound beds were pink. -Resident 2 had been incontinent multiple times. *On 2/28/22 at 11:32 a.m.n RN M documented a skin/wound note that revealed: -Open areas to buttock are closed. -Continued to use a barrier cream. *On 3/7/22 at 10:32 a.m., RN N documented a skin/wound note that revealed: -Very superficial open abrasion to right inner buttock with cleaning resident. -The resident's quote of, They wipe me too hard, was in the progress note. -Normal saline dressing was applied and education was given to resident to continue laying on her side while in bed between meals and during the night. -Director of Nursing (DON) B aware. *On 3/22/22 at 3:19 p.m., RN I communicated to the physician the following: -The area to right buttock was open 1 cm by 0.8 cm. -Normal saline dressing was used to the affected area. *On 3/23/22 at 9:40 a.m., the physician evaluated the wound and ordered normal saline dressing three times per day. Review of resident 2's skin observation documentation between 12/9/21 through 3/23/22, a total of 105 days with 306 separate entries, revealed the number of times per day resident 2 had toileting/incontinence care provided: *One day had only one entry. *18 days had two entries. *72 days had three entries. *14 days had four entries. Interview on 3/23/22 at 2:15 p.m. with DON B regarding skin evaluation revealed: *Skin evaluations had been kept in point click care (PCC) and the skin assessment book. *The wound nurse had been documenting in both places with skin measurements. *Measurements in the skin assessment book were not always documented in PCC. *She would expect other nurses to measure and document new skin findings. *The skin observation task was completed by the certified nursing assistant after providing care. Review of resident 2's undated care plan revealed: *I am at risk for skin breakdown and pressure ulcer related to decreased mobility, incontinence and moisture under my folds. *Interventions include: -Administer treatments/meds as ordered and monitor for effectiveness. -Apply protective barrier cream to peri/rectal area following incontinent episodes and as needed. -Apply lotion to my skin. *The care plan had not identified the following interventions: -Turning and repositioning a minimum of every two hours with inspection of bony prominence's. -No other interventions were identified if the resident refused. -Incontinence care every two hours and as needed. -No intervention was provided by the registered dietitian. Review of the provider's policy dated 3/21 on Prevention of Pressure Ulcers revealed: *It is the policy of this facility to prevent the development of pressure ulcers in residents whenever possible. Prevention measures shall include, but not limited to: -Assessment risk upon admission to the facility and quarterly with each MDS or significant change. --Resident had scored at risk for Braden assessments. -Appropriate skin and incontinence care. -Identification of disease and comorbid conditions which, increase skin risk. -Relief and reduction of pressure as needed. -Continued education of residents, families, and staff relative to the prevention of injury to the skin. *Nursing care shall include: -Turning and repositioning at a minimum of every two hours with inspection of bony prominence's. -Incontinent care every two hours and as needed. -Assessment of nutrition and hydration with referrals as needed. -Institution of measures to reduce the effects of pressure, friction, and shear. 2. Observation and interview with resident 28 on 3/21/22 at 3:00 p.m. revealed: *She was in bed with the head of the bed raised at 75 degrees. *Her physician said her motor neurons are shutting down her motor skills. *She did not have much pain except my tailbone due to an open area on it. *She got it from sitting in her reclining chair too long, and had it for about a month. Review of resident 28's electronic medical record revealed inconsistencies in documentation between different portions of the record that included: *A 2/10/22 quarterly Minimum Data Set (MDS) that noted several areas of decline when compared to the 8/26/21 quarterly MDS and the 11/18/21 significant change in status MDS, including: -Increased staff assistance needed for transferring and eating. -Use of a catheter. -Increased incontinence of bowel. -Increased symptoms of a swallowing disorder. -A severe weight loss of greater than 10% in 6 months. -Stage 2 pressure ulcer. *The care plan noted a focus initiated on 5/31/20 and revised on 3/7/22 for potential for altered skin integrity/pressure ulcer development with notations of a pressure ulcer to her tailbone on 2/8/22 healed and on 3/1/22. *The point of care (POC) task documentation for skin observation on each day from February 1, 2022 to March 22, 2022 revealed no areas were noted as scratched, red, discolored, torn, or open. *The Skin Only Evaluation noted measurements of the Stage 2 pressure ulcer on coccyx: -On 3/2/22, 2 centimeters (cm) length by 2 cm width by superficial depth, no drainage or odor. -On 3/9/22, same as 3/2/22 except for 0 depth. -On 3/15/22, 0.3 cm by 0.3 cm by 0 depth. -On 3/21/22, 0.8 cm by 0.7 cm by 9 depth. *Two of the four evaluations (3/2 and 3/9) noted the resident was unable to move without assistance and sat on a bedpan for long periods due to bowel concerns. *The 3/21/22 evaluation noted she had been refusing to get up in recliner and continues to set on bed pan for extended periods of time. *No skin only evaluation was found for the 2/8/22 pressure ulcer noted as healed on the care plan. Interview on 3/23/22 at 10:49 a.m. with DON B revealed: *The certified nursing assistants monitor for skin concerns every day as part of the POC tasks. *She was not aware there was no POC documentation of open areas to correlate with the pressure ulcers on 2/8/22 and 3/1/22 as noted on the care plan. *She would look for documentation related to the 2/8/22 pressure ulcer. Interview on 3/23/22 at 10:54 a.m. with registered nurse/minimum data set coordinator (RN/MDS-C) I revealed: *Resident 28 used to sit up in her recliner and several different cushions had been tried. *She had limited ability to reposition herself and chose to sit on a bedpan due to bowel concerns. *The pressure ulcer noted on the 2/10/22 MDS had closed after that date for a little while but opened again. Interview on 3/23/22 at 11:57 a.m. with DON B and RN/MDS-C I revealed: *No documentation was found regarding the pressure ulcer noted on 2/8/22 as healed on the carte plan. *A printed copy of a discontinued order on 2/17/22 for Duoderm to open area on tailbone. was provided by DON B.

