Every finding on record at White River Health Care Center

Based on observation, interview, and policy review, the provider failed to ensure hand hygiene, glove use, and medication handling according to the pharmacy instructions by one of one observed licensed practical nurse (LPN) (K) during medication preparation and administration of one of one sampled resident's (33) medications, including divalproex, a seizure medication with handling precautions. Findings include:1. Observation on 7/8/26 at 4:29 p.m. with LPN K while she prepared and administered resident 33's medications revealed LPN K removed a Flomax (a medication used to treat symptoms of an enlarged prostate)0.4 milligram (mg) capsule from the medication bubble package (a tool that organizes pills by the day and time) into her bare hand and placed that capsule on a tissue on the medication cart. She then then removed six capsules of divalproex sodium (a seizure medication) 125 mg from the bubble packaging, placed them into her bare hand, and then set them on the same tissue. With her bare hands she opened the Flomax and the divalproex capsules and placed the contents of those capsules into a medication cup with resident 33's other crushed medications and applesauce. She then administered those medications to resident 33. The six bubble pack medication cards of divalproex were labeled with directions to use gloves, hazardous medication on them. 2. Observation 7/8/26 at 4:20 p.m. of LPN K checking resident 20's blood sugar level and administering his insulin revealed LPN K performed hand hygiene, applied a pair of gloves, and checked resident 20's blood sugar level with a glucometer (a portable device used to measure the amount of sugar in the blood stream). With those same gloved hands, LPN K administered two insulin injections to resident 20, removed her gloves, discarded them in the garbage can, picked up the glucometer and the insulin pens with her bare uncleaned hands, and exited resident 20's room.LPN K took the insulin pens and glucometer to the medication cart, and placed them on top of the medication cart. Without performing hand hygiene, she put a glove on her left hand, cleansed the glucometer with a disinfectant wipe, removed her glove, discarded it in the garbage can, and did not perform hand hygiene. LPN K put the insulin pens in the medication cart, documented resident 20's blood sugar in his medication administration record (MAR), and then performed hand hygiene. 3. Observation on 7/9/26 at 11:26 a.m. of LPN K at the medication cart, preparing and administering medications for resident 33 revealed that without performing hand hygiene, she put on a pair of gloves. With those gloved hands, she prepared resident 33's medications for administration, removed her gloves, discarded them in the garbage can, and did not perform hand hygiene. She placed thickener and flavoring into resident 33's water, put a piece of trash in the garbage can on the medication cart, and then performed hand hygiene. She took the prepared medication to resident 33 in the hallway and administered the medication. 4. Interview with on 7/9/26 at 12:45 p.m. with LPN D revealed the staff were to wear gloves when they handled resident's medications, including hazardous medications. 5. Review of the provider's 1/26/26 Hazardous Drugs list revealed that divalproex, also known as Depakote, was on the list of hazardous drugs. 6. Interview on 7/9/26 at 1:17 p.m. with director of nursing (DON) B revealed she expected the staff to wear gloves when preparing and administering hazardous medications to residents. 7. Interview on 7/9/26 at 1:17 p.m. with director of nursing (DON) B revealed she expected the staff to wear gloves, while performing blood sugar checks. She expected the staff to wear gloves when they handled any residents' medications with their hands, including hazardous medications.She expected staff to use alcohol-based hand sanitizer before they put on gloves and after they removed the gloves, and before and after administering medications to a resident. Review of the provider's 2001 Hazardous Drug policy revealed, Hazardous pharmaceutical drugs are handled according to practice standards so as to minimize staff and resident exposure and environmental damage. Hazardous drugs classified by NIOSH [National Institute for Occupational Safety and Health] are drugs that exhibit one or more of the following criteria: Carcinogenicity (linked to cancer); Teratogenicity (linked to birth defects); Developmental toxicity (linked to developmental delay); Reproductive toxicity; Organ toxicity in low doses (animals or humans); Genotoxicity (linked to DNA damage); and Any new drugs that mimic existing hazardous drugs in structure or toxicity. Review of the provider's 4/26/22 Handwashing/Hand Hygiene policy revealed This facility considers hand hygiene the primary means to prevent the spread of infections. Use analcohol-based hand rub containing at least 62% [percent] alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before preparing or handlingmedications.

Based on observation, interview, and policy review, the provider failed to ensure the daily nurse staffing information, including the total number and the actual hours worked by registered nurses, licensed practical nurses, licensed vocational nurses, and certified nursing assistants per shift, was posted in a location visible and accessible to residents, staff, and visitors. Findings include: 1. Observation on 7/7/26 at 10:00 a.m. of a white dry-erase board on the wall across from the nurses' station revealed the staff had written the date, resident census, and number of nursing personnel working. The posted information was visible to the residents and visitors, but the actual hours worked by each staffing category (registered nurses, licensed practical nurses/licensed vocational nurses, certified nursing assistants) were not included. 2. Observation on 7/9/2026 at 9:27 a.m. revealed that the clipboard that had the daily staffing sheets hung on the wall next to the white dry-erase board across from the nurses' station. This is the same clipboard that had previously been hung behind the nurses' station. The clipboard with the sheet indicating the staff working was not readily accessible to the residents, staff, and visitors. 3. Observation and interview on 7/8/2026 at 9:56 a.m. with licensed practical nurse (LPN) D, revealed that the daily staffing information that indicated which nursing staff and Certified Nursing Assistants (CNA) staff were either working the day or night shift was written on the white dry-erase board across the hallway from the nurses' station. The daily staffing sheets were attached to a clipboard that hung on the wall behind the nurses' station. They were not visible to the residents and visitors. 4. Interview on 7/8/26 at 10:40 a.m. with resident 3 revealed he was not aware of the daily staffing sheets that were on the clipboard hanging behind the nurses' station. He stated, I wouldn't know; I would not go back behind the nurses' station to look for the daily posting of staff. He indicated he was only aware of the staff information written on the white dry-erase board across from the nurses' station. 5. Review of the Nurse Staffing Posting Information policy dated 12/21/25 revealed The Nurse Staffing Sheet will be posted on a daily basis and will contain the facility name,current date, facility's current resident census, the total number and the actual hours worked by registered nurses, licensed practical nurses/licensed vocational nurses, and certified nursing assistants, and unlicensed nursing staff directly responsible for resident care per shift. The facility will post the Nurse Staffing Sheet at the beginning of each shift, and the information posted will be presented in a clear and readable format and in a prominent place readily accessible to residents, staff, and visitors.

Based on observation, interview, record review, and policy review, the provider failed to ensure a medication error rate of less than 5 percent related to Flomax (a medication used to treat an enlarged prostate) was administered on time, and was administered according to the physician's order for one of one observed resident (33) by licensed practical nurse (LPN) (K,) and sodium chloride (a medication to treat low sodium levels in the blood) was administered on time for one of one observed resident (23) by LPN (K). Those observed errors resulted in a medication error rate of 6.9%. Findings include:1. Observation and medication administration record (MAR) review on 7/8/26 at 4:02 p.m. with LPN K during resident 23's medication administration revealed that she administered two tablets of sodium chloride 1000 milligrams (mg) at 4:02 p.m. She did not document that the sodium chloride was administered. The sodium chloride was scheduled to be administered at 6:00 p.m. 2. Review of resident 23's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had a 12/23/25 physician's order for sodium chloride 2,000 milligrams (mg), to be given by mouth three times per day. The medication was scheduled to be administered daily at 8:00 a.m., 12:00 p.m., and 6:00 p.m. 3. Observation, interview, and MAR review on 7/8/26 at 4:29 p.m. with LPN K while she prepared and administered resident 33's Flomax (a medication used to treat symptoms of an enlarged prostate) revealed LPN K removed a Flomax 0.4 milligram (mg) capsule from the medication bubble package (a tool that organizes pills by the day and time) into her bare hand and placed that capsule on a tissue on the medication cart. With her bare hands, she opened the Flomax capsule and placed the contents of that capsule into a medication cup with resident 33's other crushed medications with applesauce. She mixed all the medications together in apple sauce. She then administered those medications to resident 33. The banner on the top of the MAR stated, DO NOT CRUSH or OPEN Tamsulosin [Flomax] capsules.The Flomax 0.4 mg was scheduled to be administered at 2:00 p.m. It was documented in resident 33's MAR that it had already been administered. LPN K verified resident 33's Flomax was scheduled to be administered at 2:00 p.m. and it was documented that it was already administered. LPN K stated she was the person who documented the Flomax was administered but did had not administer it at 2:00 p.m. LPN K stated that medications were to be administered within one hour before or one hour after the scheduled administration time. 4. Review of resident 33's EMR revealed he admitted to the facility on [DATE]. He had a 12/25/25 physician's order for Flomax 0.4 mg, one capsule to be administered daily. The Flomax was scheduled to be administered at 2:00 p.m. The physician's order in resident 33's EMR stated, DO NOT CRUSH or OPEN. 5. Interview on 7/9/26 at 1:17 p.m. with director of nursing (DON) B revealed that the consultant pharmacist reviewed all the residents' medications and determined which medications could be crushed or opened. She expected that if the banner on the resident's MAR indicated a medication was not to be crushed or opened, the staff would not crush or open that medication.Medications were to be administered within one hour before or after the scheduled administration time. She expected medications to be documented as administered immediately after they were administered to the resident. 6. Review of the provider's 12/21/25 Medication Administration policy revealed Ensure that the six rights of medication are followed: Right resident, Right drug, Right dosage, Right route, Right time, Right documentation. Administer within 60 minutes prior to or after scheduled times unless otherwise ordered by [the] physician. Crush medications as ordered. Do not crush medications with 'do not crush' instructions. 7. Review of the provider's 1/9/26 Medication Errors policy revealed, The facility must ensure that it is free of medication error rates of 5% [percent] or greater as well as significant medication error events. The facility will consider factors indicating errors in medication administration, including but not limited to, the following: Medications administered not in accordance with the prescriber's order. Examples include, but not limited to: Incorrect dose, route of administration, dosage form, time of administration. Medication administration not in accordance with the manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological. Examples include, but not limited to: .Crushing 'do not crush' medications.

Based on observation, interview, and policy review, the provider failed to ensure the staff followed standard infection prevention and control practices by one of one observed contracted travel certified nursing assistant (CNA) (J), and one of one observed CNA (E) who did not perform hand hygiene before and after glove use while providing personal cares for one of one sampled resident (2). Findings include:1. Observation on 7/7/26 at 4:08 p.m. in resident 2's room of LPN D, contracted travel CNA J, and CNA E providing personal cares for resident 2 revealed resident 2 was incontinent (involuntary urine or bowel leakage) of bowel. LPN D and contracted travel CNA J each put on a gown, performed hand hygiene, and put on a pair of gloves. LPN D positioned resident 2 onto his right side. Contracted travel CNA J removed the resident's soiled incontinence brief, and cleansed resident 2's buttocks and genitals with disposable cleansing cloths. LPN D put a clean brief on the resident. Contracted travel CNA J removed her soiled pair of gloves and discarded them in the garbage can, did not perform hand hygiene, put on a clean pair of gloves, and removed the soiled absorbent bed pad from under resident 2. LPN D wiped resident with disposable cleansing cloths, removed her gloves, discarded them in the trash can, and performed hand hygiene. Contracted travel CNA J the removed her gown and gloves, discarded them in the trash can, and did not perform hand hygiene. With her uncleaned hands, contracted CNA J removed the trash bag with the soiled cleansing cloths and soiled brief in it, put a new trash bag in the garbage can, and exited the room with the garbage bag of soiled items.LPN D remained in resident 2's room until CNA E entered the room with a clean absorbent bed pad. CNA E performed hand hygiene, put on a gown and a pair of gloves, and assisted LPN D to put the absorbent bed pad under resident 2. CNA E removed her gown and gloves, discarded them in the garbage can, did not perform hand hygiene, and exited resident 2's room. LPN D removed her gown and gloves, discarded them in the garbage can, performed hand hygiene, and exited resident 2's room. 2. Interview on 7/9/26 at 12:45 p.m. with LPN D revealed hand hygiene was to be completed when the staff entered a resident's room, before leaving a resident's room, before gloves were put on, and after gloves were removed. 3. Interview on 7/9/26 at 1:17 p.m. with director of nursing (DON) B revealed she expected the staff to wear gloves anytime they touched something that could potentially be contaminated, or anytime there was potential for contact with bodily fluids. She expected the staff to use alcohol-based hand sanitizer before they put on gloves and after they removed the gloves. If the staff's hands were visibly soiled, then she expected the staff to use soap and water to perform hand hygiene. The staff were to perform hand hygiene before and after providing resident cares. 4. Review of the provider's 4/26/22 Handwashing/Hand Hygiene policy revealed This facility considers hand hygiene the primary means to prevent the spread of infections. Use an alcohol-based hand rub containing at least 62% [percent] alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: .Before and after direct contact with residents; .Before moving from a contaminated body site to a clean body site during resident care; After contact with a resident's intact skin; After contact with blood or bodily fluids; .After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident; After removing gloves. 5. Review of the provider's 4/24/22 Personal Protective Equipment-Using Gloves policy revealed, The use of gloves will vary according to the procedures involved. The use of disposable gloves is indicated: .When handling soiled linen or items that may be contaminated.

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, electronic medical record (EMR) review, observation, interview, and policy review, the provider failed to ensure one of one resident (1) was not abused by staff registered nurse (RN) (C), licensed practical nurse (LPN) (D), and certified nurse aide (CNA) (E) during the administration of a medication injection. Findings include: 1. Review of the provider's 11/8/24 SD DOH FRI revealed: *Resident 1 had a recent visit to the tribal Indian health service (IHS) emergency room (ER) on 10/23/24 related to increased aggressive behaviors toward other residents and staff. *The ER physician, tribal judge, facility medical director, and resident 1's guardian had consulted and agreed he was a risk to himself and others and would benefit from inpatient behavioral health care. *An inpatient placement was not available, he was placed on the waiting list and started on two medications for the aggressive behaviors. *On 10/30/24, resident 1 was seen by doctor of nurse practitioner (DNP) O; she ordered an antipsychotic medication injection to begin in one week. After the initial injection it was to be administered once every four weeks. *On 11/5/24 at approximately 2:20 p.m., seemingly in a good mood following a behavioral health visit with LPN D, director of nurses (DON) (B) determined it would be a good time to approach resident 1 about the new injection. She accompanied RN C and LPN D to resident 1's room. -He was awake and resting in bed. -DON B approached him and asked if it would be okay to give him the injection. -He immediately became aggressive, he was refusing and saying no, he was not taking any insulin. -LPN D attempted to explain the medication and provide reassurance it was not insulin but would help him with his mood; again he adamantly refused. -At that point, DON B determined to wait until the next day when DNP O and LPN M would be there as resident 1 had a good rapport with them. They then left his room. *On 11/5/24 at approximately 2:30 p.m. RN C and LPN D had CNA E accompany them and returned to resident 1's room. -He appeared to be sleeping. -While LPN D and CNA E stood by, RN C administered the injection in his right upper arm. -After the injection was administered, resident 1 became upset, stood up from his bed, swinging at the staff, he slipped and fell down on his knees and then to the floor hitting his head on slippers and the floor. -He had no loss of consciousness. -He refused an initial assessment and was assisted up from the floor to his bed by the CNA and LPN. -Neurological checks were initiated and his guardian notified. *On 11/5/24 at approximately 2:40 p.m. the DON learned of the incident of the injection being given and the resident's subsequent fall. -She immediately went to resident 1's room to assess him and asked him what happened. -He replied, They came in here and gave me that damn shot, I didn't want it and it pissed me off so I tried to hit them and ended up on the ground. Now I got this and pointed at his head. -He had a large hematoma over his left eyebrow, the skin was intact; he was able to see three fingers being held up by the DON. *On 11/5/24 at approximately 3:15 p.m. assistant DON (ADON) (N) assessed resident 1. -The hematoma over his left eyebrow measured 5.3 X 7 X 3 centimeters with purple coloration in the center. -He complained of pain at an 8 out on a scale 0 to10 with 10 being the worst. -The hematoma and the back of the right side of his head were tender to touch. -He was drowsy and mumbled his words. -He agreed to be seen in the ER. -The ADON contacted the physician for an order to send him to the ER and updated his guardian. *On 11/6/24, RN C was officially suspended, LPN D's employer was notified she was not to return to the facility pending the outcome of the investigation. Review of resident 1's EMR revealed: *He was admitted on [DATE] following a series of falls. *He had diagnoses that included previous alcohol abuse, high blood pressure, type 2 diabetes with high blood sugars, dementia, agitation, and bipolar disorder. *He was on medications for elevated blood pressure and cholesterol, oral and injected insulin for diabetes, for dementia, agitation, and bipolar disorder. *His Brief Interview for Mental Status (BIMS) assessment score was 11 that indicated he had moderate cognitive impairment. *He had a history of trauma from having been assaulted by a male acquaintance in the past. *His care plan reflected he could be very aggressive with other males and females; easily agitated by loud yelling and those that wander into his room; and his refusal to take medications including insulin as well as refusal to shower and observe personal hygiene. *Care plan approaches included: -Staff to be consistent and firm yet gentle and calm in approach. -Do not argue, leave and reapproach later. -Document refusal and behaviors, report to the charge nurse. -Offer choice in timing for shower. *Physician notifications of medication refusals. *Resident's guardian/son notifications of refusal to take medications, shower and observe personal hygiene, as well as aggressiveness toward other residents and staff. *Between 8/14/24 and 11/5/24, there were 66 entries related to refusal to take medications including insulin, refusal to allow blood sugar checks, refusal to shower or observe personal hygiene, and demonstration of aggressive verbal and physical aggressiveness toward other residents and staff. Random observations on 11/18/24 between 12:30 p.m. and 14:35 p.m. of resident 1 revealed: At 12:30 p.m. he was lying in bed snoring quietly. While he was not shaved, he did not appear unkempt. At 1:10 p.m. he continued in bed, sleeping; did not arouse when his name was spoken. At 2:00 p.m. he was awake in his wheel chair requested assistance back to bed, staff summoned. He was not interested in talking to this surveyor. At 2:35 p.m. he again was sleeping, snoring quietly. Interviews on 11/18/24 between 12:35 p.m. and 2:55 p.m. with staff about resident 1 revealed: *At 12:35 p.m. RN F stated he had had multiple instances of aggressive language and behavior toward other residents and staff. Staff had received re-education about abuse following the the incident where he was given the injection and fell . *At 1:20 p.m. LPN G shared his care plan does have approaches for his aggressiveness and staff do keep track of his behaviors and refusals. Staff received re-education from the administrator and ADON about abuse. *At 1:30 p.m. LPN H stated she had been working on the other hall the day of the reported incident and was aware he had refused the injection that was given while he was sleeping. Staff were re-educated and that education is also in the communication book. *At 1:50 p.m. social services I stated she was aware of the incident and received re-education about abuse. *At 2:05 p.m. restorative aide J stated she was aware of the incident with resident 1 and had received re-education about abuse. *At 2:15 p.m. CNA K stated she was aware of the abuse of resident 1 and had received re-education about abuse. *At 2:45 p.m. CNA L shared following the incident with resident 1 he had received re-education about abuse. Interview and review of the FRI and facility internal investigation on 11/18/24 at 3:00 p.m. with administrator A and DON B revealed: *DON B had been in her office when she stepped out and saw a staff member heading to resident 1's room with an ice pack. She was informed he had fallen on the floor following receiving the injection. She went to his room to investigate the situation. -After doing a preliminary assessment herself, she returned to the office to notify administrator A as she was out of town. -After leaving a message for administrator A, she received a return call around 3:00 p.m. from her. -She didn't begin the complete investigation until after resident 1 was sent out to the ER. -RN C received official notification of suspension. -LPN D's employer was notified she was not to return to the facility. -CNA E was not suspended. He had started at the facility three shifts prior to the date of the incident and when interviewed on three separate occasions he believed he had to follow all the orders given by the RN. He had been told to hold resident 1's arm while he was getting the shot. He received one-to-one re-education and the staff education on abuse. *Administrator A concurred with DON B that she was out of town and received notification of the incident around 3:00 p.m. on 11/5/24. -They had open communication with resident 1's guardian/son, the medical director, the behavioral health employer of LPN D, law enforcement, and the ombudsman. -At the conclusion of their investigation they made the determination to terminate RN C. -They received notification from LPN D's employer on 11/8/24 that they had terminated her from employment. -She and ADON N had provided staff re-education about abuse and their abuse policy on 11/8/24 and that education was also available in the staff communication book. *Both DON B and administrator A stated they did not believe the staff involved in the incident intended harm to resident 1 but they had ignored the decision to wait until the next day to reapproach, and did not follow resident 1's care plan approach interventions or the facility policy. *During the course of the investigation they did not identify any other residents who may have incurred abuse with medication administration. *A Quality Assurance Performance Improvement meeting was planned to occur in early December when the medical director was to be available. Review of the provider's reviewed 11/1/24 Abuse, Neglect, and Exploitation policy revealed in the definitions: Willful means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 11/18/24 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding medication administration and abuse, interviews revealed staff understood the education provided regarding those topics, observation of the resident revealed no signs of emotional distress, and review of his record revealed no documented ongoing signs of resident distress related to the reported incident. Based on the above information, non-compliance at F600 was determined on 11/5/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 11/18/24, the non-compliance is considered past noncompliance.

Based on observation, interview, record review, and policy review the provider failed to ensure one of one sampled resident (20) received recommended dental services after tooth extractions were completed. Finding include: 1. Observation and interview on 12/12/23 at 8:36 a.m. with resident 20 in his room revealed he:*Was missing all his teeth. *Stated that all of his teeth were pulled three months ago. *Was waiting for dentures. *Had not been informed of an appointment to start the process of getting dentures. Review of resident 20's electronic medical record revealed: *He was admitted on [DATE]. *His Brief Interview of Mental Status score was 15, meaning his cognition was intact. *His diagnoses included: -Cerebral infarction due to thrombosis of the right middle cerebral artery. -Hemiplegia and hemiparesis following cerebral infarction affecting the left non-dominant side. -Hypokalemia. -Gastro0esophageal reflux disease without esophagitis. *His care plan dated 9/20/23 showed a regular mechanical soft diet. *His progress notes included: -On 2/6/23 he returned from an oral surgery appointment. -Instructions were given to begin resident on Amoxicillin 500 mg three times a day for five days. -Hydrocodone 5/325 mg every six hours for pain as needed. -Chlorhexidine 15 mL mouthwash twice a day for 14 days. -The resident was instructed to keep gauze in extractions until no blood was present. -Ice packs as needed for swelling. Interview on 12/13/23 at 10:48 a.m. with director of nursing B regarding resident 20's dentures revealed: *The medical records person would have scheduled the appointments for his new dentures, but she was out on maternity leave. *The business manager was the backup person for medical records. *She agreed the appointment should have been set up when he came back from getting his teeth extracted. *The follow-up appointment must have gotten overlooked. *It was her expectation that all follow-up appointments would be scheduled and documented in the appointment book. *She confirmed his follow-up appointment with the dentist was not scheduled. Interview on 12/13/23 at 11:03 a.m. with business manager D regarding resident 20's dentures revealed: *She was the backup person for medical records while she was on maternity leave. *The Medicaid authorization did not get scanned into resident 20's medical record. *There was no paper trail for the follow-up visit with the dentist. *She agreed there should have been a follow-up dentist appointment scheduled. *The medical records person was not available for an interview. Review of the provider's revised February 2014 Medication and Treatment Orders, Dental Services policy revealed: *Orders for the treatment of the resident's dental problems must be signed by the attending dentist. *All orders must be charted and made a part of the resident's medical record and care plan.

Based on observation, interview, record review, and the provider's admission resident rights document review, the provider failed to ensure that: *Dignity and safety was maintained for one of one sampled resident (1) during one of one observed transfer from bed to wheelchair by two of two certified nursing assistants (CNA) (G and H). *One of one observed medication cart had confidential information out of the sight of visitors. Findings include: 1. Observation and interview on 12/6/22 at 11:45 a.m. of CNAs G and H helping resident 1 to transfer from his bed to his wheelchair revealed: *They had helped him to a sitting position on his bed, then without using a gait belt, each had pulled on the back of his pants and pivoted him to the wheelchair. *Two gait belts were noted hanging on separate hooks in his room. *When asked about the observation and the lack of gait belt use, they both said, We usually use a gait belt to transfer him. Review of resident 1's care plan revealed he had required a pivot transfer with two staff helping. Use gait belt for transfers. Interview on 12/7/22 at 1:35 p.m. with CNA G when asked why they did not use the gait belt to transfer resident 1 she stated, I just spaced out using it [the gait belt]. Interview on 12/7/22 at 1:43 p.m. with director of nursing (DON) B regarding resident 1's transfer revealed, They should not be using the back of his pants to transfer him. They should be using a gait belt. She agreed to transfer him in this manner did not promote his dignity. Review of the provider's 7/1/22 Attachment I Resident Rights in the admission packet revealed, Each resident has the right to a dignified existence, self-determination, and communication 1. Observation on 12/7/22 at 4:45 p.m. of the east medication cart revealed the 12/7/22 shift report sheet laying on top in full view of anyone passing by. This sheet had private health information of every resident in the building. The information included: *Medication residents received, including insulin. *Fall risks. *Remove dentures. *Wound care. *Toileting assistance or use of an incontinence product. *Elopement risk. *Check closet for soiled clothes. Interview on 12/8/22 at 2:00 p.m. with licensed practical nurse (I) revealed she had not realized she had the report sheet out in plain view. She usually puts it under the computer when she is away from the medication cart. Interview on 12/8/22 at 2:10 p.m. with DON A revealed she, expected the nurses to keep confidential information out of public view. I have to continually remind them of this almost daily. Review of the provider's 7/1/22 Attachment I Resident Rights in the admission packet revealed, Each resident has the right to confidential handling of his/her medical and personal records and will only be released with the resident's prior written consent.

Based on interview, record review, and policy review, the provider failed to ensure [MEDICATION NAME] purified protein derivative (PPD) skin test medication had been given appropriately for four of four sampled residents (4, 14, 18, and 20) reviewed. Findings include: 1. Review of resident 20's medical record revealed: *A physician order [REDACTED]. -That order did not indicate to give a PPD skin test. *He had been given a PPD skin test on 10/1/20 at 10:18 a.m. *He had a reaction to a PPD skin test in the past. *The physician had been notified. *He did not have a negative reaction when he received this test. 2. Review of resident 18's medical record revealed: *A physician order [REDACTED]. -That order did not indicate to give a PPD skin test. *He had been given a PPD skin test on 10/1/20 at 10:18 a.m. *He had a reaction to a PPD skin test in the past. *The physician had been notified. *He did not have a negative reaction when he received this test. 3. Review of resident 4's medical record revealed: *A physician order [REDACTED]. -That order did not indicate to give a PPD skin test. *He had been given a PPD skin test on 10/1/20 at 10:09 a.m. *The physician had been notified. *He did not have a negative reaction when he received this test. 4. Review of resident 14's medical record revealed: *A physician order [REDACTED]. -That order did not indicate to give a PPD skin test. *He had been given a PPD skin test on 10/1/20 at 10:09 a.m. *The physician had been notified. *He did not have a negative reaction when he received this test. 5. Interview on 10/7/20 at 1:03 p.m. with director of nursing (DON) A and licensed practical nurse (LPN) F revealed: *LPN J had administered the PPD skin tests. -She was a temporary nurse. -She had not understood the order and thought she should have given those residents a PPD skin test. -She had asked LPN K to clarify the order and still had not understood so went ahead and gave the injections. *The order was for a [MEDICAL CONDITION] (TB) risk assessment to be done annually. *They were now doing more orientation for temporary nurses. Continued interview on 10/7/20 at 5:01 p.m. with DON A revealed: *LPN J had been employed since 9/1/20 and worked about three, twelve hour shifts a week. *She had just assigned LPN J an online training titled Administration: Avoiding Common Medication Errors and Nursing Documentation. -She indicated a due date of 10/27/20. Continued interview on 10/8/20 at 10:33 a.m. with DON A revealed Potter and Perry, Ninth Edition, was used for professional standards. Review of the provider's 10/8/20 Medication Administration policy revealed: *10. Review MAR (medication administration record) to identify medication to be administered. *11. Compare medication source (bubble pack, vial, etc.) with MAR indicated [REDACTED]. Review of the provider's 10/8/20 Medication Error policy revealed: *To prevent medication errors and ensure safe medication administration, nurses should verify the following information: a. Right medication, dose, route, and time of administration; b. Right resident and right documentation. Review of Patricia A. Potter et al., Fundamentals of Nursing, 9th Ed., Elsevier, St. Louis, Mo., 2017, p. 626, revealed: *To prevent medication errors, follow the six rights of medication administration consistently every time you administer medications. *Many medication errors can be linked in some way to an inconsistency in adhering to these six rights: 1. The right medication 2. The right dose 3. The right patient 4. The right route 5. The right time 6. The right documentation.

Based on observation, interview, and policy review, the provider failed to maintain appropriate infection control practices for: *One of one resident (25) observation of appropriately handling dressing supplies for a dressing change. *Two of three observations of hand hygiene with residents' (19 and 26) personal care. Findings include: 1. Observation and interview on 10/7/20 at 9:30 a.m. of licensed practical nurse (LPN) H preparing to do a dressing change for resident 25 revealed: *She had been at the medication cart and had put her hands in multiple drawers, touched multiple items, and collected dressing supplies. *With her contaminated hands she reached into a plastic bag containing an open bulk package of 4 x 4 gauze, took out a handful of gauze, and placed it on her clean surface. *She had agreed her hands were not clean. *She had agreed the 4 x 4 gauze had been contaminated by her hands. Interview on 10/8/20 at 10:33 a.m. with director of nursing (DON) A revealed: *She had agreed LPN H had contaminated the 4 x 4 gauze when she reached into the bag. *LPN H should have washed her hands and put gloves on when touching clean dressing supplies. 2. Observation on 10/6/20 at 12:54 p.m. in resident 19's room with certified nursing assistant (CNA) B and LPN C revealed: *CNA B had ambulated with him to his room. *After they had entered his room CNA B instructed him to hold onto the overbed table beside his bed. *Without performing hand hygiene CNA B put on a pair of gloves, removed his wet brief, and discarded it into the garbage can. *With those same soiled gloves on she: -Picked up a clean brief with her left hand. -Took her right hand, placed it into her pocket, removed a highlighter, and wrote on the clean brief. -Placed the highlighter back into her pocket. -Laid the clean brief on top of the night stand. -Removed three wet wipes from a clean package. -Performed personal care wiping his buttock area first and then his front private area. -Removed her gloves and performed hand hygiene. -Put on a new pair of gloves. -Fastened the left side of the clean brief. *LPN C assisted with the right side of the brief. *CNA B assisted him to sit down in his wheel chair. -She then discarded her gloves and performed hand hygiene. 3. Observation on 10/6/20 at 2:50 p.m. in resident 26's room with LPN D and CNA E revealed: *He had put on his call light. *LPN D performed hand hygiene prior to answering his call light. *He had refused to let her put the gait belt on him. *CNA E entered his room. Without performing hand hygiene or putting on a pair of gloves he: -Assisted him to stand up with a walker. -Assisted him into the bathroom. -Removed his wet brief and discarded it into the garbage can. -Came out of the bathroom and made the resident's bed. *Without performing hand hygiene, put on a pair of gloves, assisted him to stand up, performed personal care, pulled up his brief, removed his gloves, discarded them into the garbage, and then assisted him to sit in his recliner. *He then performed hand hygiene. 4. Interview on 10/7/20 at 3:55 p.m. with DON A, LPN/Minimum Data Set coordinator F, and RN/infection control preventionist G regarding the above observations two and three revealed: *CNA B should have: -Gelled her hands, pulled the brief down, and discarded it. -Disposed of the soiled gloves, performed hand hygiene, put on new gloves, and completed personal care. -Removed her gloves and then completed hand hygiene. *She had missed hand hygiene opportunities during that observation. *CNA E: -Was a new employee and had received training on hand hygiene. -Had missed several hand hygiene opportunities during that observation. *They had spent additional time with staff with training, observation, and had completed competencies with hand hygiene. Review of the provider's 12/31/19 Handwashing/Hand Hygiene policy revealed:*This facility considers hand hygiene the primary means to prevent the spread of infection. -2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors. -7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: --b. Before and after direct contact with residents. --g. Before handling clean or soiled dressings, gauze pads, etc. --h. Before moving from a contaminated body site to a clean body site during resident care. --j. After contact with blood or bodily fluids. --m. After removing gloves. Review of the provider's 9/9/20 Perineal Care policy revealed: 6. Perform hand hygiene and put on gloves. Review of the provider's 12/31/19 Personal Protective Equipment - Using Gloves policy revealed: *Gloves must be worn when handling blood, body fluids, secretions, excretions, mucous membranes and/or non-intact skin. -1. All employees must wear gloves when touching blood, body fluids, secretions, excretions, mucous membranes, and/or non-intact skin. -7. Wash your hands after removing gloves.

