Every finding on record at Winner Regional Healthcare Center

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to ensure a thorough investigation was completed regarding an allegation of resident abuse for one of one resident (1) by one of one former contracted travel certified nursing assistant (CNA) (G) who bruised resident 1's upper right arm while providing her personal care. Findings include:1. Review of the provider's 6/20/26 FRI revealed on 6/20/26 at approximately 3:30 p.m. resident 1 told CNA E that she had right arm pain. While CNA E was providing personal care for resident 1, CNA E saw bruising on resident 1's right upper arm. CNA E asked resident 1 what the bruises were from and resident 1 told her that the CNA from the night before had hurt her arm when the CNA changed resident 1's incontinence (involuntary urine or bowel leakage) brief. The CNA had grabbed resident 1's arm and told resident 1 to turn onto her side while lying in bed. Resident 1 told the CNA that she could not turn onto her side because she had a stroke (blood flow to a part of the brain is blocked or a blood vessel in the brain bursts) and she could not use her right arm. The CNA repeatedly requested resident 1 to turn onto her side. The CNA became upset and stated, Yes, well everyone here has had a stroke, grabbed resident 1's arm, and flung it over. CNA E told contracted travel registered nurse (RN) D about the bruising on resident 1's right upper arm and the allegation of abuse.On 6/20/26 at approximately 3:30 p.m. contracted travel RN D called director of nursing (DON) B to notify her of the new bruises on resident 1's right upper arm and her allegation of abuse. When DON B spoke with resident 1 she recalled the incident as she had told CNA E. Resident 1 stated she did not know the CNA's name from the night before but was able to describe her. The CNA was determined by DON B to be former contracted travel CNA G. 2. Review of resident 1's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 6/30/26 Brief Interview for Mental Status (BIMS) assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included cerebral infarction (a stroke), and hemiplegia and hemiparesis (weakness and paralysis of one side of the body) following a cerebral infarction affecting the dominant right side.A 6/20/26 progress note, written by contracted travel RN D stated, Writer was called to resident's room this afternoon at 1540 [3:40 p.m.] to assess some bruises on resident's right upper bicep. Writer notes several nickel-size bruises to this area. Resident also stated this area 'hurts.' [The] Skin [was] intact, no open areas. When writer asked [the] resident what happened to cause these bruises, resident stated [state], 'That girl changing me last night told me to move my (right) arm to the left and turn on my side. I told her I couldn't move that arm.' Resident went on to stated, 'She asked me again, and I told her again that I couldn't move my (right) arm. So she grabbed my (right) arm and flung it over so she could turn me.'The first documented full body skin assessment was completed on 6/22/26, two days after resident 1's allegation of abuse. That skin assessment revealed she had bruises on both of her outer arms, in different stages of healing. Her 7/21/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions) indicated she was dependent on the staff to turn and reposition her in bed. 3. Review of the provider's 6/20/26 investigation regarding resident 1's bruises and allegation of abuse revealed DON B interviewed resident 1 about the abuse allegation. DON B then asked residents 2 and 3, Have you been having any problems with any of the CNAs? Resident 3 stated she did not have any problems with any of the CNAs. Resident 2 stated there was one CNA that worked the night shift that was pretty rough. No other resident interviews were completed to determine if other residents had received rough care or had allegations of abuse.DON B interviewed CNA E and contracted travel RN D about what resident 1 had reported to them, and the bruises. DON B did not interview former contracted travel CNA G about the allegation. DON B did not interview the nurse who worked on 6/19/26, when the incident was reported to have happened. She did not interview contracted travel CNA F, who was training contracted travel CNA G on 6/19/26. 4. Interview on 7/21/26 at 12:45 p.m. with DON B revealed she had interviewed the residents on the 200 hallway whose cognition was good enough to answer if they had trouble with any CNAs. She did not interview any residents down the 300 hallway because former contracted travel CNA G was not scheduled to work in that hallway. Former contracted travel CNA G could not be interviewed because DON B did not have her contact information. 5. Review of the BIMS assessment scores for the residents on the 200 hallway revealed there were five residents (2, 3, 4, 5, and 6) whose BIMS assessment scores indicated they were cognitively intact. 