Based on observation, interview, and record review, the provider failed to revise care plans to address the status for 1 of 12 sampled residents (28). Findings include: 1. Observations and interviews with resident 28 on 3/21/22 at 3:00 p.m. and 4:24 p.m. and on 3/22/22 at 8:30 a.m and 11:00 a.m. revealed: *She was in bed with the head of the bed raised at 75 degrees. *She was holding onto a tablet watching music videos and pushed the pause button to visit. *Her physician said her motor neurons are shutting down her motor skills. *She had limited ability to move including the movement of her mouth. *She decided to use syringes for eating instead of tube feeding when she started having trouble swallowing her food. *Staff now assisted her with food syringes because she no longer had the strength to do that. *Her voice was going, and she would not be able to speak much longer. *She started receiving hospice services in November 2021. Review of the order summary report revealed a physician order [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of the 2/10/22 Minimum Data Set (MDS) noted several areas of decline when compared to the 8/26/21 quarterly MDS and the 11/18/21 significant change in status MDS, including: *Increased staff assistance needed for transferring and eating. *Increased symptoms of a swallowing disorder. *A severe weight loss of greater than 10% in 6 months. *Stage 2 pressure ulcer. Review of the nutritional risk assessment dated [DATE] revealed the registered dietitian noted: *The resident's current food intake was greater than 75 percent. *The resident had Stage 1 and 2 pressure ulcers. *Swallowing difficulties included pocketing of food items and drooling. *A might shake supplement was recommended with meals, at 10:30 a.m., 3:30 p.m., and at HS (hour of sleep). *The texture of the diet was for pureed/blended fluid. *The resident had a 2 percent weight gain in the past 30 days. *The resident was completely fed by staff via syringe per [resident] request and [physician] order. Review of the care plan revealed the following were not consistent with the resident's status: *A focus revised on 11/15/21 for recommending a general surgery consult for feeding tube. Obtained declined feeding tube with an intervention revised on 10/15/21 to proceed with MRI and consult for feeding tube. Arrangements to follow. Completed on 10/14/21. *A focus revised on 11/29/21 of limited physical mobility had a goal to continue ability to feed myself after staff set-up without applicable interventions related to that goal. *A focus revised on 3/22/22 for Fortified Heart Healthy level 4 pureed regular consistency liquids. Supplement with meals and 3:30 [p.m.] and HS snack had a contradictory intervention revised on 10/26/21 for Staff will give me a supplement at meals and at 10:30 [a.m. and] 3:30 [p.m.] snack and HS snack. and four duplicative interventions including: -On 10/26/21, Staff will serve me a Fortified Heart Healthy level 4 Pureed diet with regular liquids. -On 2/1/22, May use syringe for food and liquids per residents request. May thin food to adequate consistency to pass through syringe. Staff to assist with loading syringe with food and fluids. Staff may assist resident using the syringe per residents request as long as she is awake and alert. Res feels she has better intake using this method. -On 2/13/22, I have my liquids and food put in syringes. They need to be thin to go thru the syringe Staff to assist with filling and feeding me with them. -On 2/17/22, I have requested assistance with syringe feeding due to increased weakness. *A focus revised on 3/18/21 for not choosing to attend many group activities had a goal to attend and participate in activities of my choice 2-3 times per week. *A focus revised on 6/10/21 for usually understood and usually understands .My speech is sometimes slurred and soft spoken without interventions related to alternate methods of communication. Interview on 3/22/22 at 3:42 p.m. with social service/activity manager H revealed: *The hospice social worker had brought in something for her to use as an alternate communication method. *The resident does not attend activities and was currently able to direct staff to assist her as needed. Interview on 3/23/22 at 1:53 p.m. with dietary manager K revealed: *The normal pureed food was too thick for the resident to pull up into the syringes by herself. *The pureed food needed to be thinned out. *Now it had gotten too hard for the resident to push the thinned pureed food through the syringes into her mouth. *They had been giving her a mighty shake (supplement) in the morning and afternoon between meals and in the evening, but the resident said she wasn't hungry for the morning supplement so it was only provided in the afternoon and evening. *They were trying to follow International Dysphagia Diet Standardization Initiative (IDDSI) but the diet order listed on the care plan was not consistent with the level of consistency that was currently being used. *It should be ordered as an IDDSI level 3 liquidized and moderately thick food with thin drinks.

Based on observation, interview, record review, and policy review, the provider failed to have ongoing monitoring, assessment, and implementation of interventions for pain management for one of one sampled resident (12). Findings include: 1. Review of resident 12's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Essential hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Hearing loss. -Chrohn's disease of small intestine without complications. Review of resident 12's 6/6/19 Minimum Data Set (MDS) assessment revealed: *She was unable to answer questions. *She had short and long term memory problems. *Her cognitive skills were moderately impaired, and her decision making was poor. *Her inattention and disorganized thinking would come and go. *Verbal behaviors had occurred one to three days during the assessment period. *She had rejected care four to six days out of the assessment period. *She was totally dependent on two staff members for bed mobility, transferring, locomotion off the unit, dressing, toilet use, personal care, and bathing. *She was totally dependent on one staff member for locomotion on the unit and eating. *She was frequently incontinent of bladder and always incontinent of bowel. *She had not been on a scheduled pain regimen. *She had received as needed (PRN) medications for pain. *She was unable to answer the pain assessment, so staff had completed that section. *Staff had not observed or documented any signs of pain during that review period. Observation on 8/20/19 at 11:34 a.m. of resident 12 revealed she was sleeping in her wheelchair. Observation on 8/20/19 from 12:15 p.m. through 12:21 p.m. of resident 12 in the dining room revealed: *She had been sitting with a staff member who was assisting her with eating. *Her son was sitting at the same table. *She was chanting something that was not understandable. *She continued to chant and got louder. *The staff person sitting with her put her arm around her and was patting her back. *The resident continued to chant. *At 12:21 p.m. the staff person took her out of the dining room. -She was still chanting. Interview after the above observation with the director of nursing (DON) regarding resident 12 revealed she thought she might have been singing. She sometimes did that. She had been in the facility for several years, and that was just how she was. Observation on 8/21/19 from 9:49 a.m. through 10:31 a.m. of resident 12 revealed: *She was laying in bed and was chanting loudly. *Her son was in the room sitting at her bedside. *He stated she had been chanting since he had gotten to her room at 9:30 a.m. *He stated certified nursing assistant (CNA) C had come into the room and told him she would tell the charge nurse, but no one had come back yet. *He thought she was in pain. *She continued to chant and moan when spoken to. -She was not able to be understood. *She could be heard three doors down in the hallway. *Activities assistant D and the activity director both had walked by her room without checking on her. *At 9:59 a.m. CNA C had walked by and an unidentified housekeeper was outside of her room. -Neither of those staff had checked on her. Interview on 8/21/19 at 10:04 a.m. with CNA C regarding resident 12 revealed: *She thought she had been laying down for about half an hour. *The son thought she might have a headache, so she had moved her head on the pillow. *She had told the nurse, but the nurse had not been in to see her yet. Continued observation on 8/21/19 at 10:06 a.m. and again at 10:16 a.m. of resident 12 revealed she was still chanting. At 10:31 a.m. she was still chanting but was quieter, and there were breaks in between. Observation on 8/21/19 at 11:03 a.m. of resident 12 revealed she was sitting up in her wheelchair sleeping. She was not chanting anymore. Review of resident 12's physician's orders [REDACTED]. *[MEDICATION NAME] sulfate (concentrate) solution 20 milligram/milliliter (mg/ml) give 4 mg by mouth every one hour as needed for pain. *[MEDICATION NAME] tablet 325 mg give two tablets by mouth every six hours as needed for pain or elevated temperature maximum 4000 mg in twenty-four hours. Notify medical doctor if temperature above 102 degrees or if clinical condition had deteriorated. *There were no scheduled pain medications. Review of resident 12's (MONTH) and (MONTH) 2019 medication administration records (MAR) revealed: *In (MONTH) she had received [MEDICATION NAME] thirteen times. *In (MONTH) she had received [MEDICATION NAME] nine times. Review of resident 12's (MONTH) 2019 MAR indicated [REDACTED] -Her pain level had been seven on a scale of zero to ten with ten being the highest pain. *On 8/21/19 at 10:10 a.m. she received another dose of [MEDICATION NAME]. -That had been forty minutes after the above observation of her chanting. -The medication had been documented as effective. *During