Based on observation, interview, record review, and policy review, the provided had failed to ensure: *One of one sampled resident (22) was protected and free from verbal and psychological abuse by one of one licensed practical nurse (LPN) (J) who had a disregard for her: -Personal belongings. -Personal space. -Privacy and dignity. *One of one sampled resident (22) who exhibited symptoms of mental health instability had been assessed, monitored, and evaluated to ensure her psychosocial well-being. Findings include: NOTICE: Notice of immediate jeopardy (IJ) was given verbally on 12/12/19 at 4:30 p.m. to the administrator and the director of nursing (DON). As LPN J was not scheduled to work until after the current schedule ended on 12/14/19. This ensured the immediacy had been removed before the survey team left the facility. They were asked for an immediate plan of correction (P[NAME]) to ensure all residents were safe from verbal abuse by LPN [NAME] PLAN: It is the policy of the facility to ensure that the residents are free from abuse and neglect. Immediate intervention for incident on 11-8-19 was to contact (nurses name (LPN J)) by phone on 12/12/19 and will no longer be employed by the [NAME] River Health Care Center and reported the SD (South Dakota) Board of Nursing on 12-13-19. C.N.A (CNA's name (M)) was placed on performance improvement plan on 12-13-19, reeducation on resident abuse and dignity. State was notified of incident on 12-13-19. Started interviews with resident BIMS (Brief Interview for Mental Status) scores 10-15 for all resident interviews feeling safe and follow through with interventions if concerns discussed with interdisciplinary team starting today 12-13-19 attached resident's questions. Psych (psychiatric) appointment made 12-16-19 at 10:00 am with (behavioral health provider name) for resident identified in incident 11-8-19 and the all followups as needed. All employees will be reeducated with abuse policy and resident rights before starting next shift starting immediately 12-13-19 attached training information. Administrator orientation includes abuse policy and procedures and resident rights implemented immediately to all new staff hired after the training to ensure all staff is educated about abuse and resident rights. 12-13-19. Random checks during all shift 5 times a week for one-week done by Administrator, DON (director of nursing), ADON (assistant director of nursing), or designee will determine frequency after one month starting 12-13-19 done by checklist. The above plan of correction was accepted by email on 12-13-19 at 1:00 p.m. 1. Review of resident 22's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She had a Brief Interview for Mental Status (BIMS) assessment score of fifteen indicating she had good memory recall. *She was independent with all activities of daily living (ADL) except for showering where she required the help of one staff member. *She used a wheelchair (w/c) to meet all of her mobility needs. Review of resident 22's interdisciplinary progress notes for 11/9/19 revealed: *Licensed practical nurse (LPN) K had documented: -At 7:00 a.m.: --Resident states she had 6 loose stools already today --[MEDICATION NAME] suspension 30cc (cubic centimeter) given. -At 12:16 p.m.: Resident continues to complain of diarrhea. Has had since the 5th. This morning resident stated that she had 6 loose stools this morning. Gave resident [MEDICATION NAME] this morning per standing orders. Gave applesauce, toast and tea for breakfast. Again at lunch had applesauce, toast, tea and banana. Gave [MEDICATION NAME] again around 9 am. Stated that it is better after second dose and light diet. Notified (physician name) of resident's concerns. Asked if she was running a temperature and resident had 97.4 temp. No other complaints voiced. No further orders from (physician name). Observation and interview on 12/10/19 at 8:21 a.m. with resident 22 revealed: *She had been in her room watching TV and sitting in a w/c. *Her room had: -Two beds with one of them unoccupied. -Many decorations and personal belongings in it. *She stated: -I've been here a long time. -I make my own choices, and I'm independent with taking care of myself. *As we talked her voice became low, and she looked away from me. -She stated: -I don't know if I should tell you this but, a nurse made me do something I did not want to do. -I had diarrhea one night and she didn't believe me that I was having diarrhea. -I asked for [MEDICATION NAME]. -She told me to leave it (diarrhea) in the stool and the next time she would check it out. -I had another diarrhea, so I left it in the toilet and turned my light on. -I waited and waited, and finally I just flushed it. -Then I went again and peaked at her, and yelled at her, but she wouldn't come down, so I flushed it. -She finally came down to my room and told me to take a picture of it the next time. -I had a new phone and didn't know how to use it, so this other aide that answered my call light showed me how to use it. -I took a picture of it and told her to show it to the nurse. -(LPN J) thought it was funny that I took a picture of it. -She was laughing about it to (LPN K). -(LPN K) got upset that she was making fun of me and reported it to the director of nursing (DON). -Then they talked to me and said they would talk to her. -I haven't seen her lately, and I don't know what happened to her. -That happened last month. -She was a night nurse. *She paused, stopped talking, and with downcast eyes and a frown on her face she continued to state: -(LPN J), I thought it was permitted for her to come in here to sleep in the bed and watch my TV. -I told the DON, and that was when I found out that she was not supposed to do that. *She further confirmed she was aware that nurses should not be sleeping when on duty, and they should not make residents take pictures of their own bowel movement. *Other certified nursing assistants (CNA) would come and get LPN J when a resident needed her. *She stated it worried her that other residents might need LPN J while she was in her room sleeping. *She went to nursing school with LPN J a long time ago. Interview on 12/11/19 at 4:03 p.m. with the administrator regarding resident 22 revealed: *She had confirmed there had been a situation involving a night nurse with the resident, and it had been discussed with the social service designee (SSD). *LPN J had been going into the resident's room and sleeping on the extra bed during her shift at night. *The resident had an episode of diarrhea one night and had requested something for it. *LPN J had: -Told the resident she needed to see the diarrhea. -Told the resident to take a picture of it and laughed at the resident when she did that. *The SSD or DON were to have completed a grievance with discipline on that concern. *The DON had completed a verbal warning for disciplinary action on LPN J for the concern reported by the resident. -There had been an investigation completed. *There were cameras located in the hallways and were reviewed on the nights LPN J had been working. -The camera confirmed LPN J had been in the resident's room, but they had not been able to tell if she was sleeping or not. *The concern had been unsubstantiated from those findings. Interview on 12/11/19 at 4:30 p.m. with the SSD regarding resident 22 revealed she: *Confirmed the resident had come and talked to her about the above situation with LPN [NAME] *Stated: -I do remember that, that happened not too long ago. -I do not have a grievance form filled out for that incident. -She (resident 22) did come and talk to me about it, so I visited with (DON and administrator) and they said they would talk to the nurse. -It was in the last couple of weeks. Review of the grievance binder confirmed there was no documentation to support a grievance and investigation had been completed for resident 22 regarding her concern and situation with LPN [NAME] Interview on 12/12/19 at 10:57 a.m. with LPN K regarding resident 22 revealed: *She: -Confirmed the situation that had occurred between the resident and LPN [NAME] -Had worked the next morning after the incident with the resident and LPN [NAME] *She stated: -It was reported to me when I came on that morning. -The night nurse said (resident) wanted something for diarrhea. -She (LPN J) had told (resident) she had a phone, and you take a picture of it. -She (LPN J) was laughing and joking about it. -It upset me and I didn't think it was right. -I might have mentioned it to (DON), but I'm not sure. -It was on a weekend, and I don't really remember. -I felt it was very unprofessional. -You don't ask somebody to take a picture of their bowel movement. *The resident had reported LPN J: -Was sleeping in her room on the other bed during her shift. -Had been using her blanket and other personal belongings. *She stated: -I told her to talk to (DON and administrator). -I did not tell her to fill out a grievance. Interview on 12/12/19 at 11:26 a.m. with resident 22 revealed and stated: *I told her (LPN J) I had diarrhea, but she didn't believe me, she said I couldn't have the [MEDICATION NAME] unless I took a picture of it. *She told me I have a phone and to take a picture. *I had a new phone and didn't know how to use it, so I asked (certified nursing assistant (CNA) M) to help me with it. She helped me take a picture of it. *I went three more times and pulled the light, but she would not come down. -(Nurse J) told (LPN K name) that I took a picture of it and was laughing about it. *Yeah, it's like it was a big joke. -The nurse did not apologize to me. -They never told me to fill out a grievance. -I told them that it was terrible what she did. -It was a big joke and (LPN K) didn't think it was, so she told (DON). -I was embarrassed, humiliated, and it made me feel funny. I didn't know what she was telling people. *She confirmed the SSD had talked to her about the incident and concerns that had involved LPN [NAME] *It's like she (LPN J) didn't believe me that I needed the medicine. She was laughing when I asked her to come down. I had six loose stools right in a row before she gave me some. My stomach was not feeling good. I don't trust her. I have seen her sleeping in my room. I heard her coughing, I looked over, and she was laying on the bed. She would do it a lot. She would either sit on my w/c or lay in the bed and watch TV. They(staff) started calling this room (resident 22's name) and (LPN J's name) room. They (staff) knew where to find her, so they always came and got her when a resident needed her. It would wake me up when they would come and get her. *She confirmed LPN J: -Used her remote control to watch TV. -Used her comforter as a pillow when she was sleeping. --Had done that every night while she was on duty. *She used my phone charger to charge her phone. -I would wake-up and see her rummaging through my stuff and drawers looking for it. -I just assumed she had permission to do that. First she borrowed it, and then she started digging around for it. She didn't return it the last time she used it, so they bought me a charger. Review of LPN J's personnel file revealed no documentation to support disciplinary action was completed and reviewed with her on the above concern and incident identified with resident 22. Interview on 12/12/19 at 1:57 p.m. with the DON, administrator, SSD, LPN D, and RN [NAME] regarding resident 22 revealed: *The DON confirmed: -LPN K had informed her of the incident and concerns involving the resident and LPN [NAME] -The resident had felt embarrassed about having to take a picture of her bowel movement. -She: --Had watched the cameras to see where nurse J was at on the nights she had worked. --Did see LPN J go into the resident's room. --Stated: She was gone for a while, but I am not sure for how long or the exact length of time. Then she was at the nurses station. *The DON further confirmed she had given a verbal warning as disciplinary action to LPN [NAME] *The DON stated: I told her, you can't do that. *LPN J did: -Not admit she was sleeping in the resident's room. -Confess she had been watching the resident's TV. Continued interview on 12/12/19 at 2:00 p.m. with the DON, administrator, SSD, LPN D, and RN [NAME] revealed: *There was no documentation to support: -An interview with CNA M had been completed for the incident that had occurred on 11/8/19. -A complete and thorough investigation on the above concerns and incident between resident 22 and LPN J had been done to ensure: --Abuse and neglect had not occurred. --No further mental anguish and misappropriation of the resident's belongings had occurred. --The mental health and well-being for the resident was maintained. --The safety and mental health well-being for all the residents who lived in the facility had occurred. *The administrator confirmed there should have been documentation and an investigation completed on the above incident. *The SSD confirmed: -There was no grievance completed for the incident that had occurred on 11/8/19. -She was not encouraged to do a grievance, but she should have done one. *The DON confirmed: -LPN J still worked night shift here, but was currently on vacation. -She: --Had been monitoring LPN J on the cameras and was not seen entering any residents' rooms. --Had not documented any of her findings or investigative work to rule out abuse and neglect. --Agreed if it was not documented it had not been considered done. *They all agreed the actions of LPN J: -That she had exhibited towards resident 22 had been a form of verbal and mental abuse. -Had caused unwarranted mental anguish for the resident. -Had been considered a form of misappropriation and use of the resident's personal belongings. *The DON stated: -I should have reported this. -Here is a copy of the verbal warning that I did with her. Review of the 11/22/19 progressive disciplinary action form for LPN J revealed: *Name of employee: (Name). -Verbal warning identified. -State Group Violation: Sleeping in a resident's room, watching TV asking resident to take picture of bowel movement on cell phone. -Date of Violation: 11-8-19. -Describe in detail information .: Resident showed picture taken of BM (bowel movement) on her phone. -State what corrective action you feel the employee may take to eliminate the above problem area: Will be monitoring where are during shift and consult with resident. -Form signed on 11/22/19 by LPN J , DON, and administrator. *The verbal warning was completed and reviewed with the LPN J fourteen days after the incident had occurred with resident 22. Review of resident 22's following Medication Administration Record [REDACTED] *On 11/8/19 there was no documentation to support LPN J had administered [MEDICATION NAME] to the resident per her request for an upset stomach and loose stools. *On 11/9/19 at 7:44 a.m. and 9:40 a.m. LPN K had administered [MEDICATION NAME] to the resident per her request for continued loose stools. Review of the provider's 10/30/19 staff training record on abuse and resident rights revealed: *The ombudsman had provided training for the staff on abuse and resident rights. *There was a sign-in sheet for the staff who had attended that training to sign. -There was no documentation or signature to support LPN J had attended that meeting. -There was a signature to support CNA M had attended that meeting. *The DON confirmed that (LPN J) was not on the sign-in sheet, therefore she was not at the meeting. Review of the provider's undated Resident Rights policy revealed: *Each resident has the right to be free of physical, chemical, and mental restraints or abuse. *Each resident has the right to considerate and respectful care and to be treated with honesty and dignity. *It is recognized that every resident is an individual who has feelings, preferences, personal needs and requirements. Review of the provider's 2006 Abuse Prevention Program policy revealed: Our residents have the right to be free from abuse, neglect, misappropriation of resident property, corporal punishment and involuntary seclusion. Review of the provider's 2013 Reporting Abuse to Facility Management policy revealed: *2. (a.) Abuse: is defined as the willful infliction of injury, unreasonable confinement, intimidation, corpunishment with resulting physical harm, pain or mental anguish. -(e.) Mental: abuse is defined as, but is not limited to, humiliation, harassment, threats of punishment, or withholding of treatment or services. -(f.) Neglect: is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Review of provider's 2008 Grievance policy revealed: Our facility will help residents, their representatives (sponsors), other interested family members, or resident advocates file grievances or complaints when such requests are made. Review of provider's (YEAR) Filing Grievances/Complaint policy revealed: *It is the policy of this facility that each resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which had not been furnished as well as that which has not been furnished, the behavior of staff and of the residents, and other concerns regarding their LTC facility stay. -The facility will ensure prompt resolution to all grievances, keeping the resident and resident representative informed throughout the investigation and resolution process. The facility grievance process will be overseen by a designated Grievance who will be responsible for receiving and tracking grievances through their conclusion, lead necessary investigations, maintaining the confidentiality of all information associated with grievances, communicate with residents throughout the process to resolution and coordinate with other staff (including the Administrator, if he she is not the designated Grievance Official) and with state of federal agencies as may indicated by specific allegations. *THE OBJECTIVE OF THE GRIEVANCE POLICY: The objective of the grievance policy is to ensure the facility makes prompt efforts to resolve grievances a resident may have. Review of the provider's (YEAR) Accidents and Incidents-Investigating and Reporting revealed: *All accidents or incidents involving residents, employees, visitors, venders, etc., occurring on our premises shall be investigated and reported to the Administrator. -1. The Nurse Supervisor/Charge Nurse and/or the department director or supervisor shall promptly initiate and document investigation of the accident or incident. Review of the provider's 2009 Reporting Abuse to State Agencies and Other Entities/Individuals revealed: *All suspected violations and all substantiated incident of abuse will be immediately reported to appropriate state agencies and other entities or individuals as may be required by law. -1. Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident: --a. The State licensing/certification agency responsible for surveying/licensing the facility; --b. The local/State Ombudsman; --c. The Resident's Representative (Sponsor) of Record; --d. Adult Protective Services; --e. Law enforcement officials; --f. The resident's Attending Physician; and --g. The facility Medical Director. -2. Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, e-mail, or by telephone. -4. Should the investigation reveal findings of abuse, such findings will be reported to the State Abuse Registry. -9. Any violation of this policy may result in disciplinary action. -10. Inquiries concerning resident abuse should be referred to the Director of Nursing Services or to the Administrator. Review of the Psychosocial Outcome Severity Guide revealed: *Humiliation refers to a feeling of shame due to being embarrassed, disgraced, or depreciated. Some individuals lose so much self-esteem though humiliation that they become depressed. -Examples of negative psychosocial outcomes as a result of the facility's non compliance at severity level four include, but are not limited to: --Ongoing, persistent expression of dehumanization or humiliation in response to an identifiable situation, that persists regardless of whether the precipitating event(s) has ceased and has resulted in a potentially life-threatening consequence.

Based on observation, interview, record review, job description review, and policy review, the provider failed to ensure the facility was operated in a manner that ensured the safety and overall well-being for all residents by ensuring: *Abuse allegations had been thoroughly investigated for one of one sampled resident (22) and that resident was protected and free from verbal and psychological abuse by one of one licensed practical nurse (LPN) (J) who had a disregard for her: -Personal belongings. -Personal space. -Privacy and dignity. *One of one sampled resident (22) who exhibited symptoms of mental health instability had been assessed, monitored, and evaluated to ensure her psychosocial well-being was addressed appropriately. *Investigations for all incidents whether reportable or not reportable to the South Dakota Department of Health (SD DOH) had been completed thoroughly and involved the assistance from the appropriate departments involved in the incident that included: *A staff-to-resident altercation to ensure verbal and psychological abuse had not occurred for one of one sampled resident (22) by one of one licensed practical nurse (LPN) (J). *Falls with major injury for two of five sampled residents (1 and 27). *Fall interventions had been put in place to ensure all residents were free from major injury. *Identify a decline in condition for one of one sampled resident (1) who had a recent weight loss with the placement of a [DEVICE] ([DEVICE]) for nutritional support. *Ensure one of one sampled resident (1) who was at risk for pressure injuries had preventative measures and interventions in place and implemented by the staff to ensure no skin breakdown had occurred. *Ensure one of one sampled resident (1) who was dependent upon the staff to assist her with all activities daily living and had a history of [REDACTED]. -To promote healthy skin. -According to her plan of care and the facility policy. *Implement interventions and update care plans for four of five sampled residents (8, 20, 27, and 36) who had a history of [REDACTED]. -That failure placed the residents at risk for reoccurrence of falls. *Ensure gait belts were used appropriately to support safety during stand-pivot transfers for three of three sampled residents (6, 12, and 28). *Ensuring the Quality Assurance and Improvement Program (QAPI) and the Performance Improvement Projects (PIP) were appropriately implemented and monitored. Findings include: 1. Interview on 12/12/19 at 4:34 p.m. with the administrator and the director of nursing revealed: *The QAPI committee met monthly. *The administrator and all of the department heads were to meet monthly. -Some of the meetings had been missed when the administrator went on maternity leave. *The medical director attended at least quarterly. *The pharmacist had not attended, but they planned to make that happen. *They used past deficiencies as ideas for performance improvement plans (PIP). *They had PIPs in place for hand hygiene and falls. *They had made benchmarks for the PIPs at 100% and were never able to meet those goals. *They had recognized resident's falls as a problem eight months ago but they had not made progress with that PIP. *They had not realized there was a problem with lack of documentation and investigation of resident falls. *Recent leadership changes had been a problem which resulted in a lack of consistency. *They agreed they did not have a good system in place for correcting problems within the facility. *They confirmed the QAPI program that was in place was not good, and they planned to work on it. Refer to F600, F609, F657, F686, F689, and F867.

Based on observation, interview, record review, and policy review, the provider failed to do the following for one of one sampled resident (1): *Identify a decline in condition for the resident who had a recent weight loss with the placement of a [DEVICE] ([DEVICE]) for nutritional support. *Ensure the resident who was at risk for pressure injuries had preventative measures and interventions in place and implemented by the staff to ensure no skin breakdown had occurred. *Ensure the resident who was dependent upon the staff to assist her with all activities of daily living (ADL) and had a history of [REDACTED]. -To promote healthy skin. -According to her plan of care and the their policy. Findings include: 1a. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had: -Been alert and able to mouth the words yeah or no to simple questions asked of her. -Not been interviewable and was unable to make her needs known. -Been dependent upon the staff to assist her with all ADLs. --That had included bed mobility, positioning, and transfers. -Been dependent upon the staff to anticipate her needs and develop a plan of care with goals and interventions put in place to support those needs. -Not been able to walk and required the use of a w/c. -Been at high risk for skin breakdown due to (d/t) her dependency upon the staff for assistance. *Her disease had been worsening throughout the past year causing a progressive decline in her health. *She had experienced a decline with her eating capabilities and required the placement on 9/11/19 of a [DEVICE] to support her nutritional needs. *She remained in bed during the hours of that nutritional support. -Was to have been repositioned every two hours. --There was no documentation to support she required the use of positioning devices to decrease pressure on high risk injury areas. *On 9/20/19 a blister and deep tissue injury had been identified on her right heel. -She had acquired that injury nine days after the [DEVICE] placement. -That pressure injury measured 2.2 centimeters (cm) by (x) 2.9 cm. -The wound bed had been maroon in color and boggy (soft) to touch. *That pressure injury had been documented as healed on 11/6/19. *On 9/22/19 she had been admitted to the hospital for a high fever and urinary tract infection. *On 9/25/19 she was readmitted to the facility and a significant change in status Minimum Data Set (MDS) assessment had been completed d/t her continued decline in health. b. Observation on 12/10/19 at 8:01 a.m. of resident 1 revealed: *She had been: -Laying in her bed resting. -Positioned on her back with pillows placed on each side of her. -Awake and attempted to talk to the surveyor when spoken to. -Able to silently say the word yeah when asked a question. *Her: -Bed had been put in the low position. -Mattress had built-up edges on the top and bottom of it. *A floor mat had been placed along the wall on her left side. -The bed had been positioned up next to the wall with the floor mat on that side. *She had appeared to be able to move her head and left leg without difficulty, but no spontaneous movement of her arms, right leg, and upper torso to include her bottom was observed. *She made occasional and uncontrollable jerking movements of her upper torso. *There was a large pillow placed underneath both of her knees. -That pillow offered no pressure relief for both of her heels from the mattress. *Her right leg was contracted and had been pulled up towards the back of her thigh. -The inner aspect of her right heel and foot had been laying directly on the pillow. *She had a [DEVICE] with nutritional supplement [MEDICATION NAME] 1.2 infusing through it for nutritional support. Random observations on 12/10/19 from 8:01 a.m. through 11:10 a.m. of resident 1 revealed: *She had: -Been laying in bed and in the same position as observed above. -Moved her upper torso to the right and close to the edge of the bed. -Continued: --To move her left foot and leg up and down with the entire bottom of her foot on the mattress. --To have no pressure relief from the mattress for her coccyx, buttocks, and the heels of her feet. *Been awake and continued to respond in the same manner as above. Interview on 12/10/19 at 8:49 a.m. with certified nursing assistant (CNA) A revealed: *The residents had just finished breakfast, and the staff were busy bringing them back to their rooms. *She would let the surveyor know when they were ready to assist resident 1 with personal care and transferring. Observation on 12/10/19 at 11:14 a.m. with CNAs A and B with resident 1 revealed: *They had prepared to assist the resident with personal care and getting out of her bed. *CNA B had left the room to get a sling to use for transferring the resident and protective boots for both of her feet. -The resident had not been observed wearing those protective boots on her feet during the above three hour observation. *The resident had: -Been laying in the same position as in the above observations. -Been incontinent of urine. -Required the CNAs to assist her with bed mobility, positioning, incontinence care, personal hygiene, and dressing. -Required the use of a total body mechanical lift to transfer from her bed to the reclining wheelchair (w/c). *The CNAs: -Transferred the resident into her reclining w/c and put the protective boots on her feet. -Were not observed repositioning or providing personal care for the resident until three hours later at 11:14 a.m. Interview on 12/10/19 at 2:56 p.m. with CNA B regarding resident 1 revealed: *She confirmed: -The resident had been declining and having a hard time eating. -A [DEVICE] had been put in place due to her weight loss and the need for nutritional support. -She was at risk for skin breakdown and was to have been repositioned every two hours. *She stated: -When she first got the feeding tube it was continuous and she was in bed or in her room all the time. -They changed the times on it, so she can be out of bed more, otherwise she was in bed all the time. -She can be out and about some now and during meals. Observation on 12/11/19 at 8:55 a.m. of resident 1 with licensed practical nurse (LPN) C and CNA F revealed: *LPN C had prepared to administer medications through the resident's [DEVICE]. *She had been laying in the same position as observed on 12/10/19, but had scooted her upper torso to the right. *LPN C had CNA F assisting her with re-positioning her prior to the medication administration and on her right side. *She had been wearing an incontinent brief with the numbers 514 and staff initials handwritten on the front of it in black marker. -The lines on the incontinent brief were dark in color indicating incontinence of urine and possibly bowel movement. *After they had repositioned LPN C administered her medications through the [DEVICE]. *LPN C called for assistance from an unidentified CNA to move her onto her back again. *None of the staff had attempted to check and change her during both of those repositioning observations. Interview on 12/11/19 at 9:23 a.m. with LPN C regarding resident 1 and the above observations revealed: *She confirmed: -The numbers and initials on the resident's brief had been the last time she was checked, changed, and repositioned. -She was to have been checked, changed, and repositioned every two hours. -She was at high risk for skin breakdown and dependent upon the staff for assistance. *She stated: -When they check her and if she doesn't need changing they are supposed to draw a line through it and retime and initial it. -Yes, it appears as if she hasn't been moved or changed for four hours. -It did look like she was wet. -They are supposed to check on her more often then every two hours. *She had agreed that if it was not documented it was not done. Interview on 12/11/19 at 9:26 a.m. with CNA F regarding resident 1 and the above observation revealed she: *Confirmed and supported the interview with LPN C and stated: -Yes, I did notice that (regarding the time on her incontinent brief); that is so we know when to check her next. -This morning I haven't had time yet; we have been running around and busy. Review of resident 1's 12/10/19 and 12/11/19 turning and repositioning documentation by the direct care givers revealed: *On 12/10/19 she was checked, turned, and repositioned every two hours from 12:00 midnight through 6:00 a.m. -There was no documentation to support she had been checked, turned, and repositioned by the staff after 6:00 a.m. through 10:00 p.m. that night. *On 12/11/19 she was checked, turned, and repositioned every two hours from 12:00 midnight through 4:00 a.m. -There was no documentation to support she had been checked, turned, and repositioned after 4:00 a.m. through 9:26 a.m. Review of resident 1's 9/25/19 significant change in status MDS assessment revealed she: *Had an unstagable or deep tissue injury. *Was at risk for skin breakdown/injuries. *Had pressure relieving devices for her bed and w/c. *Had no repositioning program in place. Review of resident 1's Braden Scale for Predicting Pressure ulcers assessment score from 3/20/19 through 9/25/19 revealed: *On 8/7/19: -A Braden Scale assessment was completed with her quarterly MDS assessment. -Her score was an eleven indicating she was at high risk for skin breakdown. -That had been the only Braden Scale assessment completed on her between the above dates and assessments. *There had been no documentation to support any further Braden Scale assessments had been completed to support her level of risk for skin breakdown. Review of resident 1's comprehensive care plan revealed it had different initiation and revision dates for all the focus areas developed for her and revealed: *Focus area: Initiated on 4/20/17 and identified her at risk for developing pressure ulcers related to limited mobility, friction from loss of motor control, sitting up in w/c for long periods and refusing to lay down, and bowel/bladder incontinence. -Suspected Deep Tissue Injury 9/20/19. -Revision on 9/26/19. *Goals and interventions: Had been put in place to promote prevention and healing of wounds. -The staff were to have turned and repositioned her every two hours or more often as needed or requested. -She had a pressure relieving mattress and cushion for her w/c. -She was to have worn heel protectors when in bed and when up in the w/c. --Intervention: Initiated on 9/26/19 and was six days after the identification of the deep tissue injury to her right heel. *No further interventions were written for that right heel injury to promote the healing of it. Interview on 12/11/19 at 9:36 a.m. with the director of nursing (DON) regarding resident 1 revealed she: *Confirmed: -She was at high risk for skin breakdown and had a history of [REDACTED]. -She was dependent upon the staff to anticipate her needs and ensure all ADLs were completed to ensure no further skin breakdown had occurred. -The interview with LPN C and CNA F regarding the process for checking and changing residents. *Was not aware the staff were not following her plan of care to support the resident: -Was checked and changed every two hours to promote healthy skin. -Had been repositioned every two hours to ensure no further skin breakdown had occurred. *Stated: She should be checked on more frequently than that, she moves around a lot. *Would have expected the staff to reposition, check, and change the residents every two hours or more frequently. Interview on 12/11/19 at 4:33 p.m. with LPN D and RN [NAME] regarding resident 1 revealed: *They confirmed: -The pressure injury to her right heel. -She had acquired that would while receiving care in the facility. -She had been a significant change in condition for the worse prior to and after the [DEVICE] placement on 9/11/19. -The direct care givers used the care plans to guide them with care for all the residents. -She been staying in her bed for longer periods at a time since the placement of the [DEVICE]. *There was no certain team or person responsible for: -Identifying those residents who were at high risk for skin breakdown. -Implementing interventions to ensure pressure relieving measures were put in place for high risk residents. *They had used the Braden Scale assessment form and score for predicting those residents at risk for skin breakdown. -There was no formal process or policy in place to determine what interventions should have been used after those scores had been determined. *LPN D stated: -I try to do them (Braden Scale assessment) with each MDS and I'm not sure why I didn't with her. -I should have done one with her recent sig (significant) change. *They: -Were not aware the direct care givers had not been following the care plan to promote healthy skin and ensure no further skin breakdown occurred for her. -Agreed not all the interventions on the care plan had been implemented prior to her acquiring the pressure injury, and they should have been. -Had been reactive versus proactive when reviewing the care plan and putting some of the interventions in place. c. Review of the provider's revised 7/16/18 Pressure Ulcers/Skin Breakdown - Clinical policy revealed: *The nursing staff and Attending Physician will assess and document an individual's significant risk factors for developing pressure sore; for example, immobility, recent weight loss, and a history of pressure ulcer(s). *In addition, the nurse shall describe and document/report the following: -Resident's mobility status. -Current treatments, including support surfaces. *The physician will help the staff review and modify the care plan as appropriate, especially when wounds are not healing as anticipated or new wounds develop despite existing interventions. Review of the provider's revised (MONTH) 2013 Repositioning policy revealed: *The purpose of this procedure is to provide guidelines for the evaluation of resident repositioning needs, to aid in the development of an individualized care plan for repositioning, to promote comfort for all bed-or chair-bound residents and to prevent skin breakdown, promote circulation and provide pressure relief for residents. *Repositioning is a common, effective intervention for preventing skin breakdown, promoting circulation, and providing pressure relief. *Evaluation of a resident's skin integrity after pressure has been reduced or redistributed should guide the development and implementation of repositioning plans. -Such plans should be addressed in the comprehensive plan of care consistent with the resident's needs and goals. *Repositioning is critical for a resident who is immobile or dependent upon staff for repositioning. *Residents who are in bed should be on at least an every two hour (q2 hour) repositioning schedule. *If ineffective, the turning and repositioning frequency will be increased. *Review the resident's care plan to evaluate for any special needs of the resident.