6. Phone interview on 7/21/26 at 1:00 p.m. with CNA E revealed she assisted resident 1 to get up and dressed for lunch on 6/20/26. Resident 1 had told her that her right arm hurt when CNA E was helping her, but resident 1 had a history of arthritis pain. Resident 1 then told her that the night CNA had thrown her arm against the wall.After lunch CNA E, assisted resident 1 to change her shirt and resident 1 told her that the night CAN had told resident 1 to move her arm. Resident 1 told former contracted travel CNA G that she could not move her arm because she had a stroke. Former contracted travel CNA G told resident 1 she could move her arm and that all the residents at that facility had strokes. Resident 1 stated that former contracted travel CNA G repeated herself several times and then threw resident 1's right arm against the wall.While changing resident 1's shirt CNA E saw bruising on resident 1's right upper arm. There was one larger bruise with smaller bruises surrounding the larger bruise. CNA E notified contracted travel RN D of resident 1's allegations of abuse and the bruises on her right upper arm. Contracted travel RN D came into resident 1's room, talked with resident 1 and looked at the bruises. Contracted travel RN D then called DON B. DON B came to the facility shortly after contracted travel RN D called her and started interviewing resident 1, contracted travel RN D, and CNA E. 7. Phone interview on 7/21/26 at 3:30 p.m. with contracted travel RN D revealed she was notified by CNA E that resident 1 stated former contracted travel CNA G told resident 1 several times to roll herself over. Resident 1 told former contracted travel CNA G that she could not roll over because she had a stroke and could not use her right arm. Former contracted travel CNA G had thrown resident 1's arm over to change resident 1's incontinence brief, which resulted in bruises on resident 1's right upper arm.Contracted travel RN D had went into resident 1's room after CNA E informed her of resident 1's bruises. Resident 1 told her about former contracted travel CNA G throwing her arm. While resident 1 was describing the incident to contracted travel RN D, resident 1 was holding her right upper arm with her left hand. Resident 1 stated that she had pain in her right upper arm. Contracted travel RN D looked at the skin on resident 1's upper right arm and saw three bruises. Contracted travel RN D called DON B to notify her of the bruises and abuse allegation, DON B came to the facility and started an investigation. 8. Interview on 7/21/26 at 4:20 p.m. with resident 1 in her room revealed that on the night of 6/19/26, former contracted travel CNA G came into resident 1's room to change resident 1's incontinence brief. Resident 1 attempted to assist former contracted travel CNA G with turning onto her side by using her left arm and the side rail (bar/bars attached to the bed). Former contracted travel CNA G kept telling resident 1 to roll onto her side. Resident 1 told former contracted travel CNA G multiple times that she was unable to roll onto her side because she had a stroke and could not use her right arm. Former contracted travel CNA G slammed resident 1's right arm against the wall and it bruised her right upper arm.Resident 1 stated that former contracted travel CNA G kept slamming her around that night. She said former contracted travel CNA G slammed me this way and pointed to her left, and then she slammed me this way and pointed to her right. Resident 1 told former contracted travel CNA G that she was hurting her, but former contracted travel CNA G did not stop. Resident 1 stated she told another staff member what had happened the next morning 6/20/26. That morning her arm hurt. 9. Interview on 7/22/26 at 8:00 a.m. with administrator A revealed the nurse who worked the night shift on 6/19/26 was no longer employed by the provider and could not be interviewed. 10. Phone interview on 7/22/26 at 9:00 a.m. with contracted travel CNA F revealed she was training former contracted travel CNA G the night of 6/19/26. She did not know about the incident with resident 1 until the next day, when it was passed on during the nursing shift report. She did not have any concerns with former contracted travel CNA G's interactions with the residents. On 6/19/26 former contracted travel CNA G had refused to provide cares or answer resident 1's call light because she stated resident 1 was mean to her. Then when contracted travel CNA F came out of another resident's room, former contracted travel CNA G told her she had gone into resident 1's room and changed her incontinence brief. Contracted travel CNA F stated resident 1 was able to tell the staff when she had pain or if they were being rough during cares.Contracted travel CNA F stated that she had trained former contracted travel CNA G on both the 200 and 300 hallways. The CNAs on the night shift provided care to the residents on both hallways every night because the 200 and 300 hallways have residents that require the assistance of two staff members. 11. Interview on 7/23/26 at 11:10 a.m. with DON B revealed she had interviewed contracted travel RN D, CNA E, and resident 1 related to the 6/20/26 allegation of abuse. She acknowledged she did not interview other staff members who may have been involved or had information about the incident. She acknowledged that she did not interview other residents to determine if other residents may have been potentially abused by a staff member. She acknowledged that resident 1's first full body skin assessment was completed on 6/22/26. 12. Review of the provider's 6/15/26 Abuse, Neglect, Exploitation, and Misappropriation Prevention policy revealed, The Administrator, Director of Nursing or designee shall: Initiate an investigation immediately or within Federal Regulations, Interview involved individuals, Review medical records, Interview staff, Preserve documentation.