the month she had received [MEDICATION NAME] nineteen times. Review of resident 12's current undated care plan revealed: *Focus area: I have generalized arthritis/pain; initiated on 12/27/16, and revised on 1/31/17. *Goal area: I will maintain current level of mobility; initiated on 12/27/16, and revised on 3/14/19. Pain less than 2 on cog (cognitive) pain scale; initiated on 8/16/18, and revised on 3/14/19. *Interventions included: -APAP as ordered for pain/fever; initiated on 12/1/18. -Encourage me to eat an adequate diet and fluids; initiated on 12/27/16, and revised on 12/28/16. -Monitor for fatigue. Plan activities during optimal times when pain and stiffness is abated; initiated on 12/27/16. -Monitor me for side effects to NSAIDS (nonsteroidal anti-inflamatory drugs)such as GI bleeding or renal impairment; initiated on 12/27/16, and revised on 12/28/16. -Monitor/document/report to MD PRN s/sx or complications related to arthritis: Joint pain, Joint stiffness, usually worse on wakening, Swelling, Decline in mobility, Decline in self care ability, Contracture formation/joint shape changes, Crepitus (creaking or clicking with joint movement), pain after exercise or weight bearing; initiated on 12/27/16. -MS04 solution as directed for pain; initiated on 2/18/19. -Pain less than 2 on cognitive impairment scale; initiated on 4/18/18. -Repo (reposition) every 2-3 hours with assist of 2; initiated on 5/15/18. -Staff to provide daily range of motion exercises both active and passive as tolerated when doing am and pm cares; initiated on 12/27/16, and revised on 12/28/16. *There had been no other non-pharmacological interventions documented. Review of resident 12's bowel management records revealed she had gone three or more days on eight different occasions from 6/1/19 through 8/22/19 without having a bowel movement. Refer to F690, finding 1. Interview on 8/22/19 at 1:27 p.m. with registered nurse (RN) B regarding resident 12 revealed: *She confirmed the resident appeared to have pain at times. -She was unsure if the resident's chanting and calling out was related to pain or not. *When the nurse's administered her as needed [MEDICATION NAME] they used a pain scale for cognitively impaired residents. -The pain score was based on the nurse's observation of the resident. *She felt the resident's pain was worse when she was moving. *They had stopped all oral medications recently due to her not taking them. *She was not sure if they had used a pain patch in the past for her or if they had looked into it when the oral medications were stopped. *She stated they would sometimes offer her a warm blanket, but they had not documented when that occurred. *She had constant pain when she got a bath. -They had not given her pain medications or provided any intervention before she received her bath. Interview and record review on 8/22/19 at 1:47 p.m. with the director of nursing regarding resident 12 revealed: *She had been on a [MEDICATION NAME] in the past, but it had been discontinued on 1/8/18. *They had not looked into any other alternatives for scheduled pain medications when her oral medications were stopped. *The pain assessments should have been done monthly for residents who were non-verbal. -They had not completed one for (MONTH) 2019, and (MONTH) 2019 had not been done yet. *The charge nurses did weekly pain assessments when they took vital signs, but those were not documented. *The pain score and assessment they used for cognitively impaired residents was based on staff observations of the resident. *The resident yelled out and chanted frequently and had done so for a long time. *They had not considered the yelling out or chanting could have been related to pain or constipation. *She confirmed the resident had appeared calmer and had stopped her loud chanting after she had received the dose of [MEDICATION NAME] on 8/21/19. Review of the provider's (MONTH) (YEAR) Pain Management policy revealed: *For residents who are cognitively impaired or unable to express pain, the nurse should monitor for non-verbal signs of pain. Possible indicators of pain include, but are not limited to: facial grimacing, frowning, clenched teeth, moaning, crying, yelling, screaming, swearing, unusual quietness, reluctance to cooperate with ADLs (activities of daily living), stiffness, rigidness, or withdrawing body posture when moving, changes in gait, or legs/arms drawn up in a fetal position. We use the PCC cognitive (cognitive) pain scale monthly on non-cognitive residents. *Management of pain: In collaboration with the physician/prescriber, the facility staff develops, implements, monitors and revises as necessary interventions to prevent or manage the individual resident's pain, beginning at admission. *Pharmacological. Interdisciplinary team develops pain management regimen specific to the resident including potential benefits and risks of medications to achieve the resident's goal. *Non-pharmacological. Resident specific interventions should also be considered to provide comfort, such as physical modalities, exercise, altering the environment, or cognitive/behavioral modalities. *Monitoring, reassessment, and care plan revisions. Monitor the resident over time to determine the extent to which pain is being controlled. Revise plan if needed.

Based on observation, interview, record review, and policy review, the provider failed to implement interventions for one of three sampled residents (14) who had a weight loss. Findings include: 1. Review of resident 14's medical record revealed: *He was admitted on [DATE]. *His [DIAGNOSES REDACTED].>-Heart failure, unspecified. -Weakness. -Other specified arthritis, unspecified site. -Essential (primary) hypertension. -Unspecified [MEDICAL CONDITION], unspecified site. -Other age-related cataract. -[MEDICAL CONDITION], unspecified. *On 2/28/19, the resident weighed 125.5 pounds (lb). *On 8/19/19, the resident weighed 110.5 lb. -That was a decrease of 11.95 percent (%) in six months. *On 8/22/19 he weighed 109.5 lb. Review of resident 14's 5/30/19 Minimum Data Set assessment revealed: *His Brief Interview for Mental Status score was six indicating his cognition was severely impaired. *He required extensive assistance from two staff members for bed mobility, transferring, locomotion on and off the unit, dressing, toilet use, and personal hygiene. *He required extensive assistance of one staff member for eating. *He had no swallowing problems. *His weight was 128 lb. *He had no weight loss concerns. Review of resident 14's current undated care plan revealed: *Focus area: I'm on a Fortified Heart Healthy diet Chronic cough related to swallowing issues. 5/26/19 Honey thickened fluids as tolerated 5/20/19 - may crush med's 5/28/19 Fortified Heart Healthy Pureed diet Honey thicken liquids; initiated on 4/17/18, and revised on 6/19/19. *Goal area: I will maintain my current weight and say (stay) within my goal weight of 115+-thru review date and eat 75%-100% of my meals; initiated on 4/17/18, and revised on 7/22/19. *Interventions included: -I do not like any kind of supplement; initiated on 6/28/18, and revised on 9/20/18. -I like to us (use) the nose glasses it is easier for me to drink out of; initiated on 6/19/19. -I set (sit) at (an) assisted table I can sometimes feed myself other times I need assistance; initiated on 5/29/19. -ST (speech therapy) to evaluate and treat; initiated on 6/4/19. -Staff will give me honey thickened fluids for comfort; initiated on 4/17/18, and revised on 5/26/19. *There had been no updated interventions since 6/19/19. Observation on 8/20/19 at 4:51 p.m. of resident 14 revealed he was sitting in a wheelchair out by the nurses station. His eyes were closed. He had no teeth or dentures in at that time. Observation on 8/21/19 at 9:48 a.m., 10:17 a.m., 10:30 a.m. and again at 11:02 a.m. of resident 14 revealed he was sitting in his recliner in his room. His feet were partially elevated, and he was sleeping. Review of resident 14's 6/4/19 physician's orders [REDACTED]. He was not taking a multivitamin. Review of resident 14's physician's consultation notes from 5/20/19 through 8/7/19 revealed there was no documentation regarding the weight loss. Interview on 8/22/19 at 9:10 a.m. with the director of nursing (DON) regarding resident 14 revealed: *He had been admitted to the hospital in (MONTH) 2019. *He had returned and was placed on comfort care. *They had not identified the weight loss could be associated with starting [MEDICATION NAME]. *They had not contacted the physician regarding the weight loss. *They had not identified if the interventions on the care plan were effective. *They had not discussed starting him on a multivitamin. Review of the provider's (MONTH) (YEAR) Nutritional Risk Monitoring policy revealed: *All residents will be weighed monthly or more frequently if needed. A variance of (+) or (-) 3 pounds is to be reported to the charge nurse. The charge nurse will then order a re-weigh on subsequent day. Weight changes will then be assessed. If the resident has a significant weight loss/gain (5% - 1 month, 7.5% - 3 months, or 10% - 6 months) or if the resident has had a general decrease or increase in weight (not desired) the DON and Food Service Supervisor will be notified via Resident Weight Change Evaluation Form (see attached). *If a resident is at risk of skin breakdown, poor intakes, low weight, or had a significant weight change: The dietitian will place a note in the interdisciplinary notes indicating the amount of calories and protein the resident requires and will proceed with the below process to prevent malnutrition. 1. The resident will be evaluated for fortified foods. Refer to Nutrition Intervention Monitoring. 2. The resident will be assessed for possible use of a multivitamin. 3. Evaluate use of a high calorie supplement with or between meals and/or use of protein snacks between meals. 4. The resident will be evaluated for nutrition related lab work.