Based on observation, interview, record review, and policy review, the provider failed to: *Implement interventions and update care plans for four of five sampled residents (8, 20, 27, and 36) who had a history of [REDACTED]. *Ensure gait belts were used appropriately to support safety during stand-pivot transfers for three of three sampled residents (6, 12, and 28). Findings include: 1. Review of resident 27's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *A Brief Interview for Mental Status (BIMS) assessment score was thirteen indicating she had good memory recall. *Her comprehensive care plan revealed: -She was at moderate risk for falls related to gait/balance problems, incontinence, history of falls at home, vision/hearing problem, and amputated toes. -She is independent with dressing, transfers, and toilet use, but might have needed one staff person assistance when incontinent. Observation and interview on 12/10/19 at 3:48 p.m. with resident 27 revealed: *She had been sitting slouched in her wheel chair (w/c) and leaning to the left. Her head and neck had been bent down looking at her lap. -Throughout the interview she would lift up her head to look at me. -She kept her left arm close to her left side and her left hand on her lap. -She used her right arm when she talked. *She commented she had fallen in the past. -She became unsteady at times with transfers and when going to the bathroom. -She had broken her wrist from a fall, but could not remember how that happened. -Her roommate helped her when she falls by alerting the nurse on duty . *She stated: One time I was trying to get my pullups on when I fell . I hurt my knee a little bit. I couldn't get up so my roommate got the nurse for me. Review of resident 27's interdisciplinary progress notes and occurrence reports from 4/24/19 through 8/9/19 revealed: *There had been a discrepancy on the amount and days of falls. *There had been no occurrence reports completed to support she had fallen on 5/28/19 and 12/8/19. *There had been no interdisciplinary progress notes completed to support she had fallen on 5/21/19. Review of resident 27's occurrence reports from 4/24/19 through 8/9/19 revealed: *On 4/24/18 (4/24/19) at 6:30 p.m. the charge nurse had documented: -Res (resident) stated she fell backwards on her bottom, and banged her right wrist and arm on the floor. -There was swelling and bruising of her wrist. -The physician was notified with orders given to have the resident seen in the hospital emergency room (ER). -The director of nursing (DON) and administrator had signed the report to support they had reviewed it. *The investigation report for the fall had been on the back of the initial occurrence report for 4/24/19. *The investigation report for the above 4/24/19 fall failed to have supporting documentation of: -The location of the fall. -Physical status (condition) of the resident at time of the fall. -The environmental status at the time of the fall. -A completed summary of the fall. -An action plan had been put in place to ensure no further falls with injury would occur. -A completed progress note. -A completed fall risk assessment tool. -Her care plan had been reviewed and updated after the fall. *On 5/17/19 at 3:37 a.m. the charge nurse had documented: -Res (resident) stated she was trying to get up from bed and thought w/c (wheel chair) brakes were on but one side was not a (and) slid to her bottom. -Unwitnessed fall. -No injury. -The DON had signed the report to support she had reviewed it. -The administrator had not signed the report to support she had reviewed it. -Care plan was reviewed on 5/17/19, and there were no changes implemented to ensure no further falls would occur. *On 5/21/19 at 9:37 p.m. the charge nurse had documented: CNA (certified nursing assistant) performing rounds opened door and noted res (resident) on the floor by bed. -No injury. -Summary revealed: Resident more incontinent since [MEDICATION NAME] d/c'd (discontinued). Resident fell while changing wet clothes. She refuses any toileting assistance. -Action plan: [MEDICATION NAME] restarted. -The DON had signed the report to support she had reviewed it. -The administrator had not signed the report to verify she had reviewed it. -There had been a date to support the fall had been documented in the care plan, fall risk assessment tool was completed, and the fall prevention care plan was reviewed. *The charge nurse had failed to: -Document in the resident's interdisciplinary progress notes. -Update her care plan of interventions to prevent further falling. *On 8/9/19 at 10:00 a.m. the charge nurse had documented: -Driver called nurse to room found resident lying on the floor on her back with her wheelchair tipped beside her. Resident stated she did not hit her head and that her back was hurting. No injuries noted. ROM (range of motion) within limits for resident. --Resident description: I was trying to get into my chair and tipped over and fell on my back. -Immediate action taken: ROM within limits for resident. Assist of two to get resident off of floor. Tried to check pupils and did not react to light. Notified (physician) and received order to send resident to hospital. -Unwitnessed fall. -Was taken to hospital. *The investigation report for the fall on 8/9/19 failed to support: -The DON had and administrator had reviewed the report. -An action plan had been put in place to ensure no further falls with injury would occur. -A completed progress note. -A completed fall risk assessment tool. -Her care plan had been reviewed and updated. *There was no documentation to support an occurrence report for the falls on 5/28/19 and 12/8/19 had been done. Review of resident 27's interdisciplinary progress notes from 4/24/19 through 12/8/19 revealed the following documented falls: *4/24/19: obtained a wrist fracture and was transported to hospital. *5/17/19: no injury. *5/28/19: no injury. *8/9/19: two episodes of unresponsiveness and had been transported to the hospital. *12/8/19: pain to her left hip. *No documentation was found to support the fall on 5/21/19 as described in the above occurrence report. Review of resident 27's fall assessments from 4/24/19 through 12/8/19 revealed: *Four of her falls had completed fall assessments documenting she went from a fall risk of fifty to a fall risk of eighty. *Her risk of falls had increased thirty points indicating her risk for falls had increased with each fall. Surveyor: Review of the Morse Fall Risk assessment revealed it was based upon Fall Risk Factors and it is more than a Total Score. Determine Fall Risk Factors and Target Interventions to Reduce Risks. Complete on admission, quarterly, at change of condition, and after a fall. The Morse Fall scoring was as follows: *High Risk 45 and higher. *Moderate Risk 25 to 44. *Low Risk 0 to 24. Surveyor: Review of resident 27's comprehensive care plan revealed: *Focus area last revised on 11/12/19 for falls: -I am moderate risk for falls r/t gait/balance problems, incontinence, Hx of falls at home, vision/hearing problem, amputated toes. I have history of finger fracture r/t falls. -That focus area had identified her falls for incidents on 8/9/19 and 12/8/19. *The provider failed to identify the following falls in her care plan: 4/24/19, 5/17/19, 5/21/19, and 5/28/19. *Goal with a revision date of 8/8/18 and a target date of 12/3/19: -I will be free of falls through the review date. *Interventions in place previous to the above mentioned falls were: -Anticipate and meet her needs, cue to lock w/c brakes for transfers and reach back for w/c arm when sitting down, ensure her call light is within reach, fall assessment after every fall and quarterly. Instruct resident to be sure that wheelchair is locked. Remind resident to ask for assistance when needed. *Interventions initiated between 4/24/19 to 12/8/19 with three new ones were: -5/17/19: Educate the resident/family/caregivers about safety reminders and what to do if fall occurs. Follow fall protocol. -11/12/19: W/C brakes checked and functional. *The provider failed to document in resident 27's care plan: - Four of the six identified falls. -Implement interventions for those four of six identified falls. *There had not been consistent documentation in the resident's care plan to identify interventions with each of her incidents noted above to protect her from future falls and possible injury. Interview on 12/11/19 at 2:00 p.m. with CNA F and CNA B regarding resident 27's falls revealed: *She was non-compliant with staff assistance. *She had told staff she did not need their help. *She had some incontinence. *She had many falls when she transferred herself. *They stated: We've tried putting her w/c far away, close, or lock the chair, and she gets mad. She doesn't want the wheels locked. We've tried everything. Interview on 12/11/19 at 2:08 p.m. with LPN C regarding resident 27 revealed: *She thought it had been a while since the resident had fallen. *The nurses did a follow-up report with falls. *She would: -Have assessed the resident's vitals and watched the resident. -Not have put any interventions in place to ensure the resident's safety from falls. Interview on 12/12/19 at 9:02 a.m. with resident 27 revealed: *She: -Falls, because she has [MEDICAL CONDITION]. -Falls when she transfers from her bed to the w/c or w/c to her bed. -Said she had a hard time balancing. *Her [MEDICAL CONDITION] medication had been lowered due to a past stroke, and she had gotten worse since that time. *She would be okay with staff standing next to her while transferring, but she does like to do things by herself. *She demonstrated properly how to lock her w/c breaks. Interview on 12/12/19 at 9:26 a.m. with CNA/restorative aide (RA) C regarding resident 27 revealed: *The medical record personnel or the DON would inform the RA what new changes to implement in the resident's restorative program. *The resident had a restorative program in place for her. -She had sometimes refused to do the restorative program. *There was no documentation in her care plan to support she had refused restorative services. Interview on 12/12/19 at 11:11 a.m. with LPN K revealed: *When a resident fell the nurse would do an assessment, call the physician, family, and DON. -The administrator would fill out an incident report. -The care plan would be checked to see if there would be anything else the staff could do to prevent future falls. *The majority of resident 27's falls had been when she would: -Attempt to transfer herself. -Stand up to look for something, and the w/c would roll away from her. -Not lock her w/c brakes. -Transfer herself during the night. *She identified one intervention for resident 27: -We make sure she has her shoes on. *She was not aware of any recent changes in her interventions for falls. *There was no documentation or intervention in her care plan to support making sure her shoes were on. 2. Review of the provider's occurrence reports for resident 20 revealed she had unwitnessed falls on 7/4/19, 7/14/19, 10/27/19, and 11/22/19. She had one witnessed fall on 7/17/18. The occurrence reports had action plans as follows: *On 7/4/19 at 9:00 p.m.: -She fell while trying to plug in her cell phone. Action plan Care plan review. Isolated incident. will cont (continue) to encourage her to use call light for help. *On 7/14/19 at 11:05 p.m.: -She fell after using the bathroom without assistance. Action plan Will monitor resident on ATB's (antibiotics) and added 1 assist with toileting to CP (care plan) with gripper socks at night if another fall occurs. *On 7/17/19 at 6:50 a.m.: -She was assisted to the floor after slipping in the tub room. Action plan Care plan reviewed with no new interventions. *On 10/27/19 at 11:40 p.m.: -She was found on the floor while trying to walk to the bathroom. There was no action plan documented. *On 11/22/19 at 9:00 p.m.: -She was found on the floor in her room. She had stated she had tried to get a blanket off the top of the closet. Action plan: none documented. That fall did result in a major injury of a fractured pelvis and on 12/5/19 after complaints of left shoulder pain was found to have a left scapula displacement. Review of the occurrence reports revealed all of the above unwitnessed falls occurred after 9:00 p.m. No interventions had been initiated related to the times her falls took place. There was no documentation of her hourly checks having been performed. Review of resident 20's 10/25/19 care plan revealed: *Focus area that included: I am at risk for falls r/t Gait/balance problems, incontinence, Unaware of safety needs. Vision/hearing problems, hx of falls at home, walks to her bathroom using the walls in her room. *Goal of: I will not sustain serious injury through the review date. *Interventions prior to the 11/22/19 fall included: -Be aware that resident will seek out staff members at nurse desk or passing by instead of using call light so anticipate needs. -Call placed to Dr. (name) office to check if eligible for a new pair of Rx (prescription) glasses. Won't be eligible for new pair for 2 months. Did give quote for new pair. -Fall assessment after every fall and prn (as needed). -Follow facility fall protocol. --Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. -The resident needs a safe environment with: even floors free from spills and/or clutter; adequate, glare free light, a working and reachable call light, the bed in low position at night personal items within reach. *Interventions after the 11/22/19 fall included: -Do not place blankets or other items on top of resident's closet due to fall risk. -Ensure she is wearing skid shoes when mobilizing in w/c. -Hourly fall/safety rounds. -New w/c with anti-roll back brakes, anti-tips rollers (when available). -Skid proof strip by bed, closet and bathroom (when available). -Toileting schedule: 2 staff assist with stand lift to take resident to the toilet every 3 hours until bedtime. Then check and change during the night. Review of resident 20's fall risk assessments completed after each of the above falls revealed her score was 75. 3. Observation on 12/10/19 at 9:30 a.m., at 11:30 a.m., and at 1:30 p.m. revealed resident 36 was seated in a geriatric w/c in her room. She had been placed in front of her television that was on. She moved her right leg on and off the foot rest of the chair. She also leaned towards her right side. Staff were noted in the hall but did not go into her room until she was assisted to lunch. She had not been repositioned until after lunch when she had been laid down in her bed. Review of the provider's occurrence reports for resident 36's she had unwitnessed falls on 1/21/19, 4/17/19, 5/18/19, 10/22/19, and 11/7/19. She had witnessed falls on 1/29/19, 2/13/19, 3/8/19, 3/16/19, 6/15/19, 6/28/19, and 8/18/19. The following revealed: *On 1/21/19 at 4:50 p.m.:-She had a fall out of her wheelchair after her had family has left after their visit. Action plan: Make sure wheelchair pedals are on chair at all times. Bring resident to nurses station when family leaves. *On 1/29/19 at 7:10 p.m.: -She had a fall out of her wheelchair in front of the nurses' station. Her brakes on the w/c had been locked, and she had been trying to move herself forward. She had slipped out of the w/c onto the floor. Action plan: RA (restorative aide name) fastened cushion to seat with velcro, cont (continue) with skid proof pad. Trial taking pedals off when stationary. Do not lock w/c (wheelchair) brakes. Reposition her back into w/c if sitting close to edge. *On 2/13/19 at 5:20 p.m.: -She had a fall when attempting to self-transfer herself. Action plan: Resident will not be left unattended where she can attempt to transfer self. *On 3/8/19 at 9:30 a.m.: -She had a fall when she had slid out of her w/c while moving the w/c with her feet. Action plan: Safety checks to ensure proper positioning in wheelchair. *On 3/16/19 at 5:30 p.m.: -She had a fall when she had stood up and tried to sit back down and her w/c rolled back. Action plan: None noted. *On 4/17/19 at 7:07 a.m.: -She had a fall when she attempted to stand up while holding the hall rails. Action plan: None noted. *On 5/18/19 at 10:30 a.m.: -She had a fall when she apparently fell out of her bed. The care plan was reviewed with no changes. *On 6/15/19 at 8:50 a.m.: -She had a fall from her w/c. Action plan: Re-educate about the possibility of slipping out of the w/c if a disposable pad had covered the sticky mat placed on the w/c cushion. *On 6/28/19 at 7:00 p.m.: -She had a fall after she had stood up out of her w/c in the common area. Action plan: Monitor her when near handrails and redirect her. *On 8/18/19 at 8:55 a.m.: -She had a fall when she attempted to pull herself up behind the nurse's desk. Action plan: None noted. *On 10/22/19 at 1:30 p.m.: -She had been discovered on the floor outside of her room. No interventions had been documented. *On 11/7/19 at 5:33 p.m.: -She had been discovered on the floor in her room. No interventions had been documented. Review of resident 36's revised on 11/12/19 fall care plan revealed: *Focus: I am at high risk for falls, r/t (related to) balance problems, incontinence, unaware of safety needs. hx of falls at home (10/16/18). -All of the above falls had been included in the focus area. *Goals: -I will be free of falls through the review date. Review date 12/18/19. -I will not have any further falls from sliding out of my w/c thru (through) next review date. Review date 12/18/19. *Interventions initated included: -Anticipate and meet the resident's needs, initiated 11/6/18. -Be aware resident does not use her call light, initiated 1/31/19. -Fall assessment after every fall and prn (as necessary), initiated 11/12/19. -Follow facility fall protocol, initiated 12/24/18. -Monitor that resident does not get tangled up with her call light, initiated 11/7/18. -Place her in a room near the nurses desk, initiated 11/7/18. -The resident needs a safe environment with: room free of clutter, night light on, dry floor, bed in low position at night, position her in the middle of her bed. ,initiated 11/6/18. -Transfer her with a full body lift with the assistance of two staff, initiated 11/15/19. -Use geriatric chair for all mobility, initiated 11/15/19. Review of resident 36's interdisciplinary progress notes revealed that on 11/12/19 her left hip was discovered to have been fractured during the fall on 11/7/19. Review of resident 36's Morse fall assessments for the above falls revealed she was at high risk. Her score was seventy five. 5. Review of resident 8's 9/27/19 MDS assessment revealed he: *Was admitted on [DATE]. *Had a BIMS score of thirteen meaning his cognition was intact. *Required extensive assistance of two staff for bed mobility, transfers, and use of the toilet. *Was frequently incontinent of urine and bowel. *Had not been on a toileting program. *Used a wheelchair to get around the nursing home. *had a history of [REDACTED]. Review of resident 8's medical record revealed he had fallen on the following dates: *5/3/19, no injury. *5/6/19, no injury. *7/13/19, major injury of a broken left fifth finger. *9/11/19, no injury. *9/13/19, no injury. *9/16/19, with injury. Review of the fall incident reports revealed:. *No incident report had been completed for the 9/11/19 fall. *Of those completed incident reports the summary and action plan areas had been left blank or had recommended to continue with current interventions, to praise him for using his call light, and place his bed in an optimal position. Review of resident 8's 10/9/19 care plan revealed the following interventions: *Check him every thirty minutes. *Anticipate and meet the his needs. *Call light within reach and encourage him to use it. Prompt response to all requests for assistance or he will transfer himself. *His bed was to be in the lowest position and against the wall. *Encourage him to participate in activities that promote exercise and physical activity to improve strength and mobility such as group exercise. *He should have had appropriate foot-wear or non-skid socks for transfers and using his w/c. *Fall assessment after every fall and quarterly as needed. *Follow facility fall protocol. *Review information of past falls and attempt to determine cause of falls. Record possible root causes. Alter or remove any potential causes if possible. Educate resident, family, caregivers, interdisciplinary team as to causes. *Floors free from clutter and spills, adequate and glare free lighting, working call light, and personal items within reach. *Trial self-releasing seat belt in w/c. *A urinal was to have been available for the resident to use while in bed and emptied every shift and as needed. *The care plan had not been revised with interventions that were effective in reducing his falls. Interview on 12/12/19 at 8:41 a.m. with resident 8 revealed: *He had not had a urinal provided to him. *The CNAs had not lowered his bed to the lowest position when they had put him in bed. *The CNAs had not checked on him every thirty minutes. Interview on 12/12/19 at 8:53 a.m. with CNA I and CNA G regarding resident 8 revealed: *He had not had or used a urinal and preferred to get up and use the restroom. *When he needed to use the restroom he pushed his call light for assistance or would yell at someone when they walked by . *His bed was not put in the lowest position, because they thought he would fall out of bed more often if it was that low. -They had positioned the bed up or down before they left the room when they assisted him into it. *When changes were made to the care plan the nurses would inform them. -The changes would be put onto their pocket care plans. *Confirmed he had not been monitored every thirty minutes. *He was checked often, but they did not chart when they checked on him. *They were not aware a urinal should have been available for him in his room, that his bed should have been in the lowest position, or that he was on thirty minute checks. Observation on 12/12/19 from 1:35 p.m. through 4:16 p.m. revealed resident 8 resting in bed with it in a raised position without a urinal next to him. Interview on 12/12/19 at 4:43 p.m. with the DON and the administrator regarding resident 8 revealed they: *Were aware he had several falls but did not know several interventions had not been followed by the CNAs. *Were aware falls were an issue at the nursing home and had put a performance improvement plan (PIP) in place to address it. *They planned to improve their root cause analysis and work on making investigations more complete. *Agreed it was their responsibility to ensure the safety of the residents. Surveyor: Interview on 12/12/19 at 9:45 a.m. with RNs K and L regarding the process completed after a resident's fall or incident revealed they stated they were to: *Assess the resident's for injuries and complete their vital signs. *Assist off the floor if able to unless there was a noted injury or fracture. *Contact the physician, administrator, DON, and family. *Document in the risk management portion of the electronic medical record (EMR) and fill out the information needed. That report did not show up in the progress notes section. *A Morse fall assessment was completed after each fall. *Some of the night nurses still used the paper occurrence report. Surveyor: Interview on 12/12/19 at 1:22 p.m. with the social service designee (SSD), DON, LPN D, and administrator revealed: *The charge nurse would fill out the front of the occurrence reports and have an immediate intervention on the twenty-four hour report sheet. -Some charge nurses would put the intervention on the care plan and some would not. -It was expected for the charge nurse to call the DON or administrator when there was a fall but that was not always done. -They had started a weekly risk meeting a few months ago where they talked about falls. -They had discussed falls at quality assurance performance improvement (QAPI) meetings. -RN [NAME] had been doing audits on fall incidents since (MONTH) 2019. *Their process for the occurrence reports had been as follows: -The charge nurse would fill them out and put them in a basket. -The medical record personnel would log them into the computer. -The DON used to be the one that would go into the log and look at the incidents, but that process had changed and the medical record personnel did that. -There was no time-frame or process in place for the medical record personnel to follow to ensure the logging/inputting of those incidents was completed in a timely manner. *They confirmed they: -Had not known when or if the occurrence reports for the above incidents for resident 27 were reviewed once they were put into the basket and logged. -Had done fall audits but not a root cause analysis or tracking and trending of the residents' falls. -Had not done enough interventions to protect resident 27 from future falls. -Had not updated resident 27's care plan in a timely manner to reflect the current care and services she required for her safety. Interview on 12/12/19 at 3:10 p.m. with RN [NAME] revealed she: *Had been doing audits on their fall occurrences since (MONTH) 2019. *Had not done anything with those audits. *Stated, You can do all the audits you want, but if you don't do anything about them they are no good. *Had not completed any audits on the fall occurrences for (MONTH) 2019. Surveyor- Interview on 12/12/19 at 4:00 p.m. with the DON and LPN/MDS (Minimum Data Set) coordinator D revealed: *The fall assessments were not always completed correctly. *The nurses should have completed those assessments accurately and changed the care plan to reflect the needs of the resident. *Not all of the interventions initiated were appropriate for all residents. *LPN/MDS coordinator D updated the majority of the care plans. *The CNAs were able to see all the interventions in place in the EMR. *They were aware of the amount of falls that had happened and those with major injury to the residents. *There had been no tracking or trending of when falls had happened. Review of the provider's revised (MONTH) 2012 Falls-Clinical Protocol policy revealed: *Assessment and Recognition. -6. The staff will evaluate and document falls that occur while the individual is in the facility. *Treatment/Management. -1. Based on the preceding assessment, the staff and physician will identify pertinent interventions to try to prevent subsequent falls and to address risks of serious consequences of falling. - 2. If underlying cause cannot be readily identified or corrected, staff will try various relevant intervention, based on assessment of the nature or category of falling, until falling reduces or stops or until a reason is identified for its continuation. Review of the provider's revised (MONTH) 2010 Assessing Falls and Their Causes revealed: *Identifying Causes of a Fall or Fall Risk: -1. Within 24 hours of a fall, the nursing staff will begin to try to identify possible or likely causes of the incident. -5. Completion of a falls risk assessment. (MORSE Fall Risk Assessment tool.) -6. Appropriate interventions taken to prevent future falls. 5. Observation on 12/10/19 at 9:40 a.m. of CNA A with resident 12 revealed: *She had been sitting in her w/c and was ready to lay down on her bed. *She required the CNA to assist her with transferring from one surface to another. *The CNA had prepared to assist her with a stand-pivot transfer and laying down on her bed. *During that transfer the CNA had: -Wrapped her arms underneath the resident's shoulders and clasped her hands together. -Pulled her up off the w/c by applying pressure on her shoulders, pulling her forward, and turning her to sit down on the bed. -Not attempted to use a gait belt to ensure a safe transfer had occurred for the resident. *There had been a gait belt hanging on the towel bar in the resident's bathroom. -That gait belt was easily accessible by the CNA and had been available for use. Continued observation on 12/10/19 at 11:09 a.m. of CNA A with resident 12 revealed: *She had been ready to get out of the bed and sit in her w/c. *CNA A: -Assisted her with personal care, sat her on the edge of the bed, and prepared her for a stand-pivot transfer. -Assisted her with a stand-pivot transfer from her bed into the w/c in the same manner as observed above. *A gait belt continued to hang on the towel bar in the resident's bathroom and was available for the CNA to use to ensure a safe transfer had occurred. 6. Observation on 12/19/10 at 10:10 a.m. of CNAs A and B with resident 6 revealed: *The resident had been laying on her bed and requested assistance to go to the bathroom. *The CNAs assisted her with transferring from one surface to another. *During that transfer the CNAs had: -Placed their arms underneath her shoulders, pulled up on them and the back of her pants, and assisted her into the w/c. -Not attempted to use a gait belt to ensure a safe transfer had occurred for the resident. *After they assisted the resident in the bathroom she had requested to lay back down on her bed. *The CNAs transferred the resident from her w/c onto the bed in the same manner as observed above. *Two gait belts had been hanging from a rack on the wall by the gloves and were available for use to ensure a safe transfer had occurred for the resident. Interview on 12/11/19 at 8:36 a.m. with CNA B regarding the process they used to complete stand-pivot transfers revealed: *She confirmed: -They should have used the gait belts to ensure the resident's safety from injury to their shoulders had occurred. -That was their policy, and it should have been followed. Surveyor: 7. Observation on 12/10/19 at 11:05 a.m. of resident 28 while CNA B assisted her to transfer from the bed to her w/c used a one person Hug pivot transfer to the w/c. A gait belt had not been used. Resident 28 had put her arms around CNA B's neck during the transfer. She was able to bear approximately 50 percent of her weight. Surveyor 8. Interview on 12/11/19 at 9:30 a.m. with LPN C revealed: *The staff should have used gait belts with all stand-pivot transfers. *She: -Was aware the staff had not been using the gait belt with stand-pivot transfers. -Stated: Even if you say something to them it won't change anything. -Agreed it was a safety concern for the residents, and it had put them at risk for an injury due to the amount of pressure put on their shoulders. Interview on 12/11/19 at 9:36 a.m. with the DON regarding the above observations revealed: *She confirmed the staff were to be using gait belts during stand-pivot transfers. *That process would have ensured the resident

Based on interview, plan review, and review of the roles of the quality assurance performance improvement (QAPI) members, the provider failed to ensure an effective QAPI program had been implemented and followed. Findings include: 1. Interview on 12/12/19 at 4:34 p.m. with the administrator and the director of nursing revealed: *The committee met monthly and members signed an attendance sheet. *The administrator and all of the department heads were to meet monthly. -Some of the meetings had been missed when the administrator went on maternity leave. *The medical director attended at least quarterly. *The pharmacist had not attended, but they planned to make that happen. *They used past deficiencies as ideas for performance improvement plans (PIP). *They had PIPs in place for hand hygiene and falls. *They had made benchmarks for the PIPs at 100% and were never able to meet those goals. *Resident's grievances were going to be the next PIP they implemented. *They had recognized residents' falls as a problem eight months ago, but they had not made progress with that PIP. *They had not realized there was a problem with lack of documentation and investigation of resident's falls. *Recent leadership changes had been a problem which resulted in a lack of consistency. *They agreed they did not have a good system in place for correcting problems within the facility. *They confirmed the QAPI program in place was not good, and they planned to work on it. The latest QAPI plan provided to the survey team was reviewed in (YEAR). They had not developed any new QAPI plan. Surveyor: Interview on 12/12/19 at 10:00 a.m. with the administrator revealed: *The medical director was involved in QAPI. He came to the meetings on a quarterly basis. *She would give him pertinent information regarding problems every month when he came to do rounds. *The governing board was provided information from the QAPI meetings that was pertinent. She did not go over the entire QAPI minutes with them. Interview on 12/12/19 at 10:30 a.m. the licensed practical nurse/Minimum Data Set assessment coordinator D revealed: *There had been audits completed since the same deficiency for falls had been received a couple of years ago. *She has been doing an audit of all occurrence reports on a monthly basis, and then they were given to the QAPI committee. *They had never been able to meet their benchmark ever. *She thought the benchmark was to achieve 90+% compliance. 2. Review of the provider's revised (MONTH) 2014 QAPI committee roles revealed: *QAPI coordinator: -Planning, developing, organizing, implementing, coordinating, and directing the QAPI Program, in accordance with current rules, regulations, and guidelines that govern the long-term facility. -Evaluating programs and effecting changes as necessary to improve programs and assuring compliance with regulatory requirements. -Helping to identify quality areas that are appropriate for performance improvement projects. -Assisting in monitoring PIPs (performance improvement projects) and reporting the outcomes to the QAPI committee. *Medical staff duties and responsibilities: -Quality of care issues, policy, and procedural matters, will be referred to the appropriate departments for investigation, discussion, and possible action. Some if the ways in which the medical director and medical staff will perform quality of care functions included: -Review of minutes of the facility's QAPI Committee meeting for items which need follow-up, medical consideration, further investigation, referral, or new policies or procedures. *Director of nursing services: -Developing, implementing, and maintaining an ongoing QAPI Program for the Nursing Service Department. -Developing methods for coordinating nursing services with other resident services to ensure the continuity of the residents' total regiment of care. -Reviewing nurses' notes to determine if the care plan is being followed. *Social services director: -Performing administrative requirements, such as completing necessary forms, reports, etc., and submitting such to the Administrator as required. -Assisting the QAPI Committee in developing and implementing appropriate plans of action to correct identified deficiencies.

Based on observation, interview, record review, and policy review, the provider failed to report and investigate: *A staff-to-resident altercation to ensure verbal and psychological abuse had not occurred for one of one sampled resident (22) by one of one licensed practical nurse (LPN) (J). *Falls with major injury for two of five sampled residents (1 and 27). Findings include: 1. Review of resident 22's medical record revealed: *An admission date of [DATE]. *Her [DIAGNOSES REDACTED]. *She had a Brief Interview for Mental Status (BIMS) assessment score of fifteen indicating she had good memory recall. *She was independent with all activities of daily living (ADL) except for showering where she required the help of one staff member. *She used a wheelchair (w/c) to meet all of her mobility needs. Review of resident 22's interdisciplinary progress notes for [DATE] revealed: *Licensed practical nurse (LPN) K had documented: -At 7:00 a.m.: --Resident states she had 6 loose stools already today --[MEDICATION NAME] suspension 30cc (cubic centimeter) given. -At 12:16 p.m.: Resident continues to complain of diarrhea. Has had since the 5th. This morning resident stated that she had 6 loose stools this morning. Gave resident [MEDICATION NAME] this morning per standing orders. Gave applesauce, toast and tea for breakfast. Again at lunch had applesauce, toast, tea and banana. Gave [MEDICATION NAME] again around 9 am. Stated that it is better after second dose and light diet. Notified (physician name) of resident's concerns. Asked if she was running a temperature and resident had 97.4 temp. No other complaints voiced. No further orders from (physician name). Observation and interview on [DATE] at 8:21 a.m. with resident 22 revealed: *She had been in her room watching TV and sitting in a w/c. *Her room had: -Two beds with one of them unoccupied. -Many decorations and personal belongings in it. *She stated: -I've been here a long time. -I make my own choices, and I'm independent with taking care of myself. *As we talked her voice became low, and she looked away from me. -She stated: -I don't know if I should tell you this but, a nurse made me do something I did not want to do. -I had diarrhea one night and she didn't believe me that I was having diarrhea. -I asked for [MEDICATION NAME]. -She told me to leave it (diarrhea) in the stool and the next time she would check it out. -I had another diarrhea, so I left it in the toilet and turned my light on. -I waited and waited, and finally I just flushed it. -Then I went again and peaked at her, and yelled at her, but she wouldn't come down, so I flushed it. -She finally came down to my room and told me to take a picture of it the next time. -I had a new phone and didn't know how to use it, so this other aide that answered my call light showed me how to use it. -I took a picture of it and told her to show it to the nurse. -(LPN J) thought it was funny that I took a picture of it. -She was laughing about it to (LPN K). -(LPN K) got upset that she was making fun of me and reported it to the director of nursing (DON). -Then they talked to me and said they would talk to her. -I haven't seen her lately, and I don't know what happened to her. -That happened last month. -She was a night nurse. *She paused, stopped talking, and with downcast eyes and a frown on her face she continued to state: -(LPN J), I thought it was permitted for her to come in here to sleep in the bed and watch my TV. -I told the DON, and that was when I found out that she was not supposed to do that. *She further confirmed she was aware that nurses should not be sleeping when on duty, and they should not make residents take pictures of their own bowel movement. *Other certified nursing assistants (CNA) would come and get LPN J when a resident needed her. *She stated it worried her that other residents might need LPN J while she was in her room sleeping. *She went to nursing school with LPN J a long time ago. Further review of resident 22's medical record revealed there was no documentation to support: *A complete and thorough investigation had been completed on the above incident and concern that was reported by the resident involving LPN [NAME] *The administrative staff had investigated that concern to: -Ensure no verbal and psychological abuse had occurred. -Support there was no instability of the resident's mental health and well-being. -Ensure the safety for all the residents in the facility. *A report of that incident had been completed and submitted to the South Dakota Department of Health (SD DOH) per their requirements. Refer to F600, finding 1. 2. Review of resident 27's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *A Brief Interview for Mental Status (BIMS) assessment score was thirteen indicating she had good memory recall. *Her comprehensive care plan revealed: -There were several initiation and revision dates. -She was at moderate risk for falls related to gait/balance problems, incontinence, history of falls at home, vision/hearing problem, and amputated toes. -She was independent with dressing, transfers, and toilet use, but needed one staff person to assist her when incontinent of bladder and/or bowel. Observation and interview on [DATE] at 3:48 p.m. with resident 27 revealed: *She had been sitting slouched in her wheel chair (w/c) and leaning to the left. Her head and neck had been bent down looking at her lap. -Throughout the interview she would lift up her head to look at me. -She kept her left arm close to her left side and her left hand on her lap. -She used her right arm when she talked. *She commented she had fallen in the past. -She became unsteady at times with transfers and when going to the bathroom. -She had broken her wrist from a fall, but could not remember how that happened. -Her roommate helped her when she falls by alerting the nurse on duty . *She stated: One time I was trying to get my pullups on when I fell . I hurt my knee a little bit. I couldn't get up so my roommate got the nurse for me. Review of resident 27's following interdisciplinary progress notes revealed: *On [DATE] at 6:18 p.m.: LPN C had documented: -Resident found in room lying on the floor by 110-A's bed. Stated she fell backwards on her bottom and banged her right wrist and arm. C/o (complaining of) a lot of pain in her right wrist arm and her left leg also. Ice pack applied. (Physician) notified and he ordered her to be sent to the ER (emergency room ). Will send to (hospital). (Physician) was notified at 1835 (6:35 p.m.), 911 was call at 1830 (6:30 p.m.), (administrator) called with no answer at 1850 (6:50 p.m.). Resident's sister was notified at 1855 (6:55 p.m.). Ambulance was here at 1856 (6:56 p.m.). (Hospital) ER was notified of resident leaving here and going to their facility at 1855 (6:55 p.m.). (DON's name) DON (director of nursing), was apparently notified by CNA (certified nursing assistant) via text. *On [DATE] at 2:15 a.m.: LPN J had documented: -(Hospital) did call at 9:05 p.m. stating that she is discharged and does have a fractured wrist and a splint was applied. *On [DATE] at 10:39 a.m.: LPN K had documented: Driver called nurse to room Found resident lying on the floor on her back with her wheelchair tipped beside her. Resident stated she did not hit her head and that her back was hurting. No injuries noted. ROM (range of motion) within limits for resident. Tried to check resident's pupils and they were pinpoint and did not react to light. Resident stated that she was trying to get into her chair and lost her balance and tipped over along with her wheelchair. Resident very confused today. Stated that she fell and broke her salt and pepper. Was unresponsive after getting her up into her wheelchair for a few seconds twice before being sent to hospital. Ambulance here at 1025 (10:25 .am.) to take resident to (hospital). Had received order from (physician) to send resident to (hospital) for evaluation. Notified (DON's name) DON, tried to notify family and phone was out of service. (administrator) CEO notified. Review of resident 27's occurrence reports from [DATE] and [DATE] revealed: *On [DATE] ([DATE]) at 6:30 p.m. the charge nurse had documented: -Res (resident) stated she fell backwards on her bottom, and banged her right wrist and arm on the floor. -The resident had been injured with swelling and bruising of her wrist. -The physician was notified with orders given to have the resident seen in the hospital ER. -The DON had signed the report on [DATE] at 9:46 a.m. to support she had reviewed it. -The administrator had signed the report on [DATE] at 9:45 a.m. to support she had reviewed it. *The investigation report had been located on the back of the initial occurrence report form. *The investigation report for the fall on [DATE] failed to support: -The location of the fall. -Physical status at time of the fall. -The environmental status at the time of the fall. -A completed summary of the fall. -An action plan had been put in place to ensure no further falls with injury would occur. -A completed progress note. -A completed fall risk assessment tool. -Her care plan had been reviewed and updated -That it had been reported to the SD DOH. *On [DATE] at 10:00 a.m. the charge nurse had documented: -Driver called nurse to room found resident lying on the floor on her back with her wheelchair tipped beside her. Resident stated she did not hit her head and that her back was hurting. No injuries noted. ROM within limits for resident. --Resident Description: I was trying to get into my chair and (it) tipped over and (I) fell on my back. -Immediate action taken: ROM within limits for resident. Assist of two to get resident off of floor. Tried to check pupils and did not react to light. Notified (physician) and received order to send resident to hospital. -Un-witnessed fall. -Resident was taken to hospital. *The investigation report for the fall on [DATE] failed to support: -The DON and administrator had reviewed the report. -An action plan had been put in place to ensure no further falls with injury would occur. -A completed progress note. -A completed fall risk assessment tool. -Her care plan had been reviewed and updated. -Her incident had been reported to the SD DOH. Interview on [DATE] at 2:50 p.m. with LPN D and the DON regarding resident 27 revealed they: *Were unable to provide documents the above incidents were reported to the SD DOH. *The DON stated: -Why did we not do a state report? -Myself, (administrator's name), or (LPN D's name) would be the ones to file a report to the state agency when there is a reportable. Interview on [DATE] at 1:22 p.m. with the administrator, DON, social service designee (SSD), and LPN D revealed: *The staff were supposed to call the DON or administrator with residents' falls. -That had not always happened. *They used the algorithm from the state to determine what was reportable to the SD DOH. *They confirmed they should have reported to the SD DOH when someone had an injury from a fall and/or if they went unconscious. *The DON confirmed: -There was no documentation to support the resident's fall with fracture and a fall with an episode of unconsciousness had not been reported to the SD DOH. -Both of those falls should have been reported to the SD DOH. 3. Observation on [DATE] at 8:01 a.m. of resident 1 revealed: *She had been: -Laying in her bed resting. -Positioned on her back with pillows placed on each side of her. -Awake and attempted to talk to the surveyor when spoken to. -Able to mouth the word yeah when asked a question. *Her: -Bed had been put in the low position. -Mattress had built-up edges on the top and bottom of it. *A floor mat had been placed along the wall on her left side. -The bed had been positioned up next to the wall with the floor mat on that side. *She had appeared to be able to move her head and left leg without difficulty, but no spontaneous movement was observed of her arms, right leg, and upper torso including her bottom. *She made occasional and uncontrollable jerking movements forward of her upper torso. *There was a large pillow placed underneath both of her knees. *Her right leg was contracted and had been pulled up towards the back of her thigh. *There had been a reclining wheelchair (w/c) on her side of the room. Review of resident 1's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had: -Been alert and able to mouth the words yeah or no to simple questions asked of her. -Not been interviewable and was unable to make her needs known. -Been dependent upon the staff to assist her with all activities of daily living (ADL), such as bed mobility, positioning, and transfers. -Been dependent upon the staff to anticipate her needs and develop a plan of care with goals and interventions put in place to support those needs. -Not been able to walk and required the use of a w/c. -A history of falls either out of her bed or the w/c. *A progressive decline in her health due to a specified disease process. Review of resident 1's [DATE] quarterly Minimum Data Set (MDS) assessment, Section J, Health Conditions, revealed she had a history of [REDACTED]. One of the those falls had resulted in a major injury. The MDS assessment had been completed after her fall on [DATE] that had required her to be seen by the physician at the hospital. Review of resident 1's [DATE] interdisciplinary progress notes revealed: *At 1:12 p.m.: -LPN K had documented: Resident was in her wheelchair. Was being taken out of dining room. did not have her wheelchair reclined. Jerked and toppled forward onto the floor hitting her head on the right side. Has small cut on upper right forehead and large hematoma. Was unresponsive for approximately 3 minutes. Pupils did react equally to light. Placed ice on hematoma. Assist of 4 to carry resident to her room and put her to bed. Was responding by the time we got her to her room. Small amount of bleeding noted from wound. Has scrape on left knee. Resident was able to respond to this writer. Notified (doctor) and received order to send resident to the ER to be evaluated. Notified (DON), (administrator), and her brother. Received call from her daughter asking about her condition. Stated that she had heard that her mother had died . Informed her that she was not dead and and that we had sent her to the ER to be evaluated. -At 6:27 p.m. LPN K had documented: Resident returned from (hospital name). No new orders. We are to watch for vomiting, unequal pupils, unusual drowsiness. Resident already has history of headaches and be on Topomax for her headaches. Resident in good spirits and took medication well. Was smiling when she returned. did have CT of the head done while in (hospital). Called (hospital) to get report for the CT. they did not have final report yet and will send when they get it. Interview on [DATE] at 4:38 p.m. with the DON regarding resident 1 revealed: *She had confirmed the resident had a history of [REDACTED]. *She was not aware of any falls with a major injury. *A request was made to see all of the resident's occurrence reports that had been reportable and non-reportable for the past six months. Interview on [DATE] at 4:45 p.m. with the DON and administrator regarding resident 1 revealed they: *Had provided three occurrence reports of falls the resident had during the past six months. -One of those reports had been her fall on [DATE] that had required her to be seen by a physician at the hospital in the ER. *Were not able to locate any other occurrence reports on the resident that had required reporting and submission to the SD DOH for the past year for her. *The administrator stated: She has not had any reportable incidents for a while, there are none for this past year. Review of resident 1's [DATE] occurrence report revealed: *Resident was in wheelchair. jerked forward and landed on her face, knocked off her glasses. Has small cut on rt (right) side forehead and large hematoma. Has scrap on left knee. Was unresponsive for 3 minutes. Pupils equal and reactive to light. CNA did try to catch resident before she fell . *They had applied ice to the hematoma. *The physician had been notified with orders received to take the resident to the hospital for further evaluation. *On [DATE] both the DON and administrator signed the document to support they had reviewed it. Interview on [DATE] at 3:02 p.m. with the DON regarding resident 1 revealed she: *Confirmed the resident had: -A fall on [DATE] out of her w/c and onto her face. -Been unresponsive for a short period of time, and when the physician was notified he gave LPN K orders for the resident to be seen in the ER for further assessment. *Agreed the fall on [DATE] should have been reported to the SD DOH due to the injury and ER visit. *Stated: -I have no reason why a report was not completed and sent in. -Either myself, (LPN D), or the administrator do them, and we were here that day. Interview on [DATE] at 4:11 p.m. with LPN D regarding resident 1 and her fall on [DATE] revealed: *Confirmed and supported the above interview with the DON. *Stated: -I don't know why we didn't do a reportable on that fall. -We should have, we were all here that day. Review of the provider's (MONTH) (YEAR) Accidents and Incident-Investigating and Reporting policy revealed: *All accidents or incidents involving residents, employees, visitors, vendors, ect., occurring on our premises shall be investigated and reported to the administrator. *There was no documentation to support a process was in place for the staff to determine: -When an accident or incident should have been reported to the SD DOH. -Who would have been responsible to complete and investigate a reportable incident or accident.

Based on observation, interview, record review, and policy review, the provider failed to ensure 5 of 15 sampled resident's (1, 8, 20, 27, and 36) care plans had been reviewed and revised to reflect their current status. Findings include: 1. Observation on 12/10/19 from 10:53 a.m. through 11:25 a.m. of resident 20 revealed: *She was laying in her bed and yelling for help. *She wanted to get out of bed. *Licensed practical nurse (LPN) C performed her blood glucose test and injected insulin. *Certified nursing assistant (CNA) A assisted her out of bed using the sit-to-stand lift. *She did not complain of nor had any visualized signs of pain during the transfer. *Only one staff person assisted with her transfer from her bed to the wheelchair (w/c). Observation on 12/11/19 from 1:30 p.m. through 4:00 p.m. and again on 12/12/19 from 9:00 a.m. through 11:30 a.m. revealed resident 20 was in her w/c. She was propelling herself throughout the hallways. Review of resident 20's medical record revealed: *On 11/25/19 at 2:25 p.m. a plan of care note included: -Resident's daughter/co-guardian (name), granddaughters {name) here to discuss recent fall on 11/22/19 with DON (director of nurses) and writer. Discussed current interventions and plan to add hourly safety rounds and do not place blankets on top of closet to care plan. (Name) asked about fall alarm but decision made not to use. DON will also call (name) with results of fall investigation. *There was no documentation of the hourly checks. Review of resident 20's 10/25/19 care plan revealed: *Focus area that included: I am unable to care for myself r/t (related to) weakness, incontinence, unsteady balance, and memory problems. I try to be as independent as possible but its not safe for me anymore. I recently incurred a pelvis fracture and (L) (left) scapula displacement from a fall. *Goal that included: I will maintain independence with eating and weight-bearing thru (through) review date. *Interventions that included: -Eating: Resident is able to: feed herself independently. -Toilet use: Resident requires extensive assistance by 2 staff for toileting with EZ stand. -Transfer: Resident requires extensive assistance by 2 staff and stand lift to move between surfaces. *Focus area that included: I am at risk for falls r/t Gait/balance problems, incontinence, Unaware of safety needs. Vision/hearing problems, hx (history) of falls at home, walks to her bathroom using the walls in her room. -Goal of: I will not sustain serious injury through the review date. -Interventions that included: --Follow facility fall protocol. --Hourly fall/safety rounds. --Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate resident/family/caregivers/IDT (interdisciplinary team) as to causes. 2. Observation on 12/10/19 at 10:45 a.m. revealed resident 36 was seated in a geriatric reclining chair. She appeared restless, as she moved her legs frequently and had occasional verbal outbursts. She was unable to move the geriatric chair. Interview on 12/10/19 at 11:00 a.m. with LPN C revealed resident 36 had a recent fall with a fracture of her left hip. She was unable to bear any weight and could not wander about the facility. She was unable to propel the geriatric chair. Review of resident 36's care plan revealed: *Focus area last revised on 11/15/19 for restorative nursing revealed two goals: -Goals: --I will remain free of complications related to immobility, including contractures, thrombus formation, skin-breakdown, fall related injury through the next review date, revised on 11/6/18. --I will be able to stand and bear weight longer and better by next care plan review, initiated on 4/9/19. -Interventions included: -- The resident is non weight bearing-transfer with full body lift and 2 assist, revised on 11/15/19. *Focus area revised on 11/15/19 revealed: -I have a history of wandering into other resident rooms -Interventions: None listed. 3. Review of resident 8's 9/27/19 Minimum Data Set (MDS) assessment revealed he: *Was admitted on [DATE]. *Had a Brief Interview for Mental Status score of thirteen meaning his cognition was intact. *Required extensive assistance of two staff persons for bed mobility, transfer, and use of the toilet. *Was frequently incontinent of urine and bowel. *Had not been on a toileting program. *Used a w/c to get around the nursing home. *had a history of [REDACTED]. Review of resident 8's 10/9/19 care plan revealed the following interventions: *A urinal was to have been available for the resident to use while in bed. *He was to have been checked on every thirty minutes. *His bed was to have been in the lowest position and against the wall. Observation on 12/10/19 at 9:24 a.m. of CNA G and CNA H who assisted resident 8 with toileting revealed: *He needed the assistance of two staff. *They used a sit-to-stand lift to assist him. *No urinal was observed in his restroom or bedroom. Interview on 12/12/19 at 8:53 a.m. with CNA I and CNA G regarding resident 8 revealed: *His bed was not placed in the lowest position. *He had not used a urinal, and one had not been placed in his room. *He was not on an every thirty minute monitoring check. *They had checked on him often throughout the day, but it was not charted. Observation and interview on 12/12/19 at 8:56 a.m. with resident 8 revealed: *He was in his room seated in his wheelchair. *A urinal had not been available for him to use he had to ask for one. *He thought a urinal would be more convenient than getting out of bed. *His bed had not been put in the lowest position when in bed. *He had several falls since his admission. Interview on 12/12/19 at 4:43 p.m. with the administrator and the DON regarding resident 8's care plan revealed: *They were unaware he was to have had a urinal available for his use, and it had not been provided. *They were unaware his bed had not been placed in the lowest position possible when he was in it. The thirty minute monitoring checks had not been completed and documented by staff. *The care plan could have been updated by any staff not just by nursing. *Their expectation would be the care plan would have been updated to reflect his current needs. 4. Observation on 12/10/19 at 8:01 a.m. of resident 1 revealed: *She had been: -Laying in her bed resting. -Positioned on her back with pillows placed on each side of her. -Awake and attempted to talk to the surveyor when spoken to. *She had appeared to be able to move her head and left leg without difficulty, but no spontaneous movement was observed of her arms, right leg, and upper torso to including her bottom. *She made occasional and uncontrollable jerking forward movements of her upper torso. *There was a large pillow underneath both of her knees. -That pillow offered no pressure relief for both of her heels from the mattress. *Her right leg was contracted and had been pulled up towards the back of her thigh. -The inner aspect of her right heel and foot had been laying directly on the pillow. Random observations on 12/10/19 from 8:01 a.m. through 11:10 a.m. of resident 1 revealed she had been laying in bed and in the same position as observed above for over three hours. She had no heel protectors on her feet. Interview on 12/10/19 at 8:49 a.m. with CNA A revealed: *The residents had just finished breakfast, and the staff were busy bringing them back to their rooms. *She would let the surveyor know when they were ready to assist resident 1 with personal care and transferring. Observation on 12/10/19 at 11:14 a.m. with CNAs A and B with resident 1 revealed they had prepared to assist the resident with personal care and get her out bed. -That had been the first observation of the resident being assisted with repositioning, incontinence care, and getting out of bed. -CNA B put heel protectors on her feet at that time. Review of resident 1's medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *She had: -Been dependent upon the staff to assist her with all ADL. --That had included bed mobility, positioning, and transfers. -Been dependent upon the staff to anticipate her needs and develop a plan of care with goals and interventions put in place to support those needs. -Been at risk for skin breakdown with a deep tissue injury identified on 9/20/19 to her right heel. Review of resident 1's comprehensive care plan revealed: *Multiple focus areas with different initiation and revision dates. *The most recent revision date was 10/7/19. *A focus area that included: -I have the potential for pressure ulcer development r/t limited mobility, friction from loss of motor control, sitting up in w/c for long periods and refusing to lay down, bowel/bladder incontinence. -Suspected deep tissue injury 9/20/19. *Interventions that included: -I need assistance to turn/reposition at least every 2 hours more often as needed. -Ensure my heel protectors are in place when in bed and up in w/c. --That intervention had not been put in place until six days after she had acquired a deep tissue injury. *No documentation to support she had required pressure relieving devices such as pillows to ensure no skin breakdown had occurred. Interview on 12/11/19 at 4:33 p.m. with LPN D and RN [NAME] regarding resident 1 revealed: *The IDT had the most responsibility for reviewing and revising the care plan. -But all professional staff had the capability of updating the care plan and should have. *They: -Confirmed the direct caregivers would have used the comprehensive care plans to ensure the residents received the appropriate care and services. -Were not aware the staff had not been following the care plan to ensure the resident did not acquire any further skin breakdown. -Agreed the heel protectors had not been implemented until after the resident had acquired an injury. --That intervention had been reactive versus proactive. -Agreed the care plan had not been reviewed and revised to support the current care and services the resident currently required and should have had. Refer to 686, finding 1. 5. Review of resident 27's medical record revealed: *She was admitted on [DATE]. *Her [DIAGNOSES REDACTED]. *A Brief Interview for Mental Status (BIMS) assessment score was thirteen indicating she had good memory recall. *Her comprehensive care plan revealed: -She was at moderate risk for falls related to gait/balance problems, incontinence, hx of falls at home, vision/hearing problem, and amputated toes. -She was independent with dressing, transfers, and toilet use, but might need the assistance of one staff person when incontinent of bladder and/or bowel. Observation and interview on 12/10/19 at 3:48 p.m. with resident 27 revealed: *She had been sitting slouched in her wheel chair w/c and leaning to the left. Her head, neck, and shoulders had been bent down looking at her lap. -Throughout the interview she would lift up her head to look at me. -She kept her left arm close to her left side and her left hand on her lap. -She used her right arm when she talked. *She commented she had fallen in the past. -She became unsteady at times with transfers and when going to the bathroom. -She had broken her wrist from a fall, but could not remember how that happened. -Her roommate helped her when she falls by alerting the nurse on duty . *She stated: One time I was trying to get my pullups on when I fell . I hurt my knee a little bit. I couldn't get up so my roommate got the nurse for me. Review of resident 27's interdisciplinary progress notes and occurrence reports from 4/24/19 through 12/8/19 revealed she had fallen six times during that time period. Review of resident 27's comprehensive care plan revealed: *Focus area last revised on 11/12/19 for falls: -I am moderate risk for falls r/t gait/balance problems, incontinence, Hx of falls at home, vision/hearing problem, amputated toes. I have history of finger fracture r/t falls. -That focus area had identified her falls for incidents on 8/9/19 and 12/8/19. *The provider failed to identify the following falls in her care plan: 4/24/19, 5/17/19, 5/21/19, and 5/28/19. *Goal with a revision date of 8/8/18 and a target date of 12/3/19: -I will be free of falls through the review date. *Interventions in place previous to the above mentioned falls were: -Anticipate and meet her needs, cue to lock w/c brakes for transfers and reach back for w/c arm when sitting down, ensure her call light is within reach, fall assessment after every fall and quarterly. Instruct resident to be sure that wheelchair is locked. Remind resident to ask for assistance when needed. *Interventions initiated between 4/24/19 to 12/8/19 with three new ones were: -5/17/19: Educate the resident/family/caregivers about safety reminders and what to do if fall occurs. Follow fall protocol. -11/12/19: W/C brakes checked and functional. *The provider failed to document in resident 27's care plan: - Four of the six identified falls. -Implement interventions for those four of six identified falls. *There had not been consistent documentation in the resident's care plan to identify interventions with each of her incidents noted above to protect her from future falls and possible injury. Refer to F689, finding 1. 6. Review of the provider's (MONTH) 2010 Care Plan - Comprehensive policy revealed: *An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental, and psychological needs is developed for each resident. *Our facilities Care Planning/Interdisciplinary Team, in coordination with the resident, his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident that identifies the highest level of functioning the resident may be expected to attain. *Each resident's comprehensive care plan is designed to: -Incorporate identified problem areas. -Incorporate risk factors associated with identified problems. -Build on the resident's strengths. -Reflect the resident's expressed wishes regarding care and treatment goals. -Reflect treatment goals, timetables, and objectives in measurable outcomes. -Identify the professional services that are responsible for each element of care. -Aid in preventing or reducing declines in the resident's functional status and/or functional levels. -Enhance the optimal functioning of the resident by focusing on a rehabilitative program. -Reflect currently recognized standards of practice for problem areas and conditions. *Assessments of residents are ongoing and care plans are revised as information about the resident and the resident's condition change. *The care planning/interdisciplinary team is responsible for the review and updating of care plans: -When there has been a significant change in the resident's condition. -When the desired outcome is not met.

Based on observation, interview, record review, and policy review, the provider failed to ensure complete and accurate documentation had been entered in the residents' records for 4 of 12 (8, 22, 27, and 36) sampled residents. Findings include: 1. Review of resident 8's 9/27/19 Minimum Data Set (MDS) assessment revealed he: *Was admitted on [DATE]. *Had a Brief Interview for Mental Status score of thirteen meaning his cognition was intact. *Required extensive assistance of two staff for bed mobility, transfers, and use of the toilet. *Was frequently incontinent of urine and bowel. *Had not been on a toileting program. *Used a wheelchair to get around the nursing home. *had a history of [REDACTED]. Review of resident 8's medical record revealed he had fallen on the following dates: *5/3/19, no injury. *5/6/19, no injury. *7/13/19, major injury of a broken left fifth finger. *9/11/19, no injury. *9/13/19, no injury. *9/16/19, injury. Review of the fall incident reports revealed they had been completed on of the all falls except the 9/11/19 fall. The following report revealed: *The 7/13/19 fall incident report indicated the resident had a laceration above his left eyebrow, an abrasion to his left elbow and thumb, and a hemotoma on his right palm. *The resident had x-rays on 7/15/19 after he had complained of left rib and left wrist pain. -A head, neck, lower back, and pelvis computed tomography (CT) scan was completed and found to be negative for any fracture or new injury. -A chest x-ray was completed and found to be negative. -X-rays of his left hand found a fracture of his left fifth finger. Continued review of resident 8's medical record revealed: *A [DIAGNOSES REDACTED]. *A 7/15/19 nurse's note: Appointment made for resident at (clinic name) to get x-ray of the chest and left hand. Results of x-rays show 2 fractured ribs on the left and [MEDICAL CONDITION] (sic) finger. *A 7/16/19 nurse's note: Continues to complain of pain in left rib area due to fractured ribs. *Review of the 7/15/19 x-ray results did not include information of any rib fractures. Interview on 12/12/19 at 2:44 p.m. with licensed practical nurse/MDS coordinator D regarding resident 8's rib fracture [DIAGNOSES REDACTED].>*She had entered the [DIAGNOSES REDACTED]. *She could not explain how the [DIAGNOSES REDACTED]. *Phone conversation during the above interview with the medical director confirmed he believed the nursing staff had put that into the record in error. 2. Review of resident 36's 11/12/19 fall care plan revealed she had falls on: 1/21/19, 1/30/19, 2/13/19, 3/8/19, 6/29/19, 8/18/19, 10/22/19, 10/31/19, 11/7/19, and 11/7/19. Review of resident 36's interdisciplinary progress notes revealed no description of the falls on the following: *10/22/19: There were notes on 10/20/19 at 6:35 p.m. and on 10/23/19 at 8:47 a.m. -Neither of those notes described the fall and nursing assessment or addressed any fall follow-up. *10/31/19: None of the notes below described the fall and nursing assessment of the resident immediately after the fall. There were notes on: -10/31/19 at 1:00 p.m.: Resident went to dinning room for lunch, department heads were notified. (name) ADM (administrator) notified. and (name)RN, DON was notified. ROM (range of motion) is wnl (within normal limits). No c/o (complaints of) pain noted. -11/1/19 at 6:13 a.m.: Resident is a f/u (follow-up) fall and she did sleep mostly all night, she did holler for awhile last evening and calmed down around 10 pm. Will continue to monitor. She continues to have some redness under her right breast. -11/1/19 at 5:46 p.m.: res (resident) is on post fall charting,call light was placed within reach,rounding done every two hours on res,res incontinence products changed every two hours,no issue encountered during this shift,will continue to monitor. -11/2/19 at 6:13 a.m.: Resident is a f/u fall noting no further injuries and her O 2 os (oxygen saturation) 94% and will continue to monitor. -11/3/19 at 5:48 a.m.: This resident is a f/u fall with no further injuries noted continues to have the same bruises to her arms. her O2 is 92 % and will continue to monitor. -11/3/19 at 5:54 p.m.: Resident continues on F/U fall. Resident has been resting in room most of the day. When resident is in wheel chair she is closely monitored, as she can propel self using wall rails and shuffling her feet. When Resident is resting in bed frequent bed checks are done to avoid any falls from bed. No falls this day shift. *11/7/19: None of the notes below described the fall and nursing assessment of the resident immediately after the fall. There were notes on: -11/7/19 at 5:56 p.m.: Notified (name), ADM (administrator) at 1745 (5:45 p.m.), Called (name of DON) could not leave a message mailbox is full. -11/7/19 at 6:08 p.m.: Resident's son (name) was notified at 1805 (6:05 p.m.). -11/8/19 at 5:46 a.m.: Resident is a f/u fall noting no other injuries than the bruising that she continues to have on both of her arms. Her O2 is 96% and will continue to monitor and she did sleep well thru the night. -11/8/19 at 1:08 p.m.: Resident is on f/u fall charting, ROM is wnl, able to move all extremities. Has not c/o pain or discomfort. Has a skin abrasion on her mid LFA (left forearm) cleaned and applied bandaide. Is fed at meals and appetite is good. Will continue to monitor. -11/12/19 at 1:07 p.m.: Resident noted to have more bruising and swelling to left hip/thigh area. Notified Dr. (name) and receives orders to send resident to (hospital name) for x-rays of hip. Notified her son (name) of new orders and reason for. Ambulance here at 0900 (9:00 a.m.)to take resident to (hospital). Received call from (hospital) that resident does have fractured left hip. Gave them the number of her son who they are going to call to see what they want to do. Notified Dr. (name) of results of x-ray. Waiting for call back from hospital to see what the plan of care will be. -11/12/19 at 2:17 p.m.: Received call from resident's son/guardian (name) who advised he spoke with doctors at (hospital) IHS regarding (L) [MEDICAL CONDITION]. The doctors advised if she was mobile on her feet they would recommend surgery but she is w/c bound so they recommend pain management and rest. (Name) agrees and does not want surgery to affect resident's quality of life. He requested a restraint to her w/c but writer advised IDT (interdisciplinary team) would meet to discuss possible interventions like a geri (geriatric)-chair instead. He will call us later this evening. -11/12/19 at 6:07 p.m.: Spoke with physician at (hospital). Family has opted to not have surgery done. Recommend [MEDICATION NAME] and Tylenol be given together for the pain every 6 hours. Geri chair with full body lift. Will have binder on to keep hip more stabilized. -11/13/19 at 6:19 a.m.: This resident returned to the facility via Nursing van from (name) Hospital. And x-rays were noting that she has a broken left hip and comments are to recommend a Geri-chair, Non-weight bearing-use Hoye (hoyer) lift with transfers, Abdominal/Pelvic Binder for Support and that was put into place on resident. She did take her medication well and sleep thru the night. Did notify the day nurse and will continue to monitor. -11/13/19 at 2:50 p.m.: Resident has been very quiet today. Full body lift used transfers. Geri chair used for locomotion propelled by others. Has pelvic binder on at present time. Spoke with Dr. (name)and received order for this to be on for 48 hours then to be taken off. Up in geri chair from breakfast until after lunch then laid down. Resident has yelled out a few times. Resident is pale. Continues to have bruising and swelling to left upper thigh/hip area. Interview on 12/12/19 at 3:30 p.m. with the DON confirmed the documentation for resident 36 had not reflected the nursing assessments when the resident had fallen for the above times. She stated most of that documentation would have been found on the occurrence report, but those were not part of the resident's record. She agreed all incidents should have been documented in the resident's progress notes. 3. Review of resident 22's medical record revealed incomplete or missing documentation related to: *A complete and thorough investigation after an incident involving licensed practical nurse (J). *How the staff had determined: -The resident had no longer been at risk for potential verbal and psychological abuse. -The resident's mental health well-being was stable. -The South Dakota Department of Health (SD DOH) had not required notification of the incident between the resident and LPN [NAME] Refer to F600, finding 1. Refer to F609, finding 1. 4. Review of resident 27's medical record revealed incomplete or missing documentation related to: *A complete and thorough investigation after two falls with major injuries had occurred. *How the staff determined: -The resident's care plan had been updated to reflect the current care and services she required to ensure no further falls with injury had occurred. -The SD DOH had not required notification of the incidents of falls with major injury. -Who was responsible for the review and completion of those incident reports to support reportable and non-reportable reports with investigations to the SD DOH had been completed and submitted. Refer to F609, finding 2. Refer to F689, finding 1. 5. Review of the provider's revised (MONTH) 2008 Charting and Documentation policy revealed: *All observations, medications administered, services performed, etc., must be documented in the resident's clinical records. *All incidents, accidents, or changes in the resident's condition must be recorded. *Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: a. The date and time the procedure/treatment was provided; b. The name and title of the individual(s) who provided the care' c. The assessment data and/or any unusual findings obtained during the procedure/treatment; d. How the resident tolerated the procedure/treatment; e. Whether the resident refused the procedure/treatment; f. Notification of family, physician, or other staff, if indicated; g. The signature and title of the individual documenting.