Based on interview and record review, the provider failed to ensure a bowel management program had been established and followed for one of one sampled resident (12) who was dependent on staff for using the bathroom. Findings include: 1. Review of resident 12's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-[MEDICAL CONDITION]. -Essential hypertension. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. -Hearing loss. -Chrohn's disease of small intestine without complications. Review of resident 12's 6/6/19 Minimum Data Set (MDS) assessment revealed: *She had short and long term memory problems. *Her cognitive skills were moderately impaired, and her decision making was poor. *Her inattention and disorganized thinking would come and go. *Verbal behaviors had occurred one to three days during the assessment period. *She had rejected care four to six days out of the assessment period. *She was totally dependent on two staff members for bed mobility, transferring, locomotion off the unit, dressing, toilet use, personal care, and bathing. *She was totally dependent on one staff member for locomotion on the unit and eating. *She was frequently incontinent of bladder and always incontinent of bowel. Review of resident 12's current undated care plan revealed: *Focus area: I have constipation r/t (related to) diminished appetite, poor fiber intake, poor fluid intake; initiated on 12/6/17. *Goal area: I will have a normal bowel movement at least every 3 days through the review date; initiated on 12/6/17, and revised on 3/14/19. I will pass soft, formed stool at the preferred frequency of every 3rd day through the review date; initiated on 12/6/17, and revised on 3/14/19. *Interventions included: -Encourage resident to sit on toilet to evacuate bowels if possible; initiated on 12/6/17. -Ensure the resident's feet are flat on the floor or flat on an elevated support during evacuation. Knees should be at 90 degrees or above hip height to promote ease of evacuation where possible; initiated on 12/6/17. -Follow facility bowel protocol for bowel management; initiated on 12/6/17. -[MEDICATION NAME] as needed; initiated on 4/30/19. -Monitor medications for side effects of constipation. Keep physician informed of any problems; initiated on 12/6/17. Review of resident 12's bowel records from 6/1/19 through 8/22/19 revealed: *She had a bowel movement (BM) on 6/3/19 but not again until 6/10/19. -That had been six days with no BM. *She had a BM on 6/12/19 but not again until 6/17/19. -That had been four days with no BM. *She had a BM on 6/24/19 but not again until 6/29/19. -That had been four days with no BM. *She had a BM on 6/30/19 but not again until 7/4/19. -That had been three days with no BM. *She had a BM on 7/11/19 but not again until 7/16/19. -That had been four days with no BM. *She had a BM on 7/27/19 but not again until 7/31/19. -That had been three days with no BM. *She had a BM on 8/6/19 but not again until 8/12/19. -That had been five days with no BM. *She had a BM on 8/15/19. -There was no other documented BM through 8/22/19. --That had been seven days without a BM. Review of resident 12's medication administration records from 6/1/19 through 8/22/19 revealed: *She had physician's orders [REDACTED].>-[MEDICATION NAME] suppository insert one suppository rectally every twenty-four hours as needed for constipation started on 3/15/17. -[MEDICATION NAME] powder give 17 grams by mouth as needed for constipation. -[MEDICATION NAME] sulfate solution 20 milligrams (MG)/milliliter (ML) give 4 mg by mouth every one hour as needed for pain started on 2/27/19. *June 2019: -She had not received a suppository during the month. -She had received [MEDICATION NAME] one time on 6/29/19. -She had received [MEDICATION NAME] thirteen times. *July 2019: -She had not received a suppository during the month. -She had received [MEDICATION NAME] two times during the month. -She had received [MEDICATION NAME] nine times. *August 2019: -She had not received a suppository during the month. -She had received [MEDICATION NAME] one time on 8/20/19. -She had received [MEDICATION NAME] nineteen times. Interview and record review on 8/22/19 at 1:27 p.m. with registered nurse (RN) B regarding resident 12 revealed: *The certified nursing assistants (CNA) documented in the electronic medical record when a resident had a BM. *The nurses kept a paper copy to keep track of when residents were going three days without a BM. *The resident had a history of [REDACTED]. *She was getting [MEDICATION NAME] on a scheduled basis, but then began having very loose stools. -She got [MEDICATION NAME] as needed after that. *She had not thought the [MEDICATION NAME] would have made her constipated. *Review of the paper BM records from 7/14/19 through 8/22/19 revealed: *She had a BM on: -7/27/19, but not again until 8/5/19. -8/6/19, but not again until 8/12/19. -8/16/19, but had not had another BM since then. -That had been six days. *RN B stated she did not think that was correct. -She asked the CNA working the floor if resident 12 had a BM today, and she stated no. *RN B then called CNA C who worked that hall a lot. -She could not recall if the resident had a BM since 8/16/19, but thought maybe she had one on Monday or Tuesday. --Nothing had been documented. Interview on 8/22/19 at 1:47 p.m. with the director of nursing regarding resident 12 revealed: *The CNAs should have documented in the electronic record when residents had a BM. *They did not have a written policy on bowel management. *The nurses should have at three days provided a less invasive intervention like [MEDICATION NAME] or Milk of Magnesia, next a suppository, and last an enema if the resident still had not had a BM.

Based on interview, record review, and policy review, the provider failed to have an ongoing process for assessing and monitoring blood pressure changes for one of one sampled resident (28). Findings include: 1. Review of resident 28's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED].>-Unspecified dementia without behavioral disturbance. -Moderate essential hypertension. -[MEDICAL CONDITION]. -Personal history of [MEDICAL CONDITION] embolism. -[MEDICAL CONDITION]. -Long term use of anticoagulants. *She had a physician's orders [REDACTED]. -[MEDICATION NAME] sodium tablet 5 milligram (mg) give 1 tablet by mouth one time a day. -Aspirin low dose tablet chewable 81 mg give 1 tablet by mouth one time a day. -[MEDICATION NAME] tablet 25 mg give 12.5 mg by mouth one time a day. Review of resident 28's current undated care plan revealed: *Focus area: I have hypertension, initiated on 11/2/17 and revised on 10/15/18. *Goal area: I will maintain a blood pressure within the following parameters 120/70 - 140/85 initiated on 11/2/17 and revised on 2/4/19. *Interventions included: -Give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness, initiated on 11/2/17. -Monitor for and document any [MEDICAL CONDITION]. Notify MD (medical doctor), initiated on 11/2/17. -Monitor/document abnormalities for urinary output. Report significant changes to the MD, initiated on 11/2/17. -Obtain blood pressure readings weekly and with falls and changes in condition, initiated on 11/2/17. --There had been no revisions to the above interventions since 11/2/17. Review of resident 28's baseline vital signs revealed her baseline blood pressure was 154/69 mmHg. There had been no date documented as to when that had been obtained. Review of resident 28's blood pressure records from 5/5/19 through 8/18/19 revealed: *Warnings next to several of the blood pressure readings that indicated greater than a 10 percent (%) change from her baseline. *Her blood pressures were greater than 10 % above her baseline on the following dates: -Twice on 5/22/19. -Once 6/16/19. *Her blood pressures were greater than 10 % below her baseline on the following dates: -Four times on 5/10/19. -Once on 5/19/19. -Three times on 5/21/19. -Once on 5/22/19. -Once on 5/26/19. -Once on 6/2/19. -Once on 6/9/19. -Once on 7/7/19. -Once on 7/14/19. -Once on 7/28/19. -Once on 8/4/19. -Once on 8/11/19. Review of resident 28's communication with physician's notes from 5/5/19 through 8/18/19 revealed the physician had not been notified regarding any of the above changes in her blood pressure. Interview on 8/22/19 at 10:18 a.m. with the director of nursing regarding resident 28's blood pressure revealed: *Her baseline blood pressure was 154/69 mmHg which contradicted the above care plan information. *The resident's baseline blood pressure had not been done at the time of her admission. *Recently a night nurse had been designated to get all the residents' baseline vital signs updated. *The minus and plus changes of 10% from the baseline blood pressure would have turned red in the electronic record to signal the nurse there was a change. -The nurse should have noticed that alert and followed up on those abnormal blood pressures. *They did not have any parameters for when to update the physician regarding a change in blood pressure. -The blood pressure parameters listed in the resident's care plan were not specified from the physician. Review of the provider's (MONTH) 2019 Vital Signs policy revealed: *They were to obtain baseline vital signs upon admission and annually. *The policy had not addressed parameters or what to do if the vital signs were out of range.

Based on observation, interview, record review, and policy review, the provider failed to ensure their policy for self-administration of medications had been followed for one of one randomly observed resident (15). Findings include: 1. Observation on 08/20/19 from 12:01 p.m. through 12:20 p.m. of resident 15 in the main dining room revealed: *At 12:01 p.m. certified medication assistant (CMA) A left the plastic cup of the residents' medications (med) on the dining room table with her and walked away. -She did not observe the resident taking those meds and had signed them off as administered. *At 12:20 p.m. the resident took her meds by herself. Interview on 8/20/19 at 3:54 p.m. with resident 15 in her room regarding the above revealed:*She liked to take her lunch and supper pills after she was done eating. *Usually staff just left the meds at the table with her, and she would take them by herself when she was done eating. Interview on 8/21/19 at 9:41 a.m. with registered nurse B regarding resident 15 revealed: *The resident was alert and oriented. *She did not self-administer any meds by herself or after set-up by the staff. -Staff administered her meds. *The resident did not have physician's orders [REDACTED]. *She confirmed the resident would be considered self-administering her meds after set-up when staff left the meds at the table with her and had not observed her taking them. *She thought there was a new policy on self-administration of meds, but it was not being implemented yet. Interview on 8/22/19 at 8:18 a.m. with CMA A regarding resident 15 revealed: *She confirmed she had left the resident's meds with her at the table on 8/20/19, and she had not observed her taking them. *She thought she could leave the meds with her, because someone had told her the resident was able to self-administer the meds. -She confirmed there was no mention of her self-administering her meds on her medication administration records or physician's orders [REDACTED]. *She stated she should not have left the meds with her if she did not have a physicians' order to self-administer meds. *She had heard of the policy for self-administration of meds, but she was unsure if that was being followed or not. Interview and record review on 8/22/19 at 9:03 a.m. with the director of nursing revealed:*She confirmed resident 15 should not have been self-administering her meds according to their policy guidelines. *There should have been an assessment that was done quarterly for any resident who self-administered meds even if they administered meds after set-up by the nursing staff. *There should have been a physician's orders [REDACTED]. *Self-administration should have been addressed on the resident's care plan. *Resident 15 did not have a self-administration of meds assessment done, did not have physician's orders [REDACTED]. *She thought the resident would have been able to self-administer meds, but their policy had not been followed. *In (MONTH) 2019 the policy for self-administration of meds had been added with education provided to staff. -That was not fully implemented yet. Review of the provider's (MONTH) 2019 Self Administration of Medication policy revealed:*a. If the resident desires to self-administer medication, the form Medication Self-Administration Safety Screen (MSSS) will be completed in the Electronic Medical Record (EMR) by the MDS (Minimum Data Set) Coordinator. The interdisciplinary team (IDT) will be involved in the assessment .*ii. This may include the determination by the IDT that the resident may be able to self-administer medications after dispensing by staff .*A physician's orders [REDACTED]. *e. MDS Coordinator will monitor residents capabilities of taking his/her own medications at least quarterly and with all significant changes . *a. No resident will be allowed to self-administer medications after set-up until IDT has determined resident may safely do so.

Based on record review, interview, and policy review, the provider failed to ensure two of three sampled residents (1 and 40) received proper notification of the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Medicare Part A Denial Notice). Findings include: 1. Review of resident 1's Medicare Part A Denial Notice revealed: *Her last day of covered services was on 3/27/18. *The notice had been given and signed on 3/27/18. -The resident had not received forty-eight hours notice. Review of resident 40's Medicare Part A Denial Notice revealed: *Her last day of covered services was on 3/23/18. *The notice had been given and signed on 3/22/18. -The resident had not received forty-eight hours notice. Interview on 6/19/18 at 2:20 p.m. with the social service designee regarding residents 1 and 40's Medicare Part A Denial Notice revealed she was unaware she was required to give the notice forty-eight hours prior to the last day of covered service. She confirmed she had not given the above notices in the required time frame. Review of the (MONTH) (YEAR) Medicare (Part A) policy revealed notification should have been given to the resident/family and physician two days prior to no longer being eligible for Medicare benefits.