Based on observation, interview, and policy review, the provider failed to ensure infection control procedures had been used during: *One of two dressing changes for one of two sampled residents (17) by one of two licensed practical nurses (LPN) (C). *Two of five observed resident's (1 and 20) during personal care by two of tow certified nursing assistant (CNA) (A and B). Findings include: 1. Observation on 12/10/19 at 11:13 a.m. during a wound dressing change for resident 17 revealed LPN C: *Took a plastic bag out of the medication cart. That contained a spray bottle of wound cleaner and 4 X 4 gauze. *Placed resident 17's foot on a disposable pad. *Placed the bag of supplies on part of the bedspread and part on the disposable pad. *Assisted her to lay on her left side. *Washed her hands and when she was done she pushed on the dispenser to get the first paper towel out, wiped hands, and shut the water off with a paper towel. -She had recontaminated her hands when she used the dispenser. *Put on gloves and opened the package of Derma Gauze Hydrogel. *Took her gloves off, went out of the room to the medication cart, and got a pair of scissors. *Without completing any hand hygiene she put on new gloves. *Did not sanitize the scissors and placed them on the barrier. *Cleansed the wound with wound cleanser, changed her gloves without any hand hygiene, used the scissors to cut the Derma Gauze Hydrogel, and placed on it the wound area. *Changed her gloves with no hand hygiene and applied a new cover dressing. *Changed her gloves without any hand hygiene. *Placed the unused wound care supplies back in the bag. *Put the resident's stocking on and removed her gloves. *Washed her hands for approximately five seconds and again had to push on the dispenser for a clean paper towel. *Placed the dressing supplies in the medication cart, put a glove on her right hand, and taped the rest of the Derma Gauze Hydrogel package shut. *Put a glove on her left hand and sanitized the scissors with a Super Sani-cloth wipe. *Removed her gloves and placed the scissors back in a medication cart drawer. *That drawer also contained two other pairs of scissors, markers, tape, and numerous other items. Interview on 12/11/19 at 11:49 a.m. with registered nurse (RN) [NAME] confirmed LPN C had not used proper infection control techniques during the above dressing change. She stated they had just completed education on infection control. Interview on 12/12/19 at 10:30 a.m. with LPN C revealed she: *Knew she should not have of brought the bag of supplies in the residents room. *Agreed she should have completed hand hygiene when she changed gloves. *Agreed she should have sanitized the scissors before she used them. Review of the provider's revised (MONTH) 2013 Dressings Dry and Clean policy included: *Clean equipment and supplies were to have been placed on the clean barrier. *Hands should have been washed between glove changes. 2. Observation on 12/10/19 at 9:54 a.m. of certified nursing assistants (CNA) A and B with resident 20 revealed: *She had been sitting in her wheelchair (w/c) and was ready to lay down on her bed. *She had required the use of a stand-aide mechanical lift for all transfers. *The CNAs had prepared to assist her with laying down on her bed and personal care. *Without washing or sanitizing their hands the CNAs put on clean pair of gloves. *With those gloves one they had: -Positioned the transfer sling behind the resident and attached it to the stand-aide. -Took the pedals off the w/c and positioned her feet on the base of the stand-aide. -Wrapped the safety strap around her legs and attached it to the stand-aide. -Used the remote control on the stand-aide to assist her with standing and transferring to her bed. -Layed the resident down on her bed. *CNA A: -Removed her gloves and without washing or sanitizing her hands put on a clean pair of gloves. -Assisted CNA B with pulling down her skirt and removing her incontinent brief. -Removed her gloves and without washing or sanitizing her hands put on a clean pair. -Took wet wipes and cleaned her bottom and perineal area. --She had been incontinent of bowel movement (BM). -Removed her gloves and without washing or sanitizing her hands put on a clean pair of gloves. -Assisted CNA B with dressing and positioning her in her bed. *The CNAs washed their hands prior to leaving the room. -That had been the only time the CNAs had been observed washing or sanitizing their hands. 3. Observation 12/10/19 at 11:14 a.m. of CNAs A and B with resident 1 revealed: *She had been laying on her bed resting. *The CNAs prepared to assist her with personal care and a transfer from her bed into a reclining w/c. *They: -Gathered the necessary supplies to provide personal care for her. -Used the remote control and adjusted her bed to a workable level for them. *They sanitized their hands and put on clean gloves. *With those gloves on they took off her blanket and removed an incontinent brief. -The brief had been soiled with urine. *With those now soiled gloves CNA B: -Grabbed several wet wipes from a package and cleaned her bottom first. -Then grabbed more wet wipes and cleaned her front area with the same gloves that she had used to clean her bottom with. *The CNAs removed their gloves, sanitized their hands, and finished assisting the resident. 4. Interview on 12/10/19 at 2:56 p.m. with CNA B regarding the above observations of personal care for residents 1 and 20 revealed: *That had been her usual process for providing personal care for the residents. *She had not recognized the process as unsanitary until after the observations were reviewed with her. *She agreed: -The personal care proved above had not been done in a sanitary manner and placed the residents at risk for acquiring an infection. -They should have washed or sanitized their hands prior to assisting the residents with transfers and personal care. -They should have sanitized or washed their hands between glove changing. -She should have cleaned the resident's front area before her bottom to support from clean to dirtiest. Interview on 12/11/19 at 9:36 a.m. with the director of nursing regarding the above observations revealed: *She agreed the personal care above was not completed in a sanitary manner. *The CNAs should have removed their gloves and sanitized their hands anytime they had been soiled. *The resident's front area should have been cleaned before her bottom to support from cleanest to dirtiest. *She agreed the processes above had created the potential for the residents to have acquired an infection. Review of the provider's (MONTH) (YEAR) Perineal Care policy revealed: *The purpose of this procedure are to provide cleanliness and comfort to the resident, to prevent infections, and skin irritation, and to observe the resident's skin condition. *The staff were to have: -Washed their hands prior to gathering all the necessary supplies for personal care. -Put on clean gloves prior to assisting with personal care. -Washed the resident's front area before cleaning their bottom. Review of the provider's revised 9/7/18 Handwashing/Hand Hygiene policy revealed: *This facility considers hand hygiene the primary means to prevent the spread of infections. *The staff were to have sanitized or washed their hands for the following situations: -Before and after direct contact with residents. -Before moving from a contaminated body site to a clean body site during resident care. -After contact with a resident's intact skin. -After contact with blood or bodily fluids. -After handling used dressings, contaminated equipment, etc. -After contact with objects (e.g., medical equipment) in the immediate vicinity of the resident. -After removing gloves. -The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine hand hygiene is recognized as the best practice for preventing healthcare-associated infections.

Based on observation and interview, the provider failed to ensure: *One of three sampled residents (1) had received privacy during personal care by two of two certified nursing assistants (CNA) (A and B). *Privacy had been maintained during a dressing change for one of two sampled residents (33) by one of one licensed practical nurse (LPN) (L). Findings include: 1. Observation on 12/10/19 at 11:14 a.m. of resident 1 with CNAs A and B revealed: *They had prepared to assist the resident with personal care and a transfer from her bed into her reclining wheelchair (w/c). *The resident was: -Dependent upon the staff to assist her with all activities of daily living (ADL). -Alert and able to answer yes or no questions. *The room had a large picture window that faced out into the staff and visitor parking lot. *There was a curtain on the window to allow for privacy during personal care, transfers, and while resting. -That curtain had been open and allowed for a clear view of the parking lot. *The CNAs assisted the resident with personal care which had included: -The removal of her incontinent brief, and cleaning of her perineal area and bottom. -Removal of her night time clothes and putting on clean clothes for the day. *After the CNAs had assisted the resident with personal care they transferred her into a reclining w/c. -The resident was unable to stand and had required the use of a total body mechanical lift to complete that transfer. *The CNAs had not closed the curtain to ensure privacy was maintained while assisting the resident with personal care, dressing, and the transfer. Interview on 12/10/19 at 2:50 p.m. with CNA B regarding the above observation revealed she: *Had not realized privacy was not provided when they had assisted resident 1 with her personal care and a transfer. *Stated: -We should have closed the curtain. -We are supposed to pull the privacy curtain and window curtains shut when we help the residents. Interview on 12/11/19 at 9:36 a.m. with the director of nursing revealed she: *Would have expected the CNAs to provide privacy while assisting the residents with all ADL to ensure dignity was maintained. *Was not able to provide a policy and procedure on privacy and dignity for the survey team prior to their exit from the facility on 12/12/19. 2. Observation on 12/10/19 at 3:25 p.m. of LPN L during a dressing change for resident 33 revealed she: *Entered his room and pulled the privacy curtain between him and his roommate. *Did not close the door to the room. *Assisted him on his side and adjusted his pants down. *Performed the dressing change to his buttocks. *Had not closed the curtains to the outside window during the dressing change. Observation from resident 33's room during the dressing change revealed his window faced the front of the building. The parking lot was at the front of the building. Visitors and staff would have been able to see in the window from the parking lot. Interview on 12/11/19 at 10:00 a.m. with LPN/Minimum Data Set coordinator D stated it was the expectation that all residents had privacy provided.