Based on observation, record review, interview, and policy review, the provider failed to ensure one of six sampled residents (8) receiving [MEDICAL CONDITION] medications received a gradual dose reduction (GDR) within the required time frame or had a timely response to the pharmacist by the physician that included documentation to support why a GDR was clinically contraindicated. Findings include: 1. Random observations on 6/18/18 from 3:30 p.m. until 6:00 p.m. of resident 8 revealed he: *Was alert to his environment and to others. *Was confused to place and time. *Had difficulty communicating and spoke in gibberish when spoken to. -Sometimes could say words clearly. *Spent time in the dining room playing with cards. Review of resident 8's 3/29/18 Minimum Data Set (MDS) assessments revealed he: *Had both short and long term memory impairment. *Had difficulty focusing attention and disorganized thinking. *Scored a four on the geriatric dementia screening for depression that meant he had few indicators for depression. *Showed no signs of [MEDICAL CONDITION]. *Exhibited some physical behaviors and rejected care one to three days in a week. Review of resident 8's 6/12/18 physician's orders [REDACTED]. *[MEDICATION NAME] 12.5 milligram (mg) daily for dementia related to [MEDICAL CONDITION] with behavioral disturbance; dementia in other diseases classified elsewhere with behavioral disturbance; generalized anxiety disorder. That had been started on 3/30/17. *[MEDICATION NAME] 25 mg two times a day for dementia related to [MEDICAL CONDITION] with behavioral disturbance; dementia in other diseases classified elsewhere with behavioral disturbance; generalized anxiety disorder. That had been started on 3/30/17. *[MEDICATION NAME] tablet 20 mg, 10 mg daily for [MEDICAL CONDITION] with behavioral disturbance; generalized anxiety disorder. That had been started on 3/16/17. *[MEDICATION NAME] tablet 15 mg, one tablet at bedtime related to dementia in other diseases classified elsewhere with behavioral disturbance; generalized anxiety disorder. That had been started on 3/15/17. *He did not have a [DIAGNOSES REDACTED]. Review of resident 8's monthly pharmacy consultations revealed: *On 12/19/17 the pharmacist had written: -Your residents taking antidepressants and other [MEDICAL CONDITION] medications were reviewed. The rules are that a GDR should be attempted twice within the first year (at least a month apart and in separate quarters) then yearly after that unless clinically contraindicated. -A PHQ9 depression screening is done quarterly for depression and a score of 4 or less may indicate a dose reduction would be well tolerated or that the dose needed to control symptoms may be lower. Please indicate how you would like to proceed with the following residents. *Resident 8: He is on [MEDICATION NAME] 10 mg daily with order date of 12/14/16 and [MEDICATION NAME] 15 mg at bedtime with order date of 12/23/16. His last PHQ9 was done on 9/26/17 and he scored a 0. Would you like a GDR at this time? -On 1/10/18 the physician had replied: No, I feel is clinically contraindicated at the time. Still resistive to cares. -He is also on [MEDICATION NAME] TID (12.5 mg, 25 mg and 25 mg) with an other date of 3/28/17. Do you feel we could try a decrease in the afternoon dose of 12.5 mg? -On 1/10/18 the physician had replied: No, I feel is clinically contraindicated at the time. --There was no further explanation. *There were no further recommendations to consider a GDR. Review of resident 8's 6/1/18 through 6/19/18 behavior documentation revealed he exhibited the following: *Behaviors that presented a danger to himself or others: -Kicking and hitting: twice. -Pushing: once. *Other behaviors: -Yelling and screaming: once. -Rejected care: Once. *There were fifty-one entrees where it was documented that none of the behaviors had occurred. Interview on 6/20/18 at 1:00 p.m. with the social services designee regarding resident 8 revealed: *She thought staff sometimes got used to his behaviors and did not document them. *She felt sometimes it was a training issue, and staff had become better at managing his behaviors because of the approach they used. Interview on 6/20/18 at 1:30 p.m. with certified nursing assistant (CNA) A regarding resident 8 revealed: *The way you approached the resident had an impact on how he responded. -She was 110% sure of that. *You have to maintain eye contact with him when you work with him. *You have to not be rushed. *She did not feel she had any difficulty working with him if she was patient with him. Interview on 6/20/18 at 2:30 p.m. with CNA B regarding resident 8 confirmed the above conversation with CNA A. Interview on 6/20/18 at 3:01 p.m. with the director of nurses regarding resident 8 revealed: *They reviewed each resident on [MEDICAL CONDITION] medications quarterly. -Based on that review they made recommendations to the physician. *She confirmed he had been on the same dose of medication for over a year without a dose reduction attempted. *She knew they had attempted a GDR awhile back that had not gone well, and the behaviors had escalated. -In further review she said that had been over a year ago. *She confirmed the physician had not documented why a GDR was clinically contraindicated. Interview on 6/20/18 at 4:45 p.m. with resident 8's physician revealed he thought the regulations regarding GDRs were sometimes not considering the resident. However , he agreed his documentation did not support why he thought a GDR was clinically contraindicated. Review of the provider's (MONTH) (YEAR) [MEDICAL CONDITION] Medication policy revealed: *The facility will monitor [MEDICAL CONDITION] medications for proper dose, including duplicate therapy, duration, evidence of adequate monitoring for efficacy and adverse consequences and to prevent, identify and respond to adverse consequences. *Residents who receive [MEDICAL CONDITION] medications will receive gradual dose reductions and behavioral interventions unless clinically contraindicated with the intention to decrease or discontinue the use of the [MEDICAL CONDITION] medication whenever safe and possible. *Procedure: 1. c. If antipsychotic medications are prescribed, documentation must clearly show indication for the medication, multiple attempts to implement care-planned (as written), nonpharmalogical approaches and ongoing evaluation of the effectiveness of these interventions. *For any individual who is receiving a [MEDICAL CONDITION] medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to: -The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility; -The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

Based on record review, interview, and policy review, the provider failed to ensure: *Three of three sampled residents' (10, 11, and 12) incident reports had been thoroughly investigated for abuse and neglect. *Two of three sampled residents' (11 and 12) incidents resulting in injury were reported to the South Dakota Department of Health (SD DOH) per state and federal regulations. *Two of four sampled new employees (B and C) had complete background checks. Findings include: 1a. Review of resident 10's [DATE] incident report revealed: *An unidentified resident had yelled in the dining room to get assistance for his table mate who was resident 10. *The resident was not breathing. *[MEDICATION NAME] maneuver was started. *The hospital nurse practioner arrived and took over. *The resident was transferred to the hospital where he was pronounced dead. *Investigation process included: -Diagnosis. -Table mates witness statement. -Registered nurse's witness statement. -Menu. -Amount eaten. -Staff competencies in cardiopulmonary resuscitation (CPR) and [MEDICATION NAME] maneuver. -Another possible cause of death. *Root cause(s) identified by the root cause analysis team were checked as the following items: -Behavioral assessment process. -Physical assessment process. -Care planning process/coordination of care. -Staffing levels. -Orientation and training of staff. -Competency assessment/credentialing. -Supervision of staff. -Access to care. *Root cause areas were not discussed any further than the above checkmarks. *Resident's cognition level was not listed. -The [DATE] cognition score had been listed as a nine indicating moderate impairment. *Physician ordered diet had not been included. *Care plan review had not been completed. *Texture of that meal's food items had not been evaluated. b. Review of resident 11's [DATE] incident report revealed: *Resident was found lying on right side on floor beside roommate's bed. *Type of injury stated laceration above right eye and head injury. *Witness to the event was listed as the roommate. *Incident resulted in an emergency room visit. *Attached narrative stated there was a pool of blood underneath residents head and a 3 centimeter by 2 centimeter laceration above right eye. -Tab alert was not going off at time of incident. *No resident or witness statement was obtained. *There was no cognition level mentioned. -The [DATE] cognition score had been listed as as a three indicating severe impairment. *It did not state if the resident's care plan was followed. *Report did not rule out abuse or neglect. *Incident was not reported to the SD DOH. c. Review of resident 12's [DATE] incident report revealed: *Resident's right eye was very puffy and red. *There was a bruise/abrasion to right side of eye. *Blood on floor beside bed. *When asked if he fell the resident shrugged his shoulders. *No resident or witness statement was attached. *There was no cognition level mentioned. -The [DATE] cognition score was 00 indicating the inability to assess. *It did not state if the resident's care plan had been followed. *Report did not rule out abuse or neglect. *Incident was not reported to SD DOH. d. Interview on [DATE] at 4:15 p.m. with director of resident care services (DRCS) and the social services coordinator (SSC) confirmed: *They had considered the above incidents to have been completely investigated. *More information should have been included. -Resident's cognition level would have been good information. -Resident and/or witness statements should have been included. -Care plan review should have been completed. -Investigation should have stated if incidents were substantiated or unsubstantiated. *Injuries of a serious nature should have been reported to the SD DOH. -DRCS and SSC were unaware that head injuries were considered an injury of a serious nature. -DRCS ad SSC were unaware that an emergency room visit would be considered an injury of a serious nature. The revised 2017 Abuse and Neglect Prohibition policy revealed: *The department manager or charge nurse would initiate an investigation for all cases that were of concern, were of a suspicious nature, or had indicated a pattern or trend. *The following components must have been completed during an investigation using the Investigative Report: -Interview possible witnesses, any department personnel in the vicinity of the incident, family, and resident. -Conduct a record review. -Observe resident habits and staff routine. -Documentation of all components. *Policy did not state how to handle injuries of unknown origin. 2a. Review of employee B's personnel file revealed: *A hired date of [DATE]. *The consent to conduct criminal background search was signed and dated [DATE]. *A South Dakota Unified Judicial System Record Search Report was completed on [DATE]. -Applicant was on probation for three years for a felony conviction of unauthorized ingestion of controlled drug/substance in scheduled I or II. *A new background check had not been completed at the time of her hired date of [DATE]. -Nine months had passed since the background check had been completed, and she had been offered a position. b. Review of employee C's personnel file revealed: *She had a hired date of [DATE]. *The consent to conduct a criminal background search was signed and dated on [DATE]. *A South Dakota Unified Judicial System Record Search Report had not been completed. Interview on [DATE] at 4:00 p.m. with the business office manager revealed: *Their system for background checks was to request a report through the South Dakota Unified Judicial System. *She was responsible for running background checks on potential employees. *She was unsure why a background check was not repeated for employee B. -Employee B had not been offered a position when she originally applied in [DATE]. -She would have expected a background check to have been completed when an employment offer had been made in [DATE]. *A background check was not completed for employee C. -They did not run background checks on people under the age of eighteen years of age. -She was unaware if their policy stated what to do for applicants under the age of eighteen. Review of the provider's 2004 Criminal Background Check policy revealed: *Weskota Manor/Avera Health conducts reference and criminal background checks on applicants who have been extended a conditional offer of employment. *Policy did not disclude applicants under the age of eighteen.

Based on observation and interview, the provider failed to ensure baths were given based on resident's preferences regarding length of time and water levels. Findings include: 1. Observation on 7/18/17 from 8:50 a.m. through 9:46 a.m. of the north hall whirlpool tub room revealed: *At 8:50 a.m. an unidentified resident was in the whirlpool tub. -The door had been left open with the curtain pulled. *Residents 12 and 13 had been sitting in chairs waiting for their turn. *At 9:15 a.m. resident 12 was in the tub room getting his bath. *At 9:20 a.m. the whirlpool tub room was empty, and CNA A came up to resident 13 and asked her to come into the tub room. *At 9:25 a.m. the water had started to run and surveyor saw resident 13 in the tub. *At 9:38 a.m. CNA A was walking resident 13 down the hall fully clothed to her room. -That had been thirteen minutes for the resident to get a bath and for CNA A to get the resident dressed. Surveyor: Group interview on 7/18/17 at 11:00 a.m. with multiple residents who wished to not be identified revealed: *There were two CNAs that did not give good whirlpool baths. *They did not fill the tub up with water. *The residents did not have time to soak. *The bath was very short and rushed. *Whirlpools were not enjoyable. *They stated staff and management were aware of that process and who the CNAs were. Interview on 7/18/17 at 2:10 p.m. with resident 2 revealed: *She received her whirlpool baths on Monday and Thursday. *CNA A and CNA E were primarily the bath aids down her hall. *CNA A was rough and dug her fingernails in her scalp when washing her hair. *The water hadd not covered much more than her thighs when CNA A and E had done her bath. -Both CNAs rush too much. *It was heaven when she had a different CNA that had filled the whirlpool up with water. *She had reported it to the director of nursing, but she wanted to give those CNAs a chance. Surveyor: Interview on 7/19/17 at 11:00 a.m. with an anonymous staff member revealed: *She had heard from residents that CNA A and CNA E rushed through baths. *They had not filled the tub very full with water. *They would not let residents soak in the tub if they wanted to. *CNA A and CNA E usually worked the north hall. Interview on 7/19/17 at 3:30 p.m. with the director of nursing revealed: *Not all residents wanted the tub filled with water. *They had no documentation of resident preference for that issue. *The CNAs should have let residents soak if they wanted to. *CNAs were taught how to give baths when they went through CNA training. *They did not have a policy on bathing.