Based on observation, interview, record review, manufacturer's instructions, and policy review, the provider failed to follow appropriate infection control technique for: *Two of three observed shower cleanings by two of three observed certified nursing assistants (CNA C and E). *The cleaning of two of two randomly observed resident rooms by two of two housekeepers (G and H). *Three of five observed blood sugar checks by two of three licensed staff (registered nurse (RN) B and licensed practical nurse (LPN) A) for residents 9, 12, and 13. *The cleaning of the blood glucose monitoring device per manufacturer's instructions by two of three licensed staff (LPN A and D). *Hand hygiene and glove use for one of one sampled resident's (2) personal care by two of two (RN B and CNA C) staff. Findings include: 1a. Observation and interview on 8/29/17 at 9:35 a.m. and again at 9:51 a.m. in the east hall shower room revealed: *At 9:35 a.m. certified nursing assistant (CNA) E sprayed the shower walls, grab bars, and shower chair with the product Disinfectant 256. -She stated she would let it sit about five minutes. -She left the room. *At 9:51 a.m. CNA F went into the shower room to move items in place for the next resident. -It was brought to her attention that CNA E had only sprayed the disinfectant and left the room. -She finished the cleaning of the shower room. -Stated it was her practice to spray the disinfectant then wait about fifteen minutes to finish the cleaning. b. Observation and interview on 8/29/17 at 10:25 a.m. with CNA C in the west hall shower room revealed: *He sprayed the surfaces with the product Disinfectant 256 and immediately wiped it with a dry towel. -The same towel was used with the cleaning of all surfaces in the shower room. *The floor was saturated with water, and he used a large towel to clean that area up. -He placed that towel in the dirty linen bin when finished. -Stated that he usually would have had housekeeping mop the wet floor. *He did not wash or sanitize his hands after removing his gloves. *The shower bed was cleaned by wiping the purpose with several sani-cloth wipes. -No gloves were worn while cleaning the shower bed. *He verbalized he had received his CNA certification last week and had not been trained on how to clean the shower room. c. Review of the Disinfectant 256 product directions for use revealed the surface was to remain wait for ten minutes. Interview on 8/30/17 at 10:30 a.m. with the infection control nurse and the director of nursing revealed: *If multiple staff were using the shower room there was not a procedure in place to verify that a complete cleaning had occurred after each resident. *Acknowledged product contact times needed to be followed to ensure disinfection of surfaces had occurred. *Additional education was needed regarding that procedure. Review of the provider's June 2009 Cleaning and Disinfection of Environmental Surfaces: Cleaning Shower Room Area, Whirlpool Tub Equipment and Shower Chairs policy revealed: *The shower room area, whirlpool tub equipment and shower chairs will be disinfected after each resident use and daily to prevent transmission of infectious organisms. *Sanitize the shower walls, floor and equipment by saturating the entire area with the sanitizing spray, make sure that the area have been cleaned, disinfected and before use. *The sanitizing solution must remain wet and in place for ten minutes to achieve adequate sanitation. On 8/30/17 at 10:30 a.m. a policy regarding orientation and training for CNAs or bath aides was requested from the infection control nurse and DON. No policy was received by the conclusion of the survey. 2a. Observation and interview on 8/29/17 at 11:00 a.m. with housekeeper G in a resident's room on the east hall revealed he: *Put on a pair of clean gloves. *Used the Comet with bleach product to spray the toilet. -Verbalized he allowed that to sit while he cleaned the resident's room. *Removed a bottle from the cleaning cart that was approximately half full with a clear liquid. -There was no label or other identifying information on the bottle. *Sprayed that liquid onto a cleaning towel and wiped down all the surfaces in the room. -The towel was not changed. *Finished with the resident's bathroom. *Verbalized the bottle contained a bleach and water mixture. -Pointed to an area on the bottle approximately one-half inch from the bottom and stated he added that much bleach and filled the rest of the bottle with water. -Changed or refilled the bottle at no specific interval but just when it was running out. b.Observation and interview on 8/29/17 at 11:30 a.m. with housekeeper H in a resident's room on the west hall revealed he: *Removed a bottle approximately three-quarters full of a clear liquid from the cleaning cart. -There was no label or other identifying information on the bottle. *Sprayed a surface with the cleaner and immediately wiped with a cleaning towel. *Verbalized the bottle contained a bleach and water mixture. -He described the same mixing process as above. -Changed or refilled the bottle as needed. c.Interview on 8/30/17 at 10:30 with the infection control nurse and DON revealed: *It was their understanding the housekeeping department was to be using the Comet with Bleach product, and they had discontinued use of the bleach and water mixture. *They directed any further questions regarding product use to the housekeeping supervisor. Interview on 8/30/17 at 11:15 a.m. with the housekeeping supervisor revealed: *The provider had stopped using the bleach and water mixture in February 2017. *The Comet with bleach product should have been used on all surfaces. *Each new housekeeper was trained by him over a series of three shifts. *He did not state that he followed-up with housekeepers or randomly observed their cleaning procedures. *It was his expectation that housekeeping followed the appropriate contact times and used the correct products. Review of the provider's June 2009 Cleaning and Disinfection of Environmental Surfaces policy revealed: *Manufactures' instructions will be followed for proper use of disinfecting (or detergent) products including: a. Recommended use-dilution; b. Material compatibility; c. Storage; d. Shelf-life; and e. Safe use and disposal. 3a. Observation on 8/29/17 at 11:45 a.m. with RN B on the west hallway revealed: *The nurse carried the blood glucose monitor, insulin pen, lancet, alcohol pad, and cotton ball in his hands into resident 12's room. *All the supplies were placed on the counter next to the sink with no disposable barrier placed on the counter. *The insulin pen and alcohol wipe were placed on the window sill while the nurse assisted resident 12 with pulling up his pants. *Handwashing and the change of gloves were not done before administering insulin. Observation on 8/30/17 at 11:08 a.m. with RN B on the west hallway revealed: *The nurse carried the blood glucose monitor, insulin pen, lancet, alcohol pad, and cotton ball in his hands into resident 12's room. *All the supplies were placed on resident 12's night stand with no disposable barrier placed underneath them. *Handwashing was not done before putting on his gloves to administer insulin. b. Observation on 8/30/17 at 11:25 a.m. of LPN A on the east hallway revealed: *The nurse carried the blood glucose monitor, insulin pen, lancet, alcohol pad, and cotton ball in her hands into resident 9's room. *All the supplies were placed on the resident's night stand. Observation at on 8/30/17 at 11:31 a.m. of LPN A regarding resident 13 revealed: -She carried the blood glucose monitor, insulin pen, lancet, alcohol pad, and cotton ball in her hands into her room. -All the supplies were placed on the resident's bedside table. *No barrier was used with either observation. Interview on 8/30/17 at 11:35 a.m. with LPN A regarding blood glucose testing revealed: *It was her usual practice to carry the blood sugar supplies and monitor into each resident's room and place it on an available surface without using a barrier. *Acknowledged she should have used a barrier underneath the supplies. c. Interview on 8/30/17 at 11:55 a.m. with RN B regarding blood glucose testing revealed: *It was his usual practice to carry the blood sugar supplies and monitor into each resident's room and place it on an available surface without using a barrier. *Acknowledged he should have washed his hands after direct contact with the resident and changed gloves before administering insulin. Interview on 8/30/17 at 1:04 p.m. with the director of nursing and the infection control nurse regarding the above blood glucose testing procedure revealed: *The provider: -Had no specific policy for checking blood sugars. -Would have expected nurses to do appropriate handwashing and glove use. -Acknowledged there was a risk of infection. Review of the 8/30/17 Recommended Infection-Control and Safe Injection Practices to Prevent Patient-to-Patient Transmission of Bloodborne pathogens revealed to: *Change gloves between patient (resident) contacts. *Perform hand hygiene (i.e., hand washing with soap and water or use of an alcohol-based hand rub) immediately after removal of gloves and before touching other medical supplies intended for use on other residents. *Maintain supplies and equipment such as finger stick devices and glucometers within individual patient rooms if possible. *Any trays or carts used to deliver medications or supplies to individual patients should remain outside patient rooms. Do not carry supplies and medications in pockets. 4a. Observation and interview on 8/29/17 from 10:35 a.m. through 11:00 a.m. on the east hallway with LPN D who used one blood glucose monitor to complete three residents' blood sugar checks revealed she: *Completed the blood glucose testing in each resident's room. *Returned to the medication cart, gloved, and wiped off the unclean monitor with a Sani-Cloth. -The monitor was placed on a clean barrier on top of medication cart to air dry. *Was asked about the cleaning and disinfecting of the monitor. -She stated she wiped the monitor and allowed it to air dry for two minutes. b. Observation and interview on 8/30/17 from 11:25 a.m. through 11:35 a.m. on the east hallway with LPN A who used one blood glucose monitor to complete two residents' blood sugar checks revealed she: *Completed the blood glucose testing in each resident's room. *Returned to the medication cart, gloved, and wiped off the unclean monitor with a Sani-Cloth. -The monitor was placed in the drawer of the medication cart without a two minute wet contact time. *Was asked about the cleaning and disinfecting of the monitor. -Acknowledged the monitor should have been wrapped with the Sani-Cloth for at least two minutes. c. Interview on 8/30/17 at 1:04 p.m. with the director of nursing and the infection control nurse regarding the cleaning and disinfecting of the blood glucose monitor revealed: *The provider had no specific policy for cleaning and disinfecting the blood glucose monitor. *Time needed to disinfect an item using the present disinfectant was two minutes of wet contact time. *Acknowledged there was a risk of infection with the above observations. Review of the manufacturer's instructions on the label of Professional Disposables International, Inc. (PDI) Super Sani-Cloth germicidal disposable wipes required two minutes of wet surface contact time for cleaning and decontamination. Review of the provider's July 2014 Cleaning and Disinfection of Resident-Care Items and Equipment policy revealed: *Reusable items are cleaned and disinfected or sterilized between residents. *Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. 5. Observations on 8/29/17 at 12:05 p.m. and again at 5:15 p.m. with RN B during resident 2's gastrostomy feeding tube administrations revealed he had not worn gloves during the process. Interview on 8/29/17 at 5:45 p.m. with the DON and Minimum Data Set assessment coordinator nurse revealed gloves should have been worn during feeding tube administration according to their policies for proper infection control. Review of the provider's revised May 2014 Enteral Feedings - Safety Precautions policy revealed guidelines to prevent contamination. Those guidelines included to Use disposable gloves when handling or administering enteral formulas. Review of the provider's revised August 2015 Handwashing/Hand Hygiene policy revealed single-use disposable gloves should have been used when anticipating contact with blood or body fluids. 6. Observation on 8/29/17 at 4:05 p.m. with CNA C during resident 2's personal care revealed:*He assisted the resident from his bed to his wheelchair and then to the toilet, so he could go to the bathroom. *When the resident was finished having a bowel movement on the toilet the CNA: -Assisted the resident to stand using the gait belt. -Performed perineal care for the resident. *The CNA continued to wear the soiled gloves he had used to perform the resident's perineal care and: -Transferred the resident into his wheelchair. -Used the wheelchair handles and wheeled him to his bedside. -Removed the resident's soiled disposable brief. -Assisted him into the bed. -Removed the gait belt and hung it up on the hook in the room. *He then changed his gloves without performing hand hygiene and: -Put a new disposable brief on him. -Put the blankets over him. -Put the plastic tote of additional wet wipes back into a dresser drawer. -Collected the garbage. *The resident then requested a urinal, so the CNA again changed his gloves without performing hand hygiene and assisted the resident to place the urinal. *The CNA removed his gloves without performing hand hygiene and left the room to get more gloves. *The CNA returned to the room with a box of gloves, put on a new pair, and: -Got the urinal from the resident. -Emptied the urine into the toilet. -Placed the urinal back on the resident's bedside. -Removed his gloves. -Collected the garbage. -Left the room. -Brought the garbage to the soiled utility room down the hallway. -Opened the door and disposed of the garbage into the appropriate container. -Then washed his hands in the soiled utility room. Interview with CNA C following the above observation revealed he:*Had only been working there for about a month. *Had recently completed the CNA training program and had passed the test to become certified. *Had been taught about appropriate hand hygiene and glove use. *Agreed he should have: -Performed hand hygiene between glove use. -Not touched multiple surfaces with soiled gloves. Interview on 8/30/17 at 11:20 a.m. with the DON and MDS assessment coordinator nurse regarding the above observation revealed:*Hand hygiene and appropriate glove use had not occurred. *All staff were expected to follow their hand hygiene and glove use policies to maintain appropriate infection control. Review of the provider's revised August 2015 Handwashing/Hand Hygiene policy revealed:*2. All personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of infections to other personnel, residents, and visitors.*7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or non-antimicrobial) and water for the following situations: -b. Before and after direct contact with resident; -j. After contact with blood or bodily fluids; -k. After handling used dressings, contaminated equipment, etc.; -m. After removing gloves; *8. Hand hygiene is the final step after removing and disposing of personal protective equipment. *9. The use of gloves does not replace hand washing/hand hygiene. Integration of glove use along with routine had hygiene is recognized as the best practice for preventing healthcare-associated infections.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure adequate supervision and safety for one of one resident (5) who had eloped. That failure created a situation of immediate jeopardy that had a potential for causing harm to residents who were at risk of elopement. NOTICE: Notice of immediate jeopardy was given verbally to the administrator-in-training on 6/24/13 at 8:30 p.m. The administrator was asked for an immediate plan of correction to ensure resident safety related to resident 5 and other residents who were at risk for elopement. PLAN: On 6/24/13 at 9:03 p.m. the administrator-in-training provided the surveyors with an initial written plan of correction (POC). The written POC dated 6/24/13 was accepted by the surveyors at 9:30 p.m. That immediate POC included: *All exterior door alarm codes would be changed by 9:30 p.m. on 6/24/13. *A code alert wristlet would be placed on resident 5's wheelchair on 6/24/13. That was due to resident 5 not tolerating the wristlet on his body due to behavioral issues. *Education on elopement prevention and monitoring residents who went outside who required supervision would be provided to all staff as followed: -6/24/13 evening staff would have education by 9:30 p.m. -6/24/13 night staff would have education by 10:15 p.m. -6/25/13 day staff would have education by 6:15 a.m. -6/25/13 evening staff would have education by 2:15 p.m. -6/25/13 night staff would have education by 10:15 p.m. -All remaining staff would have completed education by 5:00 p.m. on 6/26/13 or before the start of their next scheduled shift. *All residents' that had a code alert wristlet would have them tested on a daily basis. *Resident 5's plan of care would be updated by 9:00 a.m. on 6/25/13 by a registered nurse to show his elopement risk. *Resident 5 would have a full elopement/risk assessment completed by 6/25/13 at 10:00 a.m. Prior to leaving the facility on 6/24/13 at 9:30 p.m. the surveyors confirmed the components outlined in the above written plan of correction had been implemented. During the survey on 6/27/13 at 2:30 p.m. the surveyors confirmed removal of the immediate jeopardy situation. Findings include: 1. Observation on 6/24/13 at 3:55 p.m. revealed resident 5 was in his wheelchair on the front porch of the facility. Resident 5 had on shorts and a T-shirt. He was not wearing any socks or shoes. There were no staff present outside with resident 5. Observation on 6/24/13 at 7:00 p.m. revealed resident 5 was in his wheelchair outside of the facility. He was observed to open a large garbage can and take garbage out of it several times. He attempted to propel his wheelchair into a vegetable garden area. Interview with resident 5 at that time revealed his speech was unintelligible. He was not able to express what he wanted to the surveyor. He was observed for approximately fifteen minutes before the survey team re-entered the facility. Interview with the administrator-in-training at 7:15 p.m. revealed she was aware resident 5 left the building independently. She stated he was able to access the code to leave the building unsupervised. She stated staff did not monitor residents that went outside. Review of resident 5's nurses notes revealed: *A 5/13/13 late entry (no time noted): "Resident went outside prior to supper. Got wheel of w/c (wheelchair) stuck off edge of cement patio. Tried to stand up and fell over. No injuries. Dr. (physician) called." *A 6/14/13 late entry (no time noted): "When I (Minimum Data Set (MDS) coordinator now the interim director of nursing (DON)) was leaving work last p.m. _____(resident 5) was east of the facility on the road at the curve. He was standing beside his w/c. I came back in the N.F. (nursing facility) and got C.N. (charge nurse) ______licensed practical nurse (LPN) Q. She went and brought______(resident 5) back into the facility. Reported incident to the SSD (social services designee) today." *A 6/14/13 2:45 p.m. note "Will go outside for fresh air. Will continue with POC (plan of care)." *A 6/15/13 4:07 p.m. note. "Alert et (and) O (oriented) X (times ) 1, goes outside et tries to ambulate, urinates outside beside the sidewalk." *A 6/16/13 3:30 p.m. note "Res. (resident) stayed inside for most of the day." *A 6/17/13 un-timed note "Res. was outside this p.m. had shoes off et had his feet in the dirt in the garden. Assisted to get out et shoes put back on." *A 6/18/13 2:30 p.m. note "Resident seen by Dr. ________. NNO (no new orders) @ (at) this time. Will continue with POC." Observation on 6/25/13 at 9:00 a.m. of the road and curve to the east of the facility revealed: *It was an unpaved road of loose gravel. *The ditch on the curve of the road had high weeds present. Interview on 6/25/13 at 2:00 p.m. with the interim DON revealed she had notified LPN Q when resident 5 was outside of the building on 6/13/13. She stated she had not filled out an incident report, completed the risk assessment for elopement or wandering, or updated resident 5's care plan. She also stated resident 5's physician nor his responsible party had been notified of the incident. She agreed resident 5 was at risk for serious injury due to his diagnoses. Interview on 6/25/13 at 3:00 p.m. with the SSD revealed she had not been notified of the incident for resident 5 on 6/14/13. Review of resident 5's medical record revealed he had [DIAGNOSES REDACTED]. *Traumatic brain injury. *Seizure disorder. *Depression with psychotic features. *Muscle [DIAGNOSES REDACTED]. *Intermittent explosive behaviors. *Agitation. *History of alcohol abuse. Review of the provider's 6/1/12 through 6/23/13 fall/incident investigation worksheets revealed no incident investigation had been completed for resident 5's 6/14/13 elopement. Review of resident 5's entire medical record revealed no risk assessment for elopement or wandering had been completed. Review of a risk assessment for elopement or wandering completed on 6/25/13 at 8:45 a.m. revealed he: *Had a [DIAGNOSES REDACTED]. *Moved independently indoors. *Lacked the capacity to make sound decisions regarding his safety. *had a history of [REDACTED]. *had a history of [REDACTED]. *had a history of [REDACTED]. *had a history of [REDACTED]. *had a history of [REDACTED]. He scored eight points out of a possible nine points on a elopement risk assessment that put him at a high risk for elopement. That indicated he needed a watch mate wristlet monitor on him and one hour staff checks. Review of resident 5's 10/30/12 admission and 3/30/13 quarterly MDS revealed he did not have wandering behaviors. Review of resident 5's last reviewed 1/16/13 plan of care revealed no problem, goals, or interventions regarding his wandering or elopement risk. Review of the provider's revised December 2008 Elopement policy revealed: *Staff would investigate and report all cases of missing residents (elopement). *When a resident returned to the facility the DON or charge nurse would examine the resident for injuries, notify the attending physician, notify the resident's legal representative, complete and file a report of incident, and document the event in the resident's medical record. Review of the provider's revised December 2008 Wandering, Code Watch Wandering Management policy revealed: *A resident would be assessed for unsafe wandering and risk for elopement. *The resident's care plan would indicate the resident was at risk for elopement. Review of the provider's revised 1/9/12 Safety and Supervision of Residents policy revealed:*Safety risks and environmental hazards were identified on an ongoing basis through employee training, monitoring, reporting processes and quality assurance reviews of safety and incident/accident reports. *Implementation of interventions to reduce accident risks and hazards would include: -Communication of specific interventions to all relevant staff. -Assign responsibility for carrying out those interventions. -Providing training as necessary. -Ensuring interventions were implemented. -Documentation of interventions. B. Based on record review, interview, and policy review, the provider failed to fully implement and follow the plan of care to assist in the prevention of continued falls for 9 of 15 sampled residents (2, 3, 4, 5, 6, 8, 9, 12, and 14) with fall histories. Findings include: 1. Review of resident 5's entire medical record revealed: *He had been admitted on [DATE]. *He had [DIAGNOSES REDACTED]. *A 1/10/13 care plan problem of falls. Approaches included to wear non-skid socks, ask for help to toilet, allow staff to awaken him at night to use the bathroom, arm support on stool, one-half side rail on bed, and urinal at bedside. *A 1/16/13 care plan note under safety - "I have right sided weakness and I am unsteady, Remind me and cue (remind) me to ask for help. I want no further falls." *A 6/20/13 care plan problem of fall risk. Approach included "Remind resident to use call light when needed." *He had sixteen falls from 10/26/12 through 5/13/13. *Those falls had resulted from him attempting to transfer himself from his wheelchair or attempting to ambulate independently. *A 10/30/12 nurse's note revealed a pressure alarm had been "placed", but it did not specify whether it was on his wheelchair or his bed. *A 11/9/12 care plan conference was held. It was only reported that he continued to be a fall risk. No interventions were documented as being discussed. *On 11/13/12 he had been seen by his attending physician,his falls had been discussed. *Review of the 11/13/12 physician's progress note revealed no documentation regarding his falls. *On 12/11/12 he was evaluated by physical therapist (PT) AA. Recommendations were made that included to ambulate with a front wheeled walker as tolerated. There was no documentation in regards to his frequent falls. *A 1/10/13 nurse's note regarding his frequent falls with interventions that included him wear non-skid socks, toileting every two hours at night, and remind him to ask for assistance. A note would be placed in his bathroom to remind him to ask for assistance. *A 1/16/13 care plan conference note revealed an extensive discussion regarding his frequent falls. "Pt. (resident 5) was asked how arms on stool are working, smiles and mumbles some garbled words. When asked about half rails smiles and shakes his head yes." There was no further documentation of any further interventions having been tried for his fall prevention. *A 1/19/13 nurse's note that his attending physician had evaluated him and his frequent falls had been discussed. Physician was informed of previous interventions of a half side rail and hand rails to his toilet. *The 1/19/13 physician's progress note stated the Baclofen for muscle spasms would be discontinued. "He has had some falls and is possibly related to just weakness or muscle sedation." *A 1/30/13 nurse's note the South Dakota Department of Health public health advisor for nursing homes had been contacted regarding his frequent falls. A recommendation was made to check with his previous facility for possible fall interventions. The previous facility was a specialty facility for brain injured residents. No further documentation was found that the previous facility had been contacted. *A 3/7/13 nurse's note that his half side rail had been discontinued as he would tear it off the bed. *A 4/11/13 care plan conference note with no documentation regarding his fall risk. *Was seen on 4/26/13 by PT AA and to continue with the current plan of care. Review of the provider's policies revealed no policy in regards to fall prevention. The only policy was a 4/4/05 Falls policy for the evaluation of the resident after a fall and included: *Incident report completed and placed on the DONs desk. *Resident records stated occurrence, effect, and resolution. *The care plan was revised and updated. *The DON would review the incident for patterns and safety issues. 2. Review of resident 4's entire medical record revealed : *She had a fall with significant injury on 5/27/13. That fall had resulted in the resident being hospitalized and diagnosed with [REDACTED]. *The resident had returned on 6/6/13 from the hospital with a cast on her left arm and an immobilizer to her left leg. Random observations throughout the survey from 6/24/13 through 6/27/13 and from 7/1/13 through 7/2/13 of resident 4 revealed she was transferring from her wheelchair to her bed with no staff assistance, aide of a walker, or other assistive device. Interview, medical record review, and undated care plan review on 6/25/13 at 11:40 a.m. with the interim director of nursing (IDON) regarding resident 4's fall risk revealed: *No fall assessment had been done on the resident since her return from the hospital on [DATE]. *No fall prevention measures or interventions had been care planned after her return from the hospital on [DATE]. *It had been ordered on her 6/6/13 hospital discharge orders that she be evaluated by physical therapy and have no weight bearing on her injured extremities. However no physical therapy evaluation had been completed, and staff were allowing her to self transfer and bear weight on both of her extremities. *No significant change Minimum Data Set had been completed after her return from the hospital with injuries that had significantly changed her level of care. *She agreed based on the resident's last fall, casting, immobilization, and self transferring the resident should have had a fall assessment. Should of had a care plan that outlined her care to prevent future falls. *The provider had no fall committee. *She was unsure if any fall policies and procedures existed. 3. Review of resident 2's care record revealed: *A right tibula (bone on leg below the knee) and fibula (calf bone) fracture on 3/17/13 related to a fall. *He had been attempting to transfer himself into his wheelchair without locking both his wheelchair brakes. *He had been wearing only socks and no shoes when he had transferred himself. Review of resident 2's 4/1/13 Minimum Data Set (MDS) revealed short and long term memory deficits (problems). Review of resident 2's undated Resident Care Guide revealed: *"I have a hard time moving my right side." *"I can safely transfer myself from my wheelchair to the commode (bedside toilet) or to my bed and back again. If in the future I need help, I will ask." *"I have not had any falls. I feel pretty safe, but if I need help I will ask." *"I do have seizures (convulsions) and I usually know when I am going to have one. I can get myself to a safe place and notify the nurses." *There was no documentation of his memory deficits. Review of resident 2's 5/23/13 Resident Care Guide revealed: *"Fractured right leg." *"Tibia and fibula fracture healing with goal for healed fracture." *There were no interventions documented regarding falls. 4. Review of resident 12's 3/5/13 through 6/8/13 nurses notes revealed: *Multiple episodes of urine incontinence and of not making it to the bathroom in time. He was changing his own pull-ups (disposable adult briefs) and changing soiled clothes by himself at all times. *A fall on 3/5/13 in the shower room when he had attempted to self-transfer from the shower chair to his wheelchair. He slipped and then came down on his knees. *There was no documentation he was being assisted in the shower room when he fell . Review of resident 12's 4/27/13 MDS revealed: *A brief interview for mental status (BIMS) score of 3. (A score of 3 meant severe mental impairment). *Frequently incontinent of urine with no toileting program. Independent toilet use. *Supervised with bathing and one person physical assistance. Review of resident 12's 5/8/13 care plan revealed: *"I have a bad knee so this limits the amount of walking I can do." *"I can take myself to the bathroom. I have been having problems with not making it to the bathroom. I was having to change clothes two or three times a day." *"I can do most of my own bathing. I should have someone in there for transfers so I do not slip on the wet floors." *"I have problems with bowel and bladder function and have started to wear pull-ups (disposable adult undergarment.) *"I am usually pretty safe with my transfers except when the floor is wet." *There was no documentation regarding a revised toileting plan related to the increased urine incontinence. *There was no documentation of increased fall risk with potential wet bathroom floors from incontinence and of him doing his own toileting and changing his soiled clothes and briefs. 5. Review of resident 14's 2/15/13 fall/investigation worksheet revealed "Certified nursing assistant (CNA) H stated resident got himself out of sit-to-stand lift and fell backwards onto floor and hitting his head." Review of resident 14's undated care plan revealed: *"I can stand for transfers. My legs are weak." *"It will take two of you to transfer me or one of you to use the stand-lift." Interview on 7/2/13 at 9:30 a.m. with CNA H regarding resident 14 revealed: *He was a very big man and confused most of the time. *Nursing assistant DD was assisting her to transfer him. *He likely fell out of the sit-to-stand lift because the straps were not tight enough. *After he had fell out of the sit-to-stand lift, they had continued to use it to transfer him. 6. Interview on 7/1/13 at 9:30 a.m. with the interim DON regarding the above findings revealed: *Falls were discussed in care plan meetings but no revisions to their plan of care were usually done. *Remembered discussing resident 14's falls in the care plan meeting, but there was no discussion the sit-to-stand lift might not be an appropriate way to transfer him after he had fell out of it. *They had not considered the fall risk for resident 12 would be increased due to his increased urinary incontinence and trying to help himself in the bathroom. A toileting plan had never been discussed as a preventative measure to keep floors dry. *There were no preventative interventions on resident 2's care plan regarding falls. 7. Review of resident 8's complete medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. -Dementia (confusion) with agitated behaviors. -Head Injury. *He had four falls since 4/16/13. -The dates of the falls were 4/16/13, 4/24/13, 5/03/12, and 5/28/13. *He had a history of [REDACTED]. -He had bruises and lacerations from doing that. Review of resident 8's 5/01/13 care plan revealed: *There had been no care plan developed addressing his frequent falls. *The goal was to not have an injury or to cause an injury due to his angry outbursts. *A thirty minute group exercise program was offered three to six times per week. -Attendance was optional. Review of resident 8's Fall Risk Assessment revealed: *The last assessment had been completed on 5/03/13. *The assessment had a total score of ten and that represented a high risk for falls. Review of resident 8's 5/22/13 restorative progress notes revealed: *He did not like to exercise. *He used a non-skid pad in his wheelchair. Random observation from 6/24/13 through 7/02/13 of resident 8 revealed he had no alarm monitor on when he was in his chair. Review of the United States Health and Human Services, Agency for Healthcare Research and Quality, website for long term care, http://www.ahrq.gov/research/ltcix.htm, revealed the following basic steps of care for residents who fell were: "Evaluate and monitor resident for 72 hours after the fall, investigate fall circumstances, record circumstances resident outcome and staff response, FAX alert to primary care provider, implement immediate intervention within first 24 hours, complete falls assessment, develop plan of care, monitor staff compliance and resident response." 8. Review of resident 6's complete medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. -Coronary artery (heart) disease. -Chronic obstructive pulmonary (respiratory) disorder. -Chronic heart failure. -[DIAGNOSES REDACTED] (blood disorder). -Hearing loss. -Adrenal insufficiency (gland disorder). -Alcohol abuse. Review of resident 6's 5/0/13 care plan revealed: *Ambulation: "I use a cane for balance while ambulating. My gait is unsteady but the cane helps to stabilize me." An unauthored handwritten note "Refuses to use a walker or w/c (wheelchair)." *Bathing: "I can do most or my care I do need help with my hair and feet. I also like to have one person with me so I don't fall." *Safety Notes: "I have a slow, stiff, shuffling walk which causes me to be unbalanced. I use a cane for ambulation. I have had falls but no injuries. I don't wart to use a walker." Review of resident 6's Fall Risk Assessments revealed the following scores and directions "Total score above 10 represents HIGH RISK".: *5/3/13 a total score of 14. *6/11/12 a total score of 11. *3/23/12 a total score of 13. Review of the nurses notes from 6/28/12 through 6/20/13 revealed: *8/3/12 - 6:20 p.m. Resident fell in dining room. No visible injuries. *8/22/12 - 4:15 p.m. Was coming around the corner from the lobby and lost balance, fell backwards. *8/25/12 - 12:30 p.m. Generalized weakness. Stumbles frequently and catches self. *8/26/12 - 1:00 p.m. Resident was seen and evaluated by his attending physician and discussed falls and no new orders received. *8/26/12 - 4:30 p.m. Observed to trip on carpet while loosing his balance. Went down to knees. *9/10/12 - 7:45 p.m. Resident was walking in dining room to another resident table, slipped, and fell to floor. *9/18/12 10:45 a.m. Resident was seen and evaluated by PT AA for a quarterly evaluation and for follow-up for fall on 9/13/12. No changes made. Continue with plan of care. *10/1/12 - 8:00 p.m. Was going around another wheelchair, tripped over back wheel. Went down to the floor. *11/11/12 - 2:00 p.m. Unsteady gait, high risk for falls. *11/23/12 - 10:20 a.m. Care conference note "Restorative-asked again about using cane. Resident agrees. Gait unsteady. Nursing-Resident did have 2 falls past 90 days. No falls since new shoes ordered." *11/27/12 - 4:00 p.m. Starting to get up from his chair and then was seen lying on the floor on his left side with head off floor. *1/31/13 - 7:00 p.m. Resident was on the floor in the lobby, stated was getting up and lost balance. *2/13/13 - (no time) Care conference note "Nursing-____(resident 6) has increased weakness and unsteady gait. Uses a cane but probably needs to use a walker. He dose ref.(refuses) to use a walker." *3/13/13 - 4:15 p.m. Resident was sitting in the front lobby. Got up from chair, took a couple steps, stumbled, and fell to his knees, then laid down on the floor. *3/13/13 - (no time) Has had one fall due to shoestring being untied, fell to knees, but no injuries. *5/1/13 - (no time) Care conference note "Nursing-No concerns noted." *5/17/13 - 5:40 p.m. Sat in the chapel in a high stool, was getting off of his chair when he fell forward onto the floor against the piano at 3:15 p.m.. *5/24/13 - (no time) Resident was walking in dining room and fell . Said got feet tangled up and fell over. 6/20/13 - 1:10 p.m. Resident stated he slipped out of shower chair and slid to floor. Was assisted up and back into shower chair. Review of the 10/4/12 physician's progress notes revealed "Right hand is swollen - He stated he fell and hit it. It is starting to bruise. Good range of motion of finger and wrist. Ace wrap applied." Review of the 4/26/13 Care Area Assessment Trigger Analysis revealed falls had triggered in the care area and the following were to be addressed in the care plan: *Bathing: 1 - Supervision. *Wandering: 2 - Occurred four to six days, but less than daily. *Balance: Moving from seated to standing postilion - 1 - Not Steady. *Balance: Walking - 1 - Not steady. *Balance: Turning around while walking - 1 - Not steady. *Balance: Moving on or off toilet - 1 - Not steady. *Balance: Surface-to-surface transfer - 1 - Not steady. 9. Review of resident 3's complete medical record revealed: *He had been admitted on [DATE]. *His [DIAGNOSES REDACTED]. -Dementia (confusion) with aggravated behaviors. -Anxiety. -Depression. *He had a history of [REDACTED]. *His fall risk assessments included: -On 4/9/12 he had scored a twenty-three that would have been a very high risk for falls. -The next one had been completed over a year later on 5/3/13. *He had fell on [DATE], 4/11/13, 5/12/13, and 5/22/13. -On 3/29/13 at 9:30 p.m. he had fell and hit his head, and neuros (assessment done to ensure there was no brain injury) were incomplete. Neuros had been done at 9:30 p.m., 9:45 p.m., 10:15 p.m., 10:45 p.m., 11:45 p.m., and on 3/30/13 at 3:45 a.m. -On 4/11/13 he had an unwitnessed fall and there was no neuros completed. -On 5/12/13 at 4:50 p.m. he had fell again and had hit his head, and neuros were incomplete. Neuros had been done at 4:50 p.m., 5:15 p.m., 5:30 p.m., 6:00 p.m., and on 5/13/13 at midnight. *His undated comprehensive care plan revealed: -"Safety Notes: I am at risk for falls. I cannot remember that I can't walk. I will stand and fall or walk a few steps and fall. I have a tabs monitor on my wheel chair. Goal: To not fall or if I do fall to not have any serious injuries." *There was no documentation in his care plan of any new interventions that had been put in place to assist him from falling or injuring himself. Interview on 6/26/13 at 10:00 a.m. with the assistant director of nursing regarding resident 3 revealed: *He had fell approximately two years ago and fractured his hip. *He had attempted to get out of his wheelchair (w/c) several times. *He also had attempted to get up out of his bed frequently. *The staff had placed a scoop mattress that would have prevented him from getting out of bed, so staff would have been able to get into his room before he had gotten out of bed. *She agreed there should have been a fall assessment completed quarterly, new interventions should have been put in place each time he had fell , and the comprehensive care plan should have reflected those interventions. Interview on 7/1/13 at 8:15 a.m. with the interim director of nursing regarding resident 3 revealed she: *Confirmed the fall assessments had not been completed on a timely basis. *Agreed new interventions should have been put in place or attempted after each new fall. *She agreed the neurological assessments had not been completed appropriately. *Agreed the comprehensive care plan was incomplete and provided minimal information regarding his falls and interventions. Review of the provider's undated Neurological Assessment Following A Suspected Head Injury policy revealed: *A neurological assessment would be completed after a fall with a heady injury. *After a fall with a head injury had occurred a neurological assessment would be completed: -Every 15 minutes for two times. -Then every 30 minutes for two times. -Every hour for one time. -Then four hours from the hourly neuros. -Vital signs (that would include blood pressure, pulse, and respirations), pain and discomfort, bruising, and change in motor function (movement of legs and arms) would be done every shift for three days. 10. Review of resident 9's complete medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. -Diabetes Mellitus. -Hypertension. -Congestive Heart Failure. -Weakness. *On 6/20/13 at 5:45 a.m. she had been found sitting on the floor in her room. *There was no fall assessment documented. *Resident 9's 5/1/13 comprehensive care plan revealed: -"Safety Notes: I have not had any falls or injuries and I want it to stay that way. Goal: To not fall." *There was no documentation regarding her recent fall and interventions that had been put in place after her fall. Interview on 6/26/13 at 3:30 p.m. with the interim DON regarding resident 3's fall revealed: *There had been no fall assessment completed on admission or after she had fell . *The assessment had usually been completed by the former DON, and she had not completed a fall assessment on resident 3. *She agreed there should have been a fall assessment completed with admission and after her fall on 6/20/13.

Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered in a manner that ensured the safety and overall well-being of all its residents. Findings include: 1. Interview on 7/2/13 at 12:30 p.m. with the administrator-in-training revealed she had: *No working knowledge of any of the state or federal regulations for nursing facilities. When the state and federal regulations were opened on this surveyor's computer she was asked if she had seen them before. She stated "I have but I have not had time to read them." *Never seen the federal quality reports nor did she know what they were. *No experience in the health field and had been an accountant for a school prior to taking on learning the nursing home administrator's role. *Received minimal training from her former licensed nursing home administrator preceptor according to her. *No working knowledge of quality assurance or other key healthcare management processes. *No formal orientation paperwork for her current position. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed the special permit holder had not ensured the safe management and overall well-being of the residents. Refer to F156, F160, F161, F164, F166, F167, F221, F223, F241, F243, F244, F247, F248, F250, F252, F253, F274, F279, F281, F309, F313, F323, F353, F354, F356, F361, F363, F364, F366, F367, F368, F371, F431, F441, F454, F456, F466, F467, F490, F493, F494, F495, F498, F501, and F520.

Based on interview, observation, record review, and policy review, the provider failed to ensure: *A licensed administrator was available and trained to oversee the safe management of the facility. *Operational policies, procedures, and practices were in place and being followed for the safe management of the facility. Findings include: 1. Interview on 7/2/13 at 1:30 p.m. with the administrator-in-training revealed she: *Had been the administrator-in-training for the facility since November 2012. *Was not licensed in the state of South Dakota as a nursing home administrator and had no experience in health care or nursing home administration prior to starting in November 2012. *Stated she and the governing body had terminated the employment of her licensed nursing home administrator preceptor on 6/19/13 for undisclosed reasons. *Along with the governing body had not secured another licensed nursing home administrator preceptor prior to terminating her agreement leaving her without a preceptor. *Was not aware of any operational/managerial policies or procedures that had been approved by the governing body to guide her practices while she was without a licensed preceptor. Refer to F490, finding 1. 2. Interviews, observations, record reviews, and policy reviews throughout the course of the survey revealed policies, procedures, and practices had not been implemented to ensure the safe management and overall care of the residents. Refer to F156, F160, F161, F164, F166, F167, F221, F223, F241, F243, F244, F247, F248, F250, F252, F253, F274, F279, F281, F309, F313, F323, F353, F354, F356, F361, F363, F364, F366, F367, F368, F371, F431, F441, F454, F456, F466, F467, F490, F493, F494, F495, F498, F501, and F520.