Based on observation, interview, and manufacturer's instruction review, the provider failed to ensure one of two whirlpool tubs (north hall) was disinfected properly between residents. Findings include: 1. Observation on 7/18/17 in the north hallway of the whirlpool tub room revealed: *At 8:50 a.m. a resident was in the whirlpool tub. -The door had been left open with the curtain pulled. *Residents 12 and 13 had been sitting in chairs waiting for their turn. *At 9:15 a.m. resident 12 was in the tub room getting his bath. *At 9:20 a.m. the whirlpool tub room was empty. -CNA A came up to resident 13 and asked her to come into the tub room. Interview on the above date at 9:20 a.m. with CNA A regarding the disinfecting of the tub revealed: *She stated she usually disinfected the shower chair with the brush first. -She grabbed the dry brush with no solution and brushed once over the chair. -Resident 13 then sat down on the chair with her robe on. *When asked about the tub disinfection process she then walked to the tub and proceeded to do the following: *Pushed the disinfectant solution button for approximately three seconds. -The solution had not filled the bottom of the tub. -She then took the dry brush she had used on the shower chair and brushed the solution on all sides of the tub. -When asked how long the solution needed to stay on the surface she stated a few minutes. -Clarification was asked for and she replied like ten minutes I guess and pointed to the instructions on the tub. -She stood and stared at the surveyors. -When asked what the next steps were she stated next she would undress the resident. -The surveyors left the room at that time. Continued observation on 7/18/17 of the north hall whirlpool tub room revealed: *At 9:25 a.m. the water was running. *Surveyor observed resident 13 in the tub. -That was five minutes after CNA A had applied the disinfecting solution to the tub which was not long enough according to the ten minutes CNA A had stated earlier. *At 9:38 a.m. CNA A had brought resident 13 out of the tub room fully clothed and was walking her down the hall. *Observation of the whirlpool tub at that time revealed the plug had been left in with dirty water sitting at the bottom of the tub. -There had been no disinfecting solution used at that time. *At 9:41 a.m. CNA took another unidentified resident into the tub room. *At 9:44 a.m. the water had been running. *At 9:46 a.m. surveyor observed the unidentified resident in the tub. *There had not been enough time between the above observed residents to have preformed the appropriate disinfecting process. Interview on 7/19/17 at 3:00 p.m. with the director on nursing and the medical laboratory science technician revealed: *CNA A had been trained on cleaning the whirlpool tub appropriately. *She should have had the disinfecting solution set for ten minutes in-between residents. *She should have scrubbed the shower chair with disinfecting solution not a dry brush. *They had not been doing any monitoring of the disinfecting of the whirlpool tub. Review of the manufacturer's instructions for cleaning the whirlpool tub revealed: *Close and lock the door. *Press the tub fill button and turn the temperature control knob all the way to the left to its warmest level to heat the disinfectant solution and maximize its effectiveness. *Remove the visible tissue, residue, or fluids from the tub by pressing the shower button and rinsing the inside tub surfaces with the shower sprayer. *Press the fill button again to turn off the water. Allow the tub to drain, and place the drain plug over the drain. *On the aqua-aire tubs, press and hold the disinfect button located on the left side of the tub. -As the button is held down, the properly mixed cleaning solution is running through the air injection system and out all of the air jets. -Release the button after you see solution coming out of all the air jets and you have 1 to 1.5 gallons of disinfectant solution in the foot well of the tub. *Using the long-handled brush .thoroughly scrub all interior surfaces of the tub with the solution that remains in the foot well of the tub. -Let disinfectant stay on surface for 10 minutes. (Or, as recommended by the instructions on the disinfectant concentrate container. *Remove the plug from the drain. *Rinse the tub's interior surfaces thoroughly with the shower sprayer. *Press and hold the rinse button located on the left side of the control panel until clear water runs from all the air jets. -The release the rinse button. *Finish rinsing the interior surfaces of the tub with the shower sprayer. *Start the air blower by pushing the aqua-aire button. -Allow it to run for 30 seconds. -This pushes the rinse water out of the air injection system. -If it was the last bath of the day, allow the blower to run for 2 minutes to dry out of system. *Stop the aqua-aire blower by again pushing the aqua-aire button. *Visibly check that the tub was effectively cleaned during the disinfecting procedure. -If not, repeat the procedure. *If there is a delay of one or more hours before the next bath, we recommend using a towel to wipe off all excess water.

Based on observation, record review, interview, and policy review, the provider failed to ensure meaningful activities were given to one of one sampled resident (4) who had significant medical issues. Findings include: 1. Review of resident 4's medical record revealed: *She had been admitted on [DATE]. *She had the following Diagnoses: [REDACTED]. -Extrapyramidal and movement disorder. -Major [MEDICAL CONDITION]. -Anxiety. -[MEDICAL CONDITION]. -[MEDICAL CONDITION]. Review of resident 4's 3/30/17 Minimum Data Set assessment revealed she had long and short term memory problems. She needed total assistance of two staff members to transfer. She was in a wheelchair and did not walk. Observation and interview on 7/18/17 at 9:00 a.m. with certified nursing assistant (CNA) F regarding resident 4 revealed she was being transferred to her bed from her wheelchair. CNA F stated she laid down after breakfast, got up for meals, and usually laid back down after the meal. There had been no music or television turned on when she was in bed. Observation on 7/18/17 at 10:55 a.m. and 11:45 a.m. of resident 4 revealed she had been placed in her wheelchair in her room. The lights had been turned off, and there was no music or television playing for her. Observation on that date at 12:00 noon revealed resident 4 had been brought to the dining room for lunch. Observation on that date at 1:45 p.m. and again at 3:05 p.m. of resident 4 revealed she was laying in bed on her back. The lights had been turned off. There had been no music or television playing. Review of resident 4's undated care plan revealed: *A focus area stating she was dependent on staff to meet emotional, intellectual, physical, and social needs. -Interventions had been: --I need assistance/escort to activity functions. --I prefer activities which do not involve overly demanding cognitive tasks. Engage in simple, structured activities such as church, music programs, true Dakotan reading, etc . --My preferred activities are: church music programs including line dancers, story time and devotions, coffee time, and true Dakotan. *A focus area stating she had a history of [REDACTED]. -An intervention had been I will receive one-to-ones with staff as needed. Interview on 7/18/17 at 4:26 p.m. with the activities coordinator regarding resident 4 revealed they had just placed her in the one-to-one program at the beginning of July 2017. The reason was because the CNAs had stopped bringing her out to the group activities. Review of resident 4's activity documentation revealed: *May 2017 she had attended: -Coffee time: six times. -Religious activities: five times. -Music: three times. -Parties: one time. -Reading: one time. --There had been no other documentation regarding any other activities. *June 2017 she had attended: -Reading: three times. -Coffee time: two times. -Music: four times. -Religious activities: three times. --There had been no other documentation regarding any other activities. *July 2017 she had attended: -Four, group activities. -Five days of one-to-one activities that included: eye contact, visit, reading, hair care, manicure, and outdoors. Interview on 7/18/17 at 6:15 p.m. with a family member of resident 4's revealed they had brought in music for her to listen to in her room. They felt they got a response from her when it was played. She had been very interested in music and had been the church choir instructor for many years. They would have liked to have seen more individual activities regarding music. Interview on 7/19/17 at 2:55 p.m. with the activities coordinator revealed: *They had not initiated playing music in her room. *They had invited her out for the group music activities only. *The eye contact documented in the one-to-one programming documentation meant she looked at them during the activity. -She had made eye contact during one-to-ones each day they had gone into her room. *The harp could have been taken into her room to be played for her. -The activities director played the harp but had not played it for awhile. Review of the provider's July 2013 One-to-One Programming policy revealed: *One-to-one activities were used for residents who did not participate in group activities due to physical and mental limitations. *One-to-one activities could have been done by all staff. *One-to-one activities included: -Greet daily. -Visit one-to-one. -Personal touch. -Eye contact. -Outdoors. -Senses and memory. -Physical/dexterity. -Reading. -Music to include the harp.

Based on observation, interview, record review, and policy review, the provider failed to ensure physician's orders were followed for one of one sampled resident (5) who took nectar thick liquids. Findings include: 1. Observation on 7/18/17 from 5:45 p.m. through 6:15 p.m. of resident 5 revealed: *She had ordered tomato soup. *Her tomato soup appeared to not have been thickened. *She coughed when she would put a spoon full of soup in her mouth. *She also had a half of sloppy joe, peaches, Ensure, and thickened water and juice. -She did not cough when consuming those products. Interview on 7/18/17 from 12:30 p.m. through 1:00 p.m. with kitchen staff D revealed: *She denied to have thickened her soup. *She stated she had not thought about thickening her soup. *She did not have her soup replaced with thickened soup. *The resident continued to cough when eating her soup. Interview on 7/19/17 at 10:15 a.m. with the dietary manager regarding resident 5 revealed: *The kitchen staff should have thickened the tomato soup. *When asked if the soup was thickened she should have replaced her soup with thickened soup. review of the resident's medical record revealed [REDACTED]. Review of the provider's 6/2016 Thickened Liquids policy revealed the food service staff would thicken the liquids at meal times.