Based on observation, interview, record review, and policy review, the provider failed to: *Provide appropriate physical therapy and nursing services to two of two sampled residents (2 and 4) who had orthopedic injuries. *Provide appropriate physician ordered therapeutic meals and monitoring of fluid intake for two of five sampled residents (4 and 18) who received chronic [MEDICAL TREATMENT] (a procedure performed when there was no functioning kidneys to eliminate toxins from the blood stream). *Ensure policies and procedures were in place related to the care of five of five residents (4, 18, 21, 22, and 24) who received [MEDICAL TREATMENT]. *Provide appropriate intervention, assessment, and documentation for one of one sampled resident (12) who had a change in urinary continence. *Provide appropriate intervention, assessment, monitoring, and documentation for one of one sampled resident (13) who had an acute change in his mental and physical condition. Findings include: 1. Review of resident 4's medical record related to physical and restorative therapy revealed: *She had a fall with significant injury on [DATE]. That fall had resulted in the resident being hospitalized and diagnosed with [REDACTED]. *The resident had returned to the facility on [DATE] from the hospital with a cast on her left arm and an immobilizer to her left leg. *It had been ordered on her [DATE] hospital discharge orders she needed to be evaluated by physical therapy and have no weight bearing on her injured extremities. *Restorative therapy staff had been documenting they had been performing therapy on her since her return from the hospital. That therapy included: ambulation, pulley's with both arms, sit-to-stand, and leg and ankle exercises. Random observations throughout the survey from [DATE] through [DATE] and [DATE] through [DATE] of resident 4 revealed she: *Was transferring from her wheelchair to her bed with no staff assistance, no walker, nor other assistive device. *She was using her fractured arm and leg to propel herself in her wheelchair. Random interviews of licensed nurses, certified nursing assistants, and nursing assistants throughout the survey regarding resident 4's physical limitations revealed none of them were aware of any weight bearing or physical therapy orders. Interview and record review on [DATE] at 3:40 p.m. with restorative aides N and S related to resident 4's restorative program revealed: *They had been performing the above noted restorative therapy since the time she had come back from the hospital on [DATE]. *When asked why they had been trying to perform restorative therapy on a resident with a fractured arm, leg, and a knee injury they stated because she was in her annual Minimum Data Set assessment period. *When asked if the physical therapist had approved them doing that they stated they were unsure. Further conversation revealed the physical therapist had never seen the resident despite the [DATE] orthopedic physician's orders [REDACTED]. *Review of the primary physician's orders [REDACTED]. *The physical therapist was on-site only one time per month and the last time he had been at the facility was on [DATE]. Records provided by the restorative aides confirmed the physical therapist had not seen the resident on [DATE]. *They did not know the resident had orders for no weight bearing to either of her injured extremities at the time she had been readmitted on [DATE]. Interview and record review on [DATE] at 3:45 p.m. with the interim director of nursing regarding resident 4's physical therapy, restorative therapy, and overall care from the injuries that had occurred from the fall on [DATE] revealed: *The resident's undated care plan did not contain information/interventions to ensure the proper orthopedic care of the resident after her return from the hospital on [DATE]. *No significant change Minimum Data Set (MDS) had been completed upon her return to the facility that would have helped the provider address needed care areas. When asked why that had not been done she was unable to answer. *She agreed if a significant change MDS had been completed it would have found the resident was over-level-of-care for the facility as they did not have the necessary therapy services for that resident. *She agreed the weight bearing and physical therapy orders of the resident's orthopedic physician had not been followed, and she could not explain why. *She could not explain why the resident's primary physician's [DATE] orders for restorative therapy had not been questioned and clarified. *She agreed based on the above findings the resident was at risk for further injury as well as decreased healing. Interview on [DATE] at 4:30 p.m. with resident 4 revealed she was not aware of any limitations in mobility she had since her return to the facility. 2. Review of resident 4's medical record revealed: *She was a [MEDICAL TREATMENT] patient and had received [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. *She was to receive a specialized therapeutic [MEDICAL TREATMENT] diet and was on a 1500 milliliter fluid restriction. Refer to F367. Random meal observation throughout the survey from [DATE] through [DATE] revealed resident 4 never received her therapeutic diet and her fluid intake was not properly documented by dietary or nursing services. Refer to F367. Interview and record review on [DATE] at 10:15 a.m. with the interim director of nursing regarding resident 4's diet and [MEDICAL TREATMENT] revealed: *She agreed the resident's dietary and fluid orders had not been followed and monitored. She further agreed following those order's was especially important for [MEDICAL TREATMENT] residents. Those residents were very susceptible to fluid and chemical imbalances. *The provider had no policies and procedures related to the care of [MEDICAL TREATMENT] residents despite having five residents who received [MEDICAL TREATMENT]. 3. Review of resident 2's medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. *An unwitnessed fall on [DATE] during a self-transfer. He had sustained a right tibula (bone on leg below the knee) and fibula (calf bone) fracture as a result of the fall. Interview on [DATE] at 10:00 a.m. with licensed practical nurse (LPN) E regarding resident 2 revealed: *He had fell on [DATE] at 8:15 p.m. but she had not documented in the nurses' notes until 8:50 a.m. on [DATE] at the end of her shift. *She had notified the physician on [DATE] at 8:25 p.m. of the fall but again had not documented it until 8:50 a.m. on [DATE]. The physician had stated to just monitor, and if he was still hurting in the morning to send him to the hospital for an evaluation. Review of resident 2's [DATE] at 8:50 a.m. nurses notes by LPN E revealed: *"Hollering for help in his room and found laying on floor with his right leg bent backwards. States his knee hurt." *"States he had been trying to transfer himself into his wheelchair and slipped and fell to the floor." *"He had socks on but no shoes. Also noting his wheelchair was unlocked on the left side and it was locked on the right side." *"Did note his right knee cap was slightly bruised and swollen. Ice pack placed on his right knee through the night and at 8:20 p.m. Tylenol was given for pain. [MEDICATION NAME] (narcotic pain medication) was given at 3:40 a.m." *There was no further documentation regarding his condition from 8:50 a.m. through 8:13 p.m. on [DATE]. Review of resident 2's [DATE] at 8:13 p.m. nurses notes by LPN CC revealed: *"Came in for night shift and certified nursing assistant (CNA) informed this writer that resident was not getting up for bathroom or meals." *"Right leg was very swollen and has lots of pain." *"Sent to Indian Health Service emergency room per ambulance. Resident cried and moaned very loudly in pain." *"Was informed resident had a shattered knee." Review of resident 2's [DATE] transfer orders from an acute care hospital revealed: *A right tibula (bone on leg below the knee) and fibula (calf bone) fracture on [DATE] related to a fall. *No weight bearing (NWB) on right lower extremity. *Continue knee immobilizer. *Physical therapy (PT), occupational therapy (OT), and speech therapy (ST) evaluations as indicated with treatment. Review of resident 2's medical record from [DATE] through [DATE] revealed: *Documentation PT had evaluated him on [DATE]. *The [DATE] PT notes directed the following orders for restorative care to complete: -"Active assistive range of motion to right hip 15 minutes a day ,[DATE] times a week or as tolerated." -"Straight leg raises 15 times 15 minutes a day ,[DATE] times a week or as tolerated." (There was no documentation which leg or legs were to be exercised). -"Hip abduction (away from the body)/adduction (towards the body) 15 times each 15 minutes/day ,[DATE] times a week or as tolerated." *There was no documentation OT or ST had evaluated him. *Orders written by PT on [DATE] were to discontinue the order for the right lower extremity secondary to tibula/fibula fracture. Review of resident 2's [DATE] restorative charting record revealed documentation exercises to the right lower extremity had been done on [DATE], [DATE], [DATE], and [DATE]. Review of resident 2's [DATE] through [DATE] pain management flowsheet revealed [MEDICATION NAME] (narcotic pain medication) had been administered six times. Four of the doses had documentation he reported his pain level was 6 to 8 on a 1 through 10 scale. A 6 pain rating was indicative of severe pain and an 8 pain rating was indicative of very severe pain. Phone interview on [DATE] at 10:45 a.m. with PT AA regarding resident 2 revealed: *He came to the facility on ce a month. *He had evaluated the resident on [DATE] and had implemented a restorative plan of care. They were unable to provide skilled PT related to the provider not being Medicare certified. He had not informed the physician of that and did not know whether the nursing staff had. *"For skilled PT to be provided he would have come to another facility for outpatient PT. (Those facilities were approximately one-half to one hour away). *"If he was doing skilled PT for him he would be able to do more hands on care such as ultrasound, electrical stimulation, and [MEDICAL CONDITION] massage." *He knew the provider could also not provide skilled OT or ST. *He was unsure why the restorative staff were not following his orders on [DATE] to discontinue exercises to the right lower extremity. Interview on [DATE] at 8:45 a.m. with LPN BB revealed she had not removed the PT's orders of [DATE] from the restorative plan of care, and she should have. Interview on [DATE] at 2:00 p.m. with restorative aide S regarding resident 2 revealed she: *Was not sure what his weight bearing status was but thought he was still nonweight bearing (NWB) for his right leg. *Confirmed they were following the exercises to both his arms and legs as directed by the PT. *Agreed their overall restorative plan of care had not been updated since [DATE]. *She was unsure if the nurses gave him pain medication before his restorative exercises. Interview on [DATE] at 9:00 a.m. with the interim DON regarding resident 2 revealed: *They should have informed the physician they were unable to provide skilled PT, OT, and ST at their facility prior to him returning from the hospital on [DATE]. *They had not informed the physician he was not receiving skilled PT, OT, and ST as had been ordered. *His rehabilitation from the fracture was likely impaired related to him not receiving the skilled services. 4. Observation of resident 12 on [DATE] from 9:20 a.m. through 11:00 a.m. revealed he: *Was sitting at the nurse's station in his wheelchair talking on the phone. He was wearing blue jeans. The crotch area of the jeans was darker and wet. *Wheeled himself back to his room in his wheelchair. He did not go in the bathroom or change his soiled jeans. *Returned to sitting in the hallway with the same wet jeans on. Review of resident 12's [DATE] through [DATE] nurses' notes revealed: *[DATE]- "Night shift has been noticing him urinating a lot more in his pants and getting his bedding wet. When he wets his pull-ups (disposable adult brief) he will sometimes stick them in his pocket. Housekeeping stating that he will stuff his urinated pants in his drawer. Continue with plan of care." *[DATE]- "Have been noting resident being confused with his remote to his TV, and wanting to use the remote to turn the radio on. Will continue with plan of care." *[DATE]- "Gets up frequently during the night and changes his clothes. Staff place him in a gown and a pull-up, but he will get up during night and change." *[DATE]- "Seen by local physician assistant (PA). There are no new orders at this time." (There was no documentation the PA had been informed of the increased urine incontinence or the increased confusion). *[DATE]- "Sleeps well but gets up at least 3 times during the night. Comes out to desk with wet pants. Staff put a pull-up on him for bedtime, but he usually takes it off. Resident is re-directed to room and pull-up placed on again." *[DATE]- "Resident seen by physician. No new orders at this time. Will continue with plan of care." Review of resident 12's [DATE] through [DATE] nurses' notes revealed no further documentation regarding his urine incontinence and his increased confusion. Interview on [DATE] at 5:40 p.m. with LPN CC regarding resident 12 revealed: *He had been continent (no bladder accidents) on the night shift until about four months ago. *Now he needed to be changed about four times at night depending how often he wet himself. *He still got up to go to the bathroom on his own and would change his soiled pull-up and clothes. Interview on [DATE] at 2:20 p.m. with the social service designee (SSD) regarding resident 12 revealed she: *Had observed his pants were often wet when he came into her office to visit with her. *Had reported the increased incontinence back in [DATE] to the nurses. She was unsure if anything had been done for him regarding that issue. *Had observed he was more confused in addition to the increased incontinence in [DATE] and had also reported that to the nurses. *Thought he handled his own toileting and changing his wet clothes. Review of resident 12's [DATE] Minimum Data Set (MDS) revealed: *Brief interview for mental status (BIMs) score of 10 indicative of moderate mental impairment. *[DIAGNOSES REDACTED]. *Independent toilet use. *Occasionally incontinent (bladder accidents) urine. *No toileting program. Review of resident 12's [DATE] MDS revealed: *BIMs score of 3 indicative of severe mental impairment. *Independent toilet use. *Frequently incontinent of urine. *No toileting program. Review of resident 12's [DATE] care plan revealed: *Increased urine incontinence and memory problems. *Will check for urinary tract infection. "Physician notified." *Encourage use of briefs/pull-ups ( disposable adult protective undergarments). *Evaluate urinalysis and possible alternatives. *"I can take myself to the bathroom." *"I have been having problems with not making it to the bathroom." *"I was having to change clothes two or three times a day. I have started to wear pull-ups and this has helped." Interview on [DATE] at 1:00 p.m. with the interim director of nursing (DON) regarding resident 12 revealed she: *Had made the entries on his [DATE] care plan about obtaining the urinalysis and informing the physician. *Had thought the nurses were going to do it, and thought she had told the nurses to do it. *Could not remember discussing a toileting plan for him related to his increased incontinence. She thought he was still independent with using the toilet and changing his pull-ups. *Knew he did not like wearing the pull-ups, and would put his underwear on and wet his clothes. Interview on [DATE] at 12:30 p.m. with LPN BB regarding resident 12 revealed: *Each resident had "standing orders" signed by their physician that included to obtain a urinalysis if necessary. *They had not obtained the urinalysis yet. She thought it had been obtained a couple weeks ago. *She was unsure why no one had followed through on the [DATE] care plan documentation to inform the physician of his increased incontinence (bladder accidents) and confusion and to obtain a urinalysis. *He did better with using a urinal and she had been attempting for the last few days to obtain a urine specimen. 5. Review of resident 13's medical record revealed: *A [DATE] admitted . (Spouse also was admitted and was his roommate.) *[DIAGNOSES REDACTED]. *His wife had expired on [DATE]. Review of resident 13's [DATE] physician's orders [REDACTED]. *[MEDICATION NAME] (antidepressant) 10 milligrams (mg) daily and [MEDICATION NAME] (antidepressant) 15 mg daily. *Social services as needs arise. Review of resident 13's [DATE] nutrition progress notes by the registered dietitian revealed: *Weight loss again this month of 13.9 pounds. *Since wife had passed away he had been depressed and his intake had decreased significantly. Review of the social service progress notes revealed the last documentation was [DATE] by the previous social service designee (SSD.) Review of resident 13's [DATE] care plan notes completed by the interim DON revealed: *"Has lost weight. Has little interest in eating." *"All agreed that a room change or a roommate might help (his spouse of [AGE] years who had been his roommate died [DATE])." *"Doesn't leave his room except for meals." *"Does not ambulate anymore." *"Is on two antidepressants." *"All present feel that after [AGE] years of marriage the loss of a spouse is very traumatic. Will allow grieving time and allow him to express his sadness." *Care plan changed to reflect recent changes. Review of resident 13's [DATE] care plan revealed: *"I am starting to have short-term memory problems." *"I sometimes feel helpless and useless." *"I am very sad now my wife of [AGE] years has died ." *"Depression related to recent loss of wife." *"Allow me time to grieve. Listen or find someone who will listen to me." *"Make sure I get my medicine at the right time, the right amount, and that it is the right medication." *"Notify my doctor of any concerns and notify my family as needed." Review of resident 13's [DATE] through [DATE] nurses' notes revealed: *[DATE]- "Coping with his wife's death." (Spouse was roommate.) *[DATE]- "Has been on call light all night wanting little things done. Stated no one waited on him. The certified nursing assistants (CNA) waited on him all night long. Did lose wife recently and has not adjusted yet. Resident is just depressed or is becoming more and more confused possibly due to his wife passing." *[DATE]- "Has very poor appetite and hardly eats at meals even with encouragement. He states he does not feel good. Is getting weaker." *[DATE]- "Appetite continues to be very poor. Takes only sips of juice and water." *[DATE]- "Resident started on antibiotic last evening for urinary tract infection." *[DATE]- "Has been seeing people and things throughout the night. On call light many times telling staff to chase people out of his room. Looking gaunt in the face." *[DATE]- "Has been quite confused talking to self at times. Looking quite pale and losing weight. Looking for a small pistol that he had next to him. Got resident up in wheelchair. He slumped over and was unresponsive and put back to bed immediately. Son called and he said to push fluids on him due to dehydration. Continues to be very confused and talking to self a lot. Seeing people that are not there. Just restless." *[DATE] at 2:30 p.m.- "Seen by physician assistant (PA) with no new orders at this time. Will continue with plan of care." *[DATE] at 5:00 p.m.- "Resident change in condition. Appears to be confused with cares and not eating for all meals. A pastor came and talked to resident. Will continue with plan of care." *[DATE]- "Is very weak and unresponsive at times, takes awhile for him to answer. Does not get up in wheelchair. Refused all medications today." *[DATE]- "Refused all morning medications except [MEDICATION NAME] (pain medication). Complains of being too hot and needing cold air. Blood pressure (B/P) ,[DATE] (normal ,[DATE]), pulse ,[DATE] (normal ,[DATE]), and oxygen saturation 86 percent (%) on 5 liters of oxygen (normal saturation greater than 90%). Right lung has got the rattling in upper and lower lobe. Left lung had slight diminished lung sounds in lower lobe. Son was contacted." *[DATE] at 8:00 p.m.- "Is taking nothing by mouth and having deep heavy breaths. Eyes are glazed over. Resident appears to becoming close to passing on." *[DATE] at 7:45 a.m.- "Was checked as requested by CNA. No breathing, no respirations, or heart rate noted. *[DATE] at 9:15 a.m.- "Verified no breathing and no heart rate by licensed practical nurse (LPN) CC earlier at 7:50 a.m." (This was documented by LPN D.) *There was no documentation regarding the resident's condition from [DATE] at 8:00 p.m. until he had been found expired (dead) at 7:45 a.m. on [DATE] (11 hours and 45 minutes). *There was no documentation the physician had been kept updated of his condition from [DATE] until his death on [DATE]. Review of resident 13's [DATE] physician's progress notes by the PA revealed: *"Has quit eating and just taking small amounts of fluids." *"Has [MEDICAL CONDITION] (MRSA) now." (A bacteria responsible for several difficult to treat infections in humans.) Review of resident 13's [DATE] through [DATE] Turn/Reposition record completed by the CNAs revealed: *The last documentation he was repositioned was on his back at 6:00 a.m. on [DATE]. *There was no further documentation by the CNAs from 6:00 a.m. until a CNA found him expired at 7:45 a.m. Review of resident 13's [DATE] through [DATE] Pain Management Flowsheet/As needed (PRN) Flowsheet revealed a Tylenol suppository had been administered on: *[DATE] at 2:00 a.m. for a pulse reading of 147 and unable to express pain. Follow-up documentation was pulse 103. *[DATE] at 8:00 a.m. for "Resident said they were in pain" and a rating of 4 on a ,[DATE] scale indicative of moderate pain. There was no follow-up documentation if it had been effective. *[DATE] at 1:00 a.m. for pulse of 124 and pain rating of ,[DATE] indicative of moderate pain. The follow-up documentation was pulse 98. There was no documentation regarding his pain. *[DATE] at 10:12 a.m. for "Resident wanted pain medication." The pain rating was documented as 3 indicative of mild-moderate pain. The follow-up documentation was pulse 100. There was no documentation regarding his pain. Interview on [DATE] at 9:15 a.m. with the SSD regarding resident 13 revealed: *There was no discussion after his spouse had died to evaluate with the physician his present antidepressant medication for a possible increase or change in medication. *He had never received any counseling for his depression, and that also had not been considered an option to assist him with the grieving process after his wife had died . *The only thing that had been discussed was for him to move to another room or have a roommate. He refused to change rooms but was acceptive of a roommate. *She knew she had visited with him periodically but had not documented those visits in his medical record. Interview on [DATE] at 9:45 a.m. with the interim DON regarding resident 13 revealed: *They had not considered having the physician evaluate his antidepressant medication after his wife had died on [DATE]. They should have done that as he was significantly more depressed after her death. *When he had started seeing things on [DATE] that was unusual for him, and the physician should have been updated. *There was minimal documentation of vital signs from [DATE] until his death on [DATE]. *She confirmed the physician had not been updated from [DATE] through [DATE] and from [DATE] until his death on [DATE]. The physician should have been kept updated. *She was unsure if he was experiencing any pain and if the Tylenol suppository was adequate pain control. They used the Tylenol suppository since it was a standing order. They had not evaluated with the physician other pain medication alternatives. *She confirmed there was no nursing documentation from [DATE] at 8:00 p.m. until [DATE] at 7:45 a.m. when the CNA had found him "dead" and had asked the nurse to check on him. *She agreed there was no documentation in the medical record that showed any staff had observed him from 6:00 a.m. until he was found "dead" at 7:45 a.m. by a CNA on [DATE]. Review of the provider's [DATE] Medication Administration General Guidelines policy revealed: *When PRN medications were administered the following documentation should have provided: -"Complaints or symptoms for which the medication was given." -"Results achieved from giving the dose and the time the results were noted. Results should pertain to or reflect the complaints or symptoms for which the medication was given. If given for pain, the results should address pain relief." Review of the provider's [DATE] Resident Change of Condition policy revealed: *"A nursing assessment is to be done at least once every 8 hours for the first 24 hours following a condition change and then at the discretion of the nurse." *"Continue to document the resident's condition and actions taken until the problem is resolved." *"Continue to keep the physician and the family/guardian updated." Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pg. 477, revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice." Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction." *"The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01." *"The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with the direct supervision when providing nursing care in a complex nursing situation; *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary." 6. Review of resident 18's complete medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. -End stage [MEDICAL CONDITION] (kidney were not functioning) and was on chronic [MEDICAL TREATMENT] (a procedure performed when there was no functioning kidneys to eliminate toxins from the blood stream). -Insulin dependent diabetes mellitus. -[MEDICAL CONDITION] (gland disorder). -Hypertension. *Currently was receiving [MEDICAL TREATMENT] three times a week (Tuesday, Thursday, and Saturday). *She was on a therapeutic diet and was on a 1500 cc daily fluid restriction. *On [DATE] she was unable to complete [MEDICAL TREATMENT] due to the weather. *There had been no documentation in the nursing notes that she had missed [MEDICAL TREATMENT] on [DATE]. *There had been no documentation of any interventions the nursing staff would have put in place to ensure she was not compromised, because she had not completed her scheduled [MEDICAL TREATMENT]. *Her [DATE] comprehensive care plan was minimal and incomplete regarding her [MEDICAL TREATMENT] regarding the following: -"Fluid Maintenance: I am a [MEDICAL TREATMENT] pt. (patient) (my kidney aren't working) so I should be limiting my fluids. [MEDICAL TREATMENT] pt.s always have dry skin and are always dehydrated. This all normal for [MEDICAL TREATMENT] pt. But because I have dry skin I may need lotion applied more often. Goal: To be pain free without any problems with my fluids." -There had been no specific instructions for staff as to the steps that would be required if she was unable to attend [MEDICAL TREATMENT]. -There was no appropriate renal diet mentioned on her care plan. Interview on [DATE] at 4:30 p.m. with the assistant director of nursing regarding resident 18's [MEDICAL TREATMENT] revealed: *If a resident had missed [MEDICAL TREATMENT] for weather or some other reason they would be scheduled the next day. *The staff would "watch" the residents fluid intake. *The nursing staff would not chart in the nursing notes that the resident had not been able to attend [MEDICAL TREATMENT], they only charted when the resident left the building for [MEDICAL TREATMENT]. *She agreed there was no specific instructions and interventions in place to ensure residents on [MEDICAL TREATMENT] who had missed their scheduled [MEDICAL TREATMENT] had appropriate nursing care. There was no appropriate policy and procedure provided to the surveyors with regards to emergency protocols for residents who had missed their scheduled [MEDICAL TREATMENT] or protocols for the appropriate overall nursing care and interventions for all residents on [MEDICAL TREATMENT].

Based on record review and interview, the provider failed to ensure the Plan of Correction from the 7/2/13 recertification survey had been completed for education on [MEDICAL TREATMENT] care for five of five sampled residents (4, 18, 21, 22, and 24). Findings include: 1. Review of the provider's education documents revealed training had not been provided for staff on how to care for residents that received [MEDICAL TREATMENT]. Interview on 8/7/13 at 2:30 p.m. with the interim director of nursing confirmed education had not been completed as listed in the plan of correction.

Based on observation, record review, interview, and policy review, the provider failed to: *Notify the physician of the inability to provide appropriate skilled therapies (physical therapy, occupational therapy, and speech therapy) for two of two sampled residents (2 and 4). *Notify the physician of a bruise of unknown origin and [MEDICAL CONDITION] activity for one of one sampled resident (2). *Appropriately assess and intervene for one of one sampled resident (4) who had fell and sustained an injury. *Appropriately assess, monitor, intervene, and document on one of one sampled resident (12) with increased urine incontinence. *Ensure nursing staff had appropriate knowledge of medical equipment (glucose meter) (blood sugar testing device) used on one of one sampled resident (18). *Appropriately notify the physician for one of one sampled resident (18) with a blood sugar of 525 who was on [MEDICAL TREATMENT] (medical intervention for kidneys). *Ensure nursing staff administered the correct dose of eye drops during medication administration for one of one sampled resident (7). *Follow-up with documentation of the results for PRN (when ever needed) medications for two of two sampled residents (7 and 18). *Ensure physician's orders [REDACTED]. Findings include: 1. Observation on 6/26/13 at 9:45 a.m. of resident 2 revealed: *Two unidentified certified nursing assistants (CNA) transferred him into bed. A gait belt was not used for the transfer. *The CNAs gave no direction to him to not bear weight on his right leg. *He had some weight on his right leg during the transfer. Review of resident 2's 4/13/13 nurses' notes revealed: *A large bruise of unknown origin to the right upper arm extending under the arm to his elbow. *There was no documentation the physician had been informed of the bruise. Review of resident 2's 6/4/13 nurses' notes revealed: *"Had possibly what appeared to be [MEDICAL CONDITION] activity. Lasted possibly a minute." *There was no documentation the physician had been informed of the [MEDICAL CONDITION] activity. Review of resident 2's 6/18/13 physician's orders [REDACTED]. *Monitor for [MEDICAL CONDITION] activity and notify physician. *May transfer with gait belt and two staff assistance. Review of resident 2's 3/26/13 transfer orders from an acute care hospital revealed: *A right tibula (bone on leg below the knee) and fibula (calf bone) fracture on 3/17/13 related to a fall. *No weight bearing (NWB) on right lower extremity. *Continue knee immobilizer. *Physical therapy, occupational therapy, and speech therapy evaluations as indicated with treatment. Review of resident 2's medical record from 3/26/13 through 6/26/13 revealed: *Documentation physical therapy (PT) had evaluated him on 3/28/13. *The 3/28/13 PT record notes directed the following orders for restorative care to complete: -"Active assistive range of motion to right hip 15 minutes a day 3-6 times a week or as tolerated." -"Straight leg raises 15 times 15 minutes a day 3-6 times a week or as tolerated." (There was no documentation which leg or legs were to be exercised.) -"Hip abduction (bringing away from the body)/adduction (bringing to the body) 15 times each 15 minutes/day 3-6 times a week or as tolerated." *There was no documentation occupational therapy (OT) or speech therapy (ST) had evaluated him. *Orders written by PT on 6/20/13 to discontinue the therapy order for the right lower extremity secondary to a tibula/fibula fracture. Review of resident 2's June 2013 restorative charting record revealed documentation exercises to the right lower extremity had been done on 6/21/13, 6/24/13, 6/25/13, and 6/26/13. Phone interview on 6/27/13 at 10:45 a.m. with PT AA regarding resident 2 revealed: *He came to the facility on ce a month. *He did quarterly screening on all the residents and updated their restorative plan. *He had evaluated resident 2 on 3/28/13 and had implemented a restorative plan of care. They were unable to provide skilled PT related to the provider not being Medicare certified. He had not informed the physician of that and did not know whether the nursing staff had. *"We do the best we can. We try and train with the exercises as much as we can." *"For skilled PT to be provided he would have come to another facility for outpatient PT. (Those facilities were approximately one-half to one hour away.) *"If he was doing skilled PT for him he would be able to do more hands on care such as ultrasound, electrical stimulation, and [MEDICAL CONDITION] massage." *He knew the provider could also not provide skilled OT or ST. *He was unsure why the restorative staff were not following his orders on 6/20/13 to discontinue exercises to the right lower extremity. Interview on 7/2/13 at 8:45 a.m. with the licensed practical nurse/assistant DON revealed she had not removed the PT's orders of 6/20/13 from the restorative plan of care, and she should have. Nursing had not informed the physician they were unable to provide skilled PT, OT, and ST as he had ordered. Interview on 6/26/13 at 2:00 p.m. with restorative aide S regarding resident 2 revealed she: *Was not sure what his weight bearing status was but thought he was still NWB for his right leg. *Confirmed they were following the exercises to both his arms and legs as directed by the PT. *Agreed their overall restorative plan of care had not been updated since 3/1/12. Interview on 7/1/13 at 9:00 a.m. with the interim DON regarding resident 2 revealed: *His bruise should have been investigated and reported to the physician. *His [MEDICAL CONDITION] activity should have been reported to the physician. *They should have informed the physician they were unable to provide skilled PT, OT, and ST at their facility. 2. Review of resident 12's 5/8/13 care plan revealed: *Increased urine incontinence and memory problems. *Would check for urinary tract infection; "Physician notified." *Encourage use of briefs/Attends ( disposable adult protective undergarments) for urinary incontinence. *Evaluate urinalysis and possible alternatives. Review of resident 12's 4/8/13 through 6/8/13 nurses' notes revealed: *4/8/13- "Is incontinent at times." *4/23/13- "Night shift has been noticing him urinating a lot more in his pants and getting his bedding wet. When he wets his attends he will sometimes stick them in his pocket. Housekeeping stating that he will stuff his urinated pants in his drawer. Continue with plan of care." *4/26/13- "Have been noting resident being confused with his remote to his TV, and wanting to use the remote to turn the radio on. Will continue with plan of care." *4/27/13- "Gets up frequently during the night and changes his clothes. Staff place him in a gown and a pull-up (adult disposable incontinence protective garment), but he will get up during night and change." *5/2/13- "Seen by local physician assistant (PA). There are no new orders at this time." (There was no documentation the PA had been informed of the increased urine incontinence or the increased confusion.) *5/20/13- "Sleeps well but gets up at least 3 times during the night. Comes out to desk with wet pants. Staff put a pull-up on him for bedtime, but he usually takes it off. Resident is re-directed to room and pull-up placed on again." *6/8/13- "Resident seen by physician. No new orders at this time. Will continue with plan of care." Review of resident 12's 6/9/13 through 6/24/13 nurses' notes revealed no further documentation regarding his urine incontinence and his increased confusion. Interview on 6/26/13 at 5:40 p.m. with licensed practical nurse (LPN) CC regarding resident 12 revealed: *He had been continent of urine on the night shift until about four months ago. *Now he needed to be changed about four times at night depending how often he wet himself. *He still got up to go to the bathroom on his own and would change his soiled pull-up and clothes. Interview on 7/1/13 at 1:00 p.m. with the interim director of nursing (DON) regarding resident 12 revealed she: *Had made the entries on his 5/8/13 care plan about obtaining the urinalysis and informing the physician. *Had thought the nurses were going to do it, and thought she had told the nurses to do it. *Could not remember discussing a toileting plan for him related to his increased incontinence. She thought he was still independent with using the toilet and changing his pull-ups. *Knew he did not like wearing the pull-ups, and would put his underwear on then and wet his clothes. Interview on 7/1/13 at 12:30 p.m. with LPN BB regarding resident 12 revealed: *Each resident had "standing orders" signed by their physician that included to obtain a urinalysis if necessary. *They had not obtained the urinalysis yet. She thought it had been obtained a couple weeks ago. *She was unsure why no one had followed through on the 5/8/13 care plan documentation to inform the physician of his increased incontinence and confusion and to obtain a urinalysis. *He did better with using a urinal and she had been attempting for the last few days to obtain a urine specimen. *She confirmed there was no documentation his physician or psychiatrist had been informed of his increased confusion. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pp. 414-419 and pp. 477, revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client (resident) outcomes, and reflect current standards of nursing practice." *"Any significant changes in the client's condition must be reported to the physician and documented in the chart." *"Nurses should know and follow the policies and procedures of the institution in which they work." *"Nurses are obligated to follow physicians' orders unless they believe the orders are in error or could be detrimental to clients." *"All nurses should know the laws that apply to their area of practice." *"Nurses are responsible for performing all procedures correctly and exercising professional judgment as they carry out physicians' orders." Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction." *"The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01." *"The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with the direct supervision when providing nursing care in a complex nursing situation; *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary." 3. Review of resident 5's entire medical record revealed: *He had been admitted on [DATE]. *He had [DIAGNOSES REDACTED]. *A 1/10/13 care plan problem of falls. Approaches included to wear non-skid socks, ask for help to toilet, allow staff to awaken at night to use the bathroom, arm support on stool, one-half side rail on bed, and urinal at bedside. *A 1/16/13 care plan note under safety - "I have right sided weakness and I am unsteady, Remind me and cue (remind) me to ask for help. I want no further falls" *A 6/20/13 care plan problem of fall risk. Approach included "Remind resident to use call light when needed." *He had sixteen falls from 10/26/12 through 5/13/13. *Those falls had resulted from him attempting to transfer himself from his wheelchair or from attempting to ambulate independently. *A 10/30/12 nurse's note revealed a pressure alarm had been "placed", but it did not specify whether it was on his wheelchair or his bed. *A 11/9/12 care plan conference had been held. It was only reported that he continued to be a fall risk. No interventions for falls were documented as having been discussed. *On 11/13/12 he had been seen by his attending physician, and his falls were discussed. *Review of the 11/13/12 physician's progress note revealed no documentation regarding his falls. *On 12/11/12 he had been evaluated by the physical therapist (PT) AA. Recommendations had been made that included to ambulate with a front wheeled walker as tolerated. There was no documentation in regards to his frequent falls. *A 1/10/13 nurse's note regarding his frequent falls with interventions that included having him wear non-skid socks, toileting every two hours at night, and reminding him to ask for assistance. A note would be placed in his bathroom to remind him to ask for assistance. *A 1/16/13 care plan conference note revealed an extensive discussion regarding his frequent falls. "Pt. (resident 5) was asked how arms on stool are working, smiles and mumbles some garbled words. When asked about half rails smiles and shakes his head yes." There was no further documentation of any further interventions having been tried for his fall prevention. *A 1/19/13 nurse's note that his attending physician had evaluated him and his frequent falls had been discussed. Physician was informed of previous interventions of a half side rail and hand rails to his toilet. *The 1/19/13 physician's progress note stated the [MEDICATION NAME] for muscle spasms would be discontinued. "He has had some falls and is possibly related to just weakness or muscle sedation." *A 1/30/13 nurse's note the South Dakota Department of Health public health advisor for nursing homes had been contacted regarding his frequent falls. A recommendation was made to check with his previous facility for possible fall interventions. The previous facility was a specialty facility for brain injured residents. No further documentation was found that the previous facility had been contacted. *A 3/7/13 nurse's note that his half side rail had been discontinued, as he would tear it off the bed. *A 4/11/13 care plan conference note with no documentation regarding his fall risk. *Was seen on 4/26/13 by PT AA and to continue with the current plan of care. Review of the provider's policies revealed there was no policy in regards to fall prevention. The only policy was for the evaluation of the resident after a fall. That 4/4/05 Falls policy included: *Incident report completed and placed on the DONs desk. *Resident records stated occurrence, effect, and resolution. *The care plan would be revised and updated. *The DON would review the incident for patterns and safety issues. Review of a 11/6/12 swallow study report for resident 5 revealed he had requested to be on thin liquids. The report stated the dietary manager had been contacted, and a soft diet with ground meats would be continued. The report stated he was at a great risk for aspiration (inhaling food or fluid particles). But given his wishes to continue thin liquids it was recommended that his lung sounds should have been checked to ensure they were clear and check for any low grade fevers. A 1/10/13 physician's orders [REDACTED]. There was no documentation he had ever been assessed for signs or symptoms of aspiration. His 1/10/13 care plan revealed he was to be served a soft diet with nectar thickened liquids. Review of a 6/20/13 physician's orders [REDACTED]. A 6/20/13 nurse's note of a call to the physician to clarify that large increase of [MEDICATION NAME]. Continued review of the nurse's notes through 6/26/13 revealed no further documentation of that physician's orders [REDACTED]. Interview on 6/25/13 at 9:30 a.m. with the interim DON and LPN BB revealed no further contact had been made with the physician regarding the above [MEDICATION NAME] order. They stated there was no way to track if contact with a physician had been completed or if a follow-up call was required. 4. Review of resident 4's medical record revealed: *She had fell on [DATE] and had sustained injuries to her left arm and leg. *The 5/27/13 fall had not been witnessed by anyone. *Nursing documentation from 5/27/13 indicated forty-five minutes had passed prior to nursing contacting an ambulance to transfer the resident after her fall. Interview on 6/25/13 at 11:10 a.m. with LPN D who was the nurse on duty at the time of resident 4's fall on 5/27/13 revealed: *She had found the resident on her bathroom floor after being notified of the fall by the residents roommate on 5/27/13. *At the time she found her the resident was in significant pain with the majority of her pain being in her left leg. She also noted at that time the resident had significant swelling and bruising to her left lower arm and left knee. *After noting the above injuries she and another staff member decided to place a gait belt around the patient, pick her up off of the floor, and take her to her bed. When asked by this surveyor what the condition of the resident's left leg was when she had moved her she stated, "Her leg was floppy and she wasn't able to move it." When asked why she had moved the resident when she had noted significant injury she was unable to answer. *She had waited forty-five minutes to contact the ambulance, because she had needed to help the resident to go to the bathroom in a bed pan. She further stated she had no further rationale for waiting forty-five minutes to contact the ambulance service. *She agreed she should not have moved the resident and should had contacted the ambulance immediately on 5/27/13 based upon the condition she had found the resident in. 5. Observation on 7/1/13 at 11:40 a.m. with LPN Y during a blood sugar (BS) testing procedure with resident 18 revealed: *She was unsure of the correct lancet to use for the glucose meter (a machine that tests a blood sugar). *When she had obtained the lancets she was unsure about the correct way to load the One Touch Penlet Plus that would be used on the residents finger to obtain blood. *After she had loaded the One Touch Penlet Plus she was unable to obtain the blood as she: *Had the wrong lancets for the One Touch Penlet Plus. *Left to find the appropriate lancets for the above machine. *Returned several minutes later with the appropriate lancets. *The resident's BS was 525 (normal range was 70-110). Interview with LPN Y immediately after the above procedure revealed: *She was unsure as to the procedure she would follow regarding a BS that was 525. *She thought any BS over 400 should have been reported to the physician. *She had not received much orientation and training in regards to the appropriate procedures. *She was not concerned about resident 18's BS because she was on [MEDICAL TREATMENT] (Tuesday, Thursday, and Saturday) as she would have a high BS and then she would drop to a very low BS. She had very unstable BS readings. Interview on 7/1/13 at 12:35 p.m. with LPN Y regarding resident 18's BS revealed: *She had called the resident's physician twice and had left a message each time. *She had called the clinic and spoke with the receptionist and had been informed resident 18's physician was not in the office. *She was going to notify the assistant director of nursing (ADON) regarding the high BS, because she would know the procedure to follow for resident 18's BS. Interview on 7/1/13 at 3:15 p.m. with LPN Y regarding resident 18's high BS reading revealed: *The physician had never returned her phone calls. *She had obtained the residents BS at 1:00 p.m. and the results had been 320 and then again at 3:00 p.m. the BS had been 370. *She was not concerned about the 370 BS at 3:00 p.m., because she had just had an afternoon snack. Interview on 7/1/13 at 3:30 p.m. with the ADON regarding abnormal BS readings revealed: *Resident 18's BS were always high and low. *Information regarding abnormal BS had been passed on in nursing report. *Staff would just know when to hold insulin if a BS was too low. *All nursing staff were aware the medical director was available on his cell phone at all times. Interview on 7/1/13 at 4:30 p.m. with ADON regarding abnormal BS readings revealed: *There was no specific instructions for the nurses to follow for abnormal BS. *The nurses would use their nursing judgement regarding abnormal BS. *She thought the physician should be notified of BS over 400 or below 80. *There were standing orders at one time, but they were no longer being used. *Resident 18 would always have either very high or very low BS, but that was normal for her. Review of the provider's undated standing orders revealed "blood sugar check (Accuchecks) PRN (when ever necessary) per S (sliding)/S (scale) of high/low levels." Interview on 7/1/13 at 5:30 p.m. with the medical director revealed he thought there were parameters in place for abnormal BS readings for the nurses to follow. Interview on 7/2/13 at 8:15 a.m. with the interim director of nursing revealed there were standing orders for abnormal BS readings but no specific directions for the nurses to follow. 6. Review of resident 9's complete medical record revealed: *She had been admitted on [DATE]. *Her [DIAGNOSES REDACTED]. -Diabetes mellitus. -Hypertension. -Congested heart failure. -Weakness. *She had complained of dizziness at times during her admission process. *She had an unwitnessed fall on 6/20/13. *She was showering independently in the bathing room. *There was no documentation regarding assessment for falls or a skin assessment for predicting pressure ulcer risk. Interview on 6/26/13 with the DON regarding the fall and skin assessment for resident 9 revealed: *There was no fall assessment completed on admission nor after the resident had a fall on 6/20/13. *There was no skin assessment completed on admission. *The assessments were usually completed by the former DON, but she had not completed any of those forms since she had taken over the DON position. Review of the provider's 2008 Charting and Documentation policy revealed: *The purpose of charting and documentation was to provide: -A completed account of the residents care, treatment, response to the care, signs, symptoms and the progress of the resident's care. -Guidance to the physician when prescribing appropriate medications and treatments. -The provider as well as other interested persons, with a tool for measuring the quality of care provided to the resident. -Nursing service personnel with a record of the physical and mental status of the resident. -Assistance in the development of a plan of care for each resident. 7. Observation on 6/27/13 at 8:45 a.m. with LPN D during the medication administration observation revealed: *She was administering Artificial tears (eye drops) to resident 7. *She administered one drop of Artificial tears in each eye. *The instruction on the label read two drops in each eye twice daily. *The Medication Administration Record [REDACTED]. Interview with LPN D during the administration revealed she should have administered two drops of the eye drop medication in each eye as ordered and she had administered an incorrect dose to resident 7. Review of the physician's orders [REDACTED]. Interview on 7/1/13 at 12:35 p.m. with the DON regarding the eye drops for resident 7 revealed: *She was unsure why the staff had not corrected the physician's orders [REDACTED]. *She was unsure as to why the physician would sign an incorrect typed order. *She agreed LPN D had administered the incorrect dose of eye drops to resident 7. Review of the provider's October 2010 Medication Orders policy revealed the purpose of that procedure was to establish uniform guidelines in the receiving and recording of medication orders. Review of the provider's April 2010 Physician Medication Orders policy revealed: *Medications should have been administered only upon the written order of a person duly licensed and authorized to prescribe such medications in the state. *All drugs and biological orders should have been written, dated, and signed by the person lawfully authorized to give such an order. The signing of orders should have been by signature or a personal computer key. 8. Review of resident 7's June 1 through June 24, 2013 Pain Management Flowsheet and other PRN Medications sheet revealed: *There had been no follow-up on the [MEDICATION NAME] (controlled pain medication) 5/325 milligrams (mg) administered on 6/24/13 at 11:30 p.m. *There had been no follow-up on [MEDICATION NAME](medication used for sleep) 5 mg that had been administered at the same time as the [MEDICATION NAME] mentioned above. Review of resident 18's March, April, and May 2013 Pain Management Flowsheets and other PRN Medications sheet revealed: *On 3/20/13 at 2:00 a.m. [MEDICATION NAME] (an intramuscular (IM) injection given for low blood sugars in diabetics) 1 mg had been administered for a blood sugar reading of 23. There was no nursing documentation regarding the results of that injection. *On 3/21/13 at 5:15 p.m. she had been given Tylenol 325 mg, two tablets orally for complaints of left side pain. There was no follow-up results documented. *On 3/26/13 at 9:00 p.m. Tylenol 325 mg, two tablets had been administered for "c/o (complaints of) pain", and no results had been documented. Upon request of the provider revealed there was no policy regarding follow-up documentation of PRN medications.

A. Based on record review and interview, the provider failed to ensure an appropriate assessment had been completed for one of one sampled resident (17) who had been admitted to the emergency room (ER) with a high blood sugar (BS) and right-sided weakness, and then had returned to the facility. Findings include: 1. Review of resident 17's complete medical record revealed: *She had a [DIAGNOSES REDACTED]. *She was alert and oriented. *On 7/26/13 at 8:55 a.m. the resident stated she had felt "odd." -Her blood pressure (B/P) was 96/68 (normal B/P was 120/80). -The nurse charted the resident had not looked good. -The resident had been favoring her left side. *On 7/26/13 at 12:55 p.m. she was transferred to the ER per ambulance. *On 7/26/13 at 7:20 p.m. the ER had called and informed the staff the resident would be returning to the provider with her son per private vehicle. *On 7/27/13 at 8:40 a.m. the resident returned to the facility accompanied by her son. -Her breath smelled of alcohol. -She had stated she had felt weak, and her body ached "all over." -She had gone directly to bed. *There was no documentation regarding the following: -An assessment had been completed. -Vital signs (B/P, pulse, respirations, and temperature) obtained upon return to the facility. *A BS had been obtained because, she was an insulin dependent diabetic. -A follow-up regarding the resident's whereabouts after she had left the ER. -A follow-up regarding the smell of alcohol on her breath. *There had been no VS obtained until twenty-nine hours after the resident had returned to the facility. Interview on 8/6/13 at 10:45 a.m. with the social service designee revealed: *She was unaware the resident had gone to the emergency room and had not returned appropriately to the facility. *The staff should have informed her of the above situation. Interview on 8/7/13 at 9:55 a.m. with the interim director of nursing (DON) revealed: *The nurse should have completed a thorough assessment upon her return to the facility. *There should have been VS and a BS obtained when she had returned to the facility. *The staff should have followed-up when the resident had failed to return to the facility. *There should have been documentation of an on-going assessment after she had returned to the facility. Surveyor B. Based on interview, observation, record review, and policy review, the provider failed to monitor fluid restriction amounts for six of six residents (4, 21, 22, 23, 24, and 27) on fluid restricted diets. Findings include: 1. Record review on 8/05/13 of the provider's mandatory mini in-service on fluid intake monitoring revealed thirteen of forty nine employees had attended. The training was to have been completed by 8/1/13. Interview on 8/06/13 at 1:50 p.m. with the interim director of nursing (DON) revealed: *The weekly intake and output (I and O) record for all residents on fluid restrictions had been started on 8/04/13. *The documentation on that record was incomplete. *The recording sheet from dietary was received after the evening meal. *The nursing staff were to complete the additional I and Os during the day and night shifts. *The fluid amounts were not consistent and changed from ounces to cubic centimeter (cc). *The expectation was to match physician's orders [REDACTED]. Review of resident 4, 21, 22, 23, 24, and 27's complete medical records regarding fluid restrictions revealed: *Resident 4 had a 8/5/13 physician's orders [REDACTED]. *Resident 21 had a 8/5/13 physician's orders [REDACTED]. -Her undated care plan stated she was on 1800 cc of fluid a day. -Her July and August 2013 medication administration record (MAR) stated she was on 1800 cc per day. *Resident 22 had a 7/24/13 physician's orders [REDACTED]. -Her 7/24/13 care plan stated she was to limit fluids to two liters (2000 cc) or less per day. -Her July and August 2013 MARs stated two liters or less of fluids every day. *Resident 23 had a 8/5/13 physician's orders [REDACTED]. -Her July and August 2013 MARs stated nothing regarding a fluid restriction. *Resident 24 had a 8/5/13 physician's orders [REDACTED]. -Her July and August MARs stated 1500 cc fluid restriction with no specified amount to provide with medications. *Resident 27 had a 8/21/12 physician's orders [REDACTED]. Gatorade only. Therapeutic but not textural diet holiday on occasion. Observation on 8/06/13 at 5:05 p.m. in resident 27's room revealed: *A water pitcher on the bedside table with 500 cc (approximately 2 cups) water. *A water glass on the bedside table with 240 cc (1 cup). *A water bottle on the bedside table with approximately 240 cc. *An unopened 12 ounce strawberry pop can on her bed. Interview on 8/07/13 at 11:15 a.m. with the DON regarding the residents on fluid restrictions revealed: *Those residents with physician's orders [REDACTED]. *The provider's system was currently a "work in progress." *There had been no care plan updates. Review of the provider's 2001 Intake, Measuring, and Recording policy revealed the purpose of the procedure was to accurately determine the amount of liquid a resident consumed in a twenty-four hour period. Review of the provider's 2001 Encouraging and Restricting Fluids policy revealed: *The purpose of the procedure was to provide the resident with the amount of fluids necessary to maintain optimum health. *The policy included encouraging or restricting fluids. *There needed to be a physician's orders [REDACTED]. *The resident's care plans and/or daily assignment sheets were assessed for any special needs of the resident. Surveyor C. Based on record review and interview, the provider failed to ensure the appropriate transcription for one of one sampled resident (7) who had scheduled eye drops. Findings include: 1. Review of resident 7's August 2013 medication administration record (MAR) revealed: *"Artificial Tears (0.2 - 0.2 -1%) [MEDICATION NAME] - Hypromellose - Polyethylene [MEDICATION NAME] 400, 2 drops each eye solution ophthalmic (eye) BID (twice daily) (2 drops each eye) dry eyes." *Polyethylene [MEDICATION NAME] ([MEDICATION NAME]) was used for constipation and was to have been taken orally. Interview on 8/7/13 at 9:55 a.m. with the interim DON revealed that was an incorrect transcription. I should have been removed from the resident's MAR and transcribed correctly. D. Based on observation, interview, and record review, the provider failed to ensure: *Two of two licensed nurses (Y and BB) appropriately cleaned the glucose ( blood sugar) meter after each individual resident use for three of three sampled residents ( 2, 4, and 29) testing. *Education on the blood glucose meter had been initiated for employees as stated on the 7/2/13 recertification survey plan of correction. Findings include: 1. Observation on 8/5/13 at 4:00 p.m. with licensed practical nurse (LPN) Y during blood glucose testing on resident 2 revealed she: *Took the glucose meter into the resident's room. *Placed the meter directly on the resident's bedside table. *Obtained the glucose reading. *Left the resident's room. *Placed the meter on top of the medication (med) cart prior to cleaning the meter. *Cleaned the meter with a Sanicloth wipe. *Placed the meter on top of the med cart where she had placed the meter prior to the cleaning. *Had not sanitized the med cart. 2. Observation on 8/5/13 at 4:10 p.m. with LPN Y during the glucose testing on resident 29 revealed she: *Entered resident 29's room and placed the meter directly on the bedside table. *Obtained the glucose reading. *Left the room and placed the glucose meter on top of the med cart prior to cleaning the meter. *Cleaned the meter with a Sanicloth wipe and placed the meter on top of the med cart. *Had not sanitized the med cart. 3. Observation on 8/5/13 at 4:25 p.m. with LPN BB during the glucose testing on resident 4 revealed she: *Entered the resident's room. *Placed the glucose meter directly on the resident's bed. *Obtained the glucose reading. *Left the room and placed the glucose meter on top of the med cart prior to cleaning the meter. *Cleaned the meter with a Sanicloth wipe and returned the meter to the top of the med cart. *Had not sanitized the top of the med cart. Interview on 8/7/13 at 9:55 a.m. with the interim DON revealed there had been no training provided for the nursing staff regarding the appropriate use and cleaning of the glucose meters. Surveyor E. Based on record review and interview, the provider failed to follow the plan of correction for the 7/2/13 recertification survey for information to have been given to one of two sampled(4) residents that were above the level of care the provider was certified to provide. Findings include: 1. Review of resident 4's medical record revealed no documentation her guardian had been informed the provider was unable to provide skilled therapies as had been ordered by her physician on admission. Interview on 8/7/13 at 10:00 a.m. with the interim director of nursing confirmed resident 4's guardian had not been notified.

Based on record review, interview, and policy review, the provider failed to appropriately assess, monitor, intervene, and document pain management and follow physician's orders [REDACTED]. Findings include: 1. Review of resident 1's medical record revealed: *A [DATE] admitted . *[DIAGNOSES REDACTED]. *He had been hospitalized [DATE] through [DATE] at an acute care hospital related to [MEDICAL CONDITION] (without oxygen) secondary to pneumonia. *He had been alert and able to verbalize his needs. Review of resident 1's undated care plan revealed: *"My memory is intact." *"I am paralyzed so I can not stand, walk, or transfer myself." *"I have alot of pain in my legs. I take pain medication around the clock. Please be prompt to give me my medication when I ask. Make sure you give me the right medication, in the right amount, and at the right time." Review of resident 1's February 2013 Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED] *[MEDICATION NAME] 300 milligrams (mg) three times a day (TID). *[MEDICATION NAME] ,[DATE] mg one to two tablets every 4 hours as needed (PRN) for pain. (If pain rating was ,[DATE] give one tablet. If pain rating was ,[DATE] give two tablets). *[MEDICATION NAME] 100 microgram (mcg) patch every three days. *Tylenol 325 mg two tablets every 4 hours PRN pain/temperature. Review of resident 1's February 2013 PRN pain management flowsheet revealed: *Pain rating of ,[DATE] was indicative of no pain to mild pain. *Pain rating of ,[DATE] was indicative of moderate pain. *Pain rating of ,[DATE] was severe pain. A pain rating of 10 was the "worst possible pain." *[MEDICATION NAME] ,[DATE] mg one tablet was administered on [DATE] at 8:20 a.m. for a pain rating of a 9. There was no follow-up documentation if the [MEDICATION NAME] had been effective. *[MEDICATION NAME] ,[DATE] mg one tablet was administered on [DATE] at 8:00 p.m. There was follow-up documentation [MEDICATION NAME] had been "effective." *Both doses of the above [MEDICATION NAME] were not the correct dosage that should have been administered. Two tablets should have been administered for the pain rating of ,[DATE]. Review of resident 1's [DATE] MAR indicated [REDACTED] *[MEDICATION NAME] 300 mg TID. The [MEDICATION NAME] dosage was changed on [DATE] to 600 mg twice a day (BID) at 8:00 a.m. and 6:00 p.m. and 300 mg at noon. *[MEDICATION NAME] 100 mcg patch every three days. The [MEDICATION NAME] dosage was changed on [DATE] to 150 mcg patch every three days. *[MEDICATION NAME] ,[DATE] mg one to two tablets every 4 hours PRN. (If pain rating was ,[DATE] give one tablet. If pain rating was ,[DATE] give two tablets.) The [MEDICATION NAME] was discontinued on [DATE]. *Tylenol 325 mg two tablets every 4 hours PRN pain/fever. *[MEDICATION NAME] ,[DATE] mg one to two tablets four times a day (QID) PRN. (If pain rating was ,[DATE] give one tablet. If pain rating was ,[DATE] give two tablets). Review of resident 1's [DATE] physician's orders [REDACTED]. *[MEDICATION NAME] 600 mg at 8:00 a.m. and 6:00 p.m. *There was no documentation [MEDICATION NAME] 300 mg was to have been administered at noon. Review of resident 1's [DATE] through [DATE] PRN pain management flowsheet revealed: *Tylenol 325 mg two tablets had been administered seventeen times. -Twelve doses of Tylenol had been administered for a pain rating of ,[DATE]. Three doses of the Tylenol had no follow-up documentation as to it's effectiveness. -Two doses of Tylenol had been administered for a pain rating of ,[DATE]. One dose of the Tylenol had no follow-up documentation as to it's effectiveness. -Three doses of Tylenol had been administered for a pain rating of ,[DATE]. One dose of the Tylenol had no follow-up documentation as to it's effectiveness. *[MEDICATION NAME] ,[DATE] mg one tablet had been administered five times. -All the doses of the [MEDICATION NAME] had been administered for a pain rating of ,[DATE]. -Three doses of the [MEDICATION NAME] had been documented as "ineffective." *[MEDICATION NAME] ,[DATE] mg two tablets had been administered eighteen times. -Seven doses of the [MEDICATION NAME] had been administered for a pain rating of ,[DATE]. (One tablet should have been administered.) -Four doses of the [MEDICATION NAME] had no follow-up documentation as to it's effectiveness. *[MEDICATION NAME] ,[DATE] mg one tablet had been administered nine times. -Five doses of the [MEDICATION NAME] had been administered for a pain rating of ,[DATE]. (Two tablets should have been administered.) -Two doses of the [MEDICATION NAME] had no follow-up documentation as to it's effectiveness. *[MEDICATION NAME] ,[DATE] mg two tablets had been administered twenty-five times. -Twelve doses of the [MEDICATION NAME] had been administered for a pain rating of ,[DATE]. (One tablet should have been administered.) -One dose had no pain rating documented. -Three doses had no documentation as to it's effectiveness. Review of resident 1's [DATE] MAR indicated [REDACTED] *[MEDICATION NAME] 150 mcg patch every three days. The [MEDICATION NAME] had been decreased to 100 mcg patch every three days on [DATE] related to possible sedation. *[MEDICATION NAME] 600 mg bid at 8:00 a.m. and 6:00 p.m. and 300 mg at noon. The [MEDICATION NAME] had been changed to 300 mg tid on [DATE] related to possible sedation. *Tylenol 325 mg two tablets every 4 hours PRN pain/fever. *[MEDICATION NAME] ,[DATE] mg one or two tablets QID PRN. (If pain rating was ,[DATE] give one tablet. If pain rating was ,[DATE] give two tablets.) Review of resident 1's [DATE] through [DATE] PRN pain management flowsheet revealed: *[MEDICATION NAME] ,[DATE] mg two tablets had been adminstered four times for a pain rating of ,[DATE]. (One tablet should have been administered.) *One dose had no follow-up documentation as to it's effectiveness. *There was no documentation any PRN pain medication had been administered from [DATE] until his death on [DATE] at 10:12 a.m. Interview on [DATE] at 10:10 a.m. with the assistant director of nursing, licensed practical nurse A regarding resident 1 revealed: *He had often told his sister he had not been getting pain medication. *They had kept getting calls from the sister who was upset he was not receiving his pain medication. The family was told they gave him his pain medication "as needed." *When he was in the hospital from [DATE] through [DATE] he had told them his pain medications were effective pain control. He had told the hospital the same pain medication regimen was not helping at their facility. "It takes some residents time to adjust." *They thought the [MEDICATION NAME] was effective pain control, but after two hours he was asking for more pain medication. *They thought the [MEDICATION NAME] controlled his pain better. *He often complained of more pain after his restorative exercises. They had told restorative staff to let them know about an hour before his exercises, so they could give him some pain medication. She did not work on the floor often enough to know if that had been done. *About a week before his death they had noticed he was doing more facial grimacing of pain in addition to his complaints. The physican had increased his [MEDICATION NAME] and [MEDICATION NAME] but had to decrease it when he had started getting more sleepy and was not as alert. *She thought even after he was getting sleepy from the [MEDICATION NAME] and [MEDICATION NAME] increase he was still consistently asking for PRN [MEDICATION NAME] for pain control. *She confirmed they were not following the physician's orders [REDACTED]. *She confirmed not doing follow-up documentation as to the effectiveness of PRN medications made it difficult to determine if he was having adequate pain control. *She confirmed on [DATE] when the physician had increased the [MEDICATION NAME] to 600 mg BID at 8:00 a.m. and 6:00 p.m., she had not written to administer [MEDICATION NAME] 300 mg daily at noon and should have. "He told me to just change the morning and evening dose and leave the noon dose as it was." Review of the provider's [DATE] Medication Administration General Guidelines policy revealed documentation was required for results acheived from the administration of a PRN medication. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pp. ,[DATE] and pp. 477, revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *"Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client (resident) outcomes, and reflect current standards of nursing practice." *"Any significant changes in the client's (resident's) condition must be reported to the physician and documented in the chart." *"Nurses should know and follow the policies and procedures of the institution in which they work." *"Nurses are obligated to follow physicians' orders unless they believe the orders are in error or could be detrimental to clients." *"All nurses should know the laws that apply to their area of practice." *"Nurses are responsible for performing all procedures correctly and exercising professional judgment as they carry out physicians' orders." Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *"A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person." *"The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction." *"The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01." *"The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation; and with the direct supervision when providing nursing care in a complex nursing situation; *"The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary."

Based on record review, interview, and policy review, the provider failed to render the necessary services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of one sampled resident (1) who had a significant change in condition resulting in death. Findings include: 1. Review of resident 1's undated care plan revealed: *My memory is intact. *I am paralyzed so I can not stand, walk, or transfer myself. *I have alot of pain in my legs. I take pain medication around the clock. Please be prompt to give me my medication when I ask. Make sure you give me the right medication, in the right amount, and at the right time. Review of resident 1's [DATE] through [DATE] nurses' notes revealed: *[DATE] (no time documented)- Called physician on resident complaint of pain in legs. Changed [MEDICATION NAME] to 600 mg BID at 8:00 a.m. and 6:00 p.m. and 300 mg daily at noon. *[DATE] at 4:10 p.m.- Called physician on resident complaint of pain. [MEDICATION NAME] increased from 100 mcg to 150 mcg every 3 days. *[DATE] at 4:30 p.m.- Resident complained of pain in legs and coccyx (tailbone) at 9:30 a.m. and PRN pain medications given. As the day progressed resident had no further complaints of pain. At 3:00 p.m. sister here for visit and he immediately began to cry and complains of being in severe pain. Said he had not received his pain medication. Sister said medication ([MEDICATION NAME]) was to be given scheduled and not QID PRN. Gave another dose ([MEDICATION NAME]) at 3:00 p.m. Asked unlicensed assistive personnel for more [MEDICATION NAME] at 4:00 p.m. and 5:00 p.m. *[DATE] at 6:20 p.m.- Has not complained of any pain all day and no pain medications ([MEDICATION NAME]) given. [MEDICATION NAME] 150 mcg applied. Slept at long intervals today. *[DATE] at 8:00 p.m.- Noted resident appears very sleepy and sleeping alot. Very confused and has slurred speech. No pain medications ([MEDICATION NAME]) given as sleeping. *[DATE] at 5:00 a.m.- Very sleepy through entire night. No special requests for pain medications ([MEDICATION NAME]). Awakens when spoken to. Drinks some water but does choke a little bit on it. Color is a little grayish-looking also. Will continue to observe resident. *[DATE] (no time) Late entry-Talked to physician about resident being sleepy. [MEDICATION NAME] changed to 300 mg tid. Called back later in the evening to remove the [MEDICATION NAME] 50 mcg patch and hold it until resident more alert. *[DATE] at 7:00 a.m. (by unlicensed assistive personnel (UAP) B)- Went into resident's room to give him his medications. He then refused by shaking his head no. I asked him if he was okay and he nodded yes to me. I reported it to charge nurse he did not take his medications. *[DATE] at 8:00 a.m. (by UAP B)- Checked on resident to try and give him his medications and he was sleeping. *[DATE] at 9:35 a.m. (by UAP B)- Charge nurse asked me to give him a nebulizer treatment because his oxygen saturation was low at 80 percent (%). (Normal oxygen saturation is greater than 90%.) She decided to send him out. *[DATE] at 7:15 a.m. (by LPN A)- UAP B came to me and informed me the resident did not want to take his medications. I said okay and try later. *[DATE] at 8:30 a.m. (by LPN A)- Received phone call from resident's wife wanting to know if he was awake. Asked aide and she said (yes he was sleeping.) *[DATE] at 8:40 a.m. (by LPN A)- Went into resident's room. Manual pulse 104 (normal pulse ,[DATE]) and breathing normal. Oxygen on at 2 liters per nasal cannula. Came out to finish my work. Received another call from his wife asking why he was sleeping so much. I informed her we are following physician's orders [REDACTED]. Told her the [MEDICATION NAME] 50 mcg patch had just been removed and it would take awhile. Stated she was going to call the physician and hung up. *[DATE] at 9:30 a.m. (by LPN A)- Administrator came in and I went with her to check on resident. Resident had audible crackles and labored breathing. Oxygen level was 80% (normal level greater than 90%). I informed UAP B to give him a nebulizer treatment. *[DATE] at 9:35 a.m. (by LPN A)- I decided to send resident to the hospital. *[DATE] at 9:45 a.m. (by LPN A)- Called for ambulance. DON was called into the room to help assess resident. [DATE] at 10:10 a.m. (by LPN A)- Ambulance arrived. [DATE] at 10:12 a.m. (by LPN A)- No breaths, pulse, or heartbeat detected. [DATE] at approximately 10:20 a.m. (by LPN A)- Coroner was on the ambulance and pronounced death. DON informed the family. Interview on [DATE] at 11:50 a.m. with UAP B regarding the above nurse's notes on [DATE] regarding resident 1 revealed she: *Had come on duty at 6:00 a.m. on [DATE]. *Thought she had first gone to his room between 6:30 a.m. and 6:45 a.m. initially to give him his morning medications. Stated he had refused his medications. He looked alright. She had informed LPN A he had refused his medications and she had been told to try again later. *Had given him a nebulizer treatment as directed by LPN A but was unsure of the time. *Stated at about 7:15 a.m. she had tried to awaken him to take his medications again, but he would not awaken. She stated He looked different than before. You know, more tired. She stated she went to the dining room to ask charge nurse LPN A to check on the resident. LPN A had informed her she would come to the resident's room after she had finished giving the resident she was with their medications. Interview on [DATE] at 10:10 a.m. with LPN A regarding resident 1 revealed: *She had been the charge nurse on [DATE]. *She only worked in the charge nurse capacity once in awhile since she had assumed the assistant DON position in [DATE]. *She stated on [DATE] she would have arrived about 5:00 a.m. to 5:30 a.m. My shift does not start until 6:00 a.m. The night nurse left at 6:00 a.m. *She knew that on the morning of [DATE] it had been hard to get him to wake up for breakfast and take his medications. *The night nurse on [DATE] had told her he had slept all night with no complaints. He had woke up once and had requested pain pills. (Review of resident 1's as needed (PRN) pain management record for the night shift revealed no PRN [MEDICATION NAME] had been administered or requested by the resident.) The night nurse had not mentioned his color was grey. The night nurse had not told her she had not taken any vital signs on him during the night, and she had omitted to ask her if she had taken any. *UAP B had told her she had first tried to give his medications between 6:30 a.m. to 6:45 a.m. *UAP B had told her he had answered her and had responded to her between 7:00 a.m. and 7:15 a.m. *UAP B had told her about 7:15 a.m. to check on him. Stated UAP B told her He did not look right. His color was not right. He just won't wake up. She had stated she mentioned nothing about his breathing, and she had not asked her how his breathing was. Stated she told UAP B to go back to his room and stay with him until she got to his room. *She stated she went to his room about 7:30 a.m. She had to wait about ten minutes in the dining room to wait for the resident she had been administering medications to to take all her medications. She took her pills very slowly one at a time. *When asked why she had not let UAP B stay with the resident she had been administering medications to and she go immediately to his room stated She had not thought of that. UAP B's voice had not sounded alarming when she had asked her to check on him. *She stated when she went into his room at 7:30 a.m. she had noticed his breathing was labored and told UAP B to get a set of vital signs on him. The prior DON had come into the room and stated We need to get him out of here. Stated the DON and UAP B stayed with him while she went out to call the ambulance. She had called the ambulance prior to calling the physician. She was unsure what his vital signs had been and had not documented them. I think I put them on the transfer form. Stated his oxygen was on 3 liters and was increased to 5 liters without improvement in his breathing. Stated He died just as the ambulance pulled up. The ambulance driver was also the coroner. *She stated she had not viewed him as a critcally ill resident and had not checked on him from 6:00 a.m. until asked to by UAP B at 7:15 a.m. *She confirmed a nurse had likely not assessed him from 5:00 a.m. until 7:30 a.m. *She was unsure why his family had not been contacted at 5:00 a.m. when the night nurse had documented his color as greyish looking. *She had no comment when asked why the times in her interview differed from her documentation in the medical record. Review of resident 1's [DATE] physician's progress notes revealed: *Nursing called yesterday reporting him to be much more somolent (sleepy) with the recent change in his Fenanyl patch. I had them remove that last p.m. We also returned his [MEDICATION NAME] back to its prior dosing levels. He was struggling some with pain over the past week and we titrated them up recently. *By report this a.m. he was awake, alert and conversive, but refused his medications. They subsequently checked on him in a hour at which point he was struggling to breathe. Was not complaining of chest discomfort. *Emergency medical service was summoned to transport to the hospital. I do not have definitive reports on type of [MEDICAL CONDITION] noted. He was pronounced terminal before leaving the facility. Review of the provider's [DATE] Resident Change of Condition policy revealed: *Any staff member who notices a resident change in condition must immediately notify the nurse assigned to care for that resident. *Changes in resident condition include but are not limited to: -Significant change in physical, mental, or psychosocial status. -Blood pressure less than 90 systolic or above 200 systolic (top number of blood pressure reading). -Blood pressure less than 50 diastolic or above 110 diastolic (bottom number of blood pressure reading). -Pulse less than 50 or greater than 120. *An assessment by a licensed nurse will be done any time there is a change in the condition of a resident. Review of the South Dakota Board of Nursing's Administrative Rules, Chapter 20:48, revealed: *A licensee is personally responsible for the actions that the licensee performs relating to the nursing care furnished to clients and cannot avoid this responsibility by accepting the orders or directions of another person. *The registered nurse is responsible for the nature and quality of nursing care that a client receives under the nurse's direction. *The registered nurse shall recognize and understand the legal implications of delegation and supervision. The nurse may delegate to another only those nursing interventions which that person is prepared or qualified to perform and shall provide minimal or direct supervision to others to whom nursing interventions are delegated. The registered nurse may only delegate nursing tasks to unlicensed assistive personnel in accordance with the standards in chapter 20:48:04.01. *The licensed practical nurse may practice in two general settings: with at least minimal supervision when providing nursing care in a stable nursing situation and with the direct supervision when providing nursing care in a complex nursing situation. *The licensed practical nurse shall consult with a registered nurse or other health team members and seek guidance as necessary and shall obtain instruction and supervision as necessary. Review of Patricia A. Potter and Anne Griffin Perry, Fundamentals of Nursing, 6th ED., St. Louis, MO, pp. ,[DATE] and pp. 477, revealed: *Complete and appropriate documentation was a vital aspect of nursing practice. *Nursing documentation must be accurate, comprehensive, and flexible enough to retrieve critical data, maintain continuity of care, track client outcomes, and reflect current standards of nursing practice. *Any significant changes in the client's condition must be reported to the physician and documented in the chart. *Nurses should know and follow the policies and procedures of the institution in which they work.