A. Based on observation, interview, record review, and policy review, the provider failed to ensure resident safety by not assessing the side rails/grab bars and mattresses on the resident's beds for entrapment (trapped between the rail, mattress, or bedframe spaces) for four of six sampled residents (17, 21, 25, and 26) with loose side rails/grab bars on their beds, five of six sampled residents (6, 14, 17, 21, and 25) with an unsecured mattress on their bed, and one of six sampled residents (17) with a side rail/grab bar that was not indicated for use on the bed. Those failures put those residents at risk for entrapment, injury, or harm.Immediate Jeopardy (IJ) at F689, with a scope and severity of K, began on 5/28/26 at 10:05 a.m. upon observation of resident 14's bed. The bed was unlocked and moved away from the wall; the mattress slid away from the side rail/grab bar with minimal effort, creating a gap of more than five inches. The bed frame did not have mattress guards, which held the mattress in place, preventing the mattress from sliding when a side rail/grab bar was on the bed, putting the resident at risk for entrapment, injury, or harm.Chief executive officer A and director of nursing (DON) B were notified of the IJ on 5/28/26 at 12:45 p.m., and a removal plan was requested. The edited removal plan was received on 5/28/26 at 3:03 p.m. and was accepted on 5/28/26 at 5:10 p.m.The IJ was removed on 5/28/26 at 5:25 p.m. as confirmed by onsite verification by the survey team. After the IJ removal, the severity of non-compliance remained at a G.Current census was: 27Findings include: 1. Observation on 5/27/26 at 9:52 a.m., with resident 6 and resident 14 in their shared room, revealed that a right-side rail/grab bar was attached to each bed. Their mattresses were not securely attached to the beds and created a gap between the side rails/grab bars and the mattresses when the mattresses moved. The gap between resident 14's bed and the side rail/grab bar measured four and a half inches when the mattress slid to the wall when touched. 2. Observation on 5/27/26 at 9:53 a.m. with resident 17 in her room revealed that she had a side rail on the left side of her bed, which was up against a wall in her room. The side rail was loose and could be pulled away from the bed. It was not properly attached to the bed and was held in place with a zip tie. The side rail's bar was not attached to the frame of the bed, was unsecured under the mattress, and could move around. 3. Observation on 5/27/26 at 9:54 a.m., with resident 26 in his room, revealed he had side rails/grab bars on both sides of his bed. The rail/grab bar on the right-handed side of the bed was loose and moved approximately four inches away from the mattress when touched. 4. Observation on 5/27/26 at 10:06 am, with resident 21 in his bed, revealed that he had a rail on the right side of his bed, which was loose, with a four-inch gap between the loose rail and his mattress. The left side of his bed was up against the wall. 5. Observation and interview on 5/27/26 at 9:58 a.m. with resident 25 in his room revealed that he had side rails on both sides of his bed. The right-side rail was loose and could be pulled away from the bed. The left side of the bed was positioned against the wall. Resident 25 was lying in bed with his head resting against the left side rail. He did not use the side rails for transferring in or out of bed or repositioning while he was in bed. There was a gap between the headboard and the head of the mattress that was unable to be measured at that time with resident 25 lying in the bed. 6. Observation on 5/27/26 at 12:04 p.m. of resident 25's bed revealed there was a five-inch gap between the top of the mattress and the headboard. The loose rail on the right side moved four inches away from the mattress when pulled on. The left side rail was securely attached to the bed. 7. Review of resident 25's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. He had a Brief Interview of Mental Status (BIMS) assessment score of 15, which indicated his cognition was intact. His diagnoses included alcohol induced dementia (a group of symptoms affecting memory, thinking, and social abilities caused by excessive prolonged use of alcohol), and an eye movement disorder. His 5/28/26 care plan indicated that resident 25 was unable to see out of his left eye. Resident 25's 1/9/24 side rail and safety screen indicated bilateral side rails were recommended to be installed by occupational therapy due to [Resident 25] was using bed rails in [the] hospital. Without them he requires increased assistance. Recommending Bilateral [bed] rails. There was no documentation that indicated when resident 25's side rails were installed. A 10/8/25 progress note indicated resident 25 fell on his face over his bed hitting the headboard and lacerating [cutting] his nose on the right side. He was sent to the emergency room for further assessment. 8. Observation on 5/27/26 at 12:05 p.m. of the bed in resident 21's room revealed the gap between the loose rail on the right side of the bed and his mattress measured five inches when the mattress slid to the wall and the loose rail was pulled out from the bed. The gap measured four and a half inches between his headboard and the head of the mattress. 9. Interview and observation on 5/28/26 at 10:05 a.m., with DON B in resident 14 and 6's shared room revealed she was unaware that the side rails/grab bars and mattresses needed to be assessed for entrapment risks. She was unsure if maintenance assessed the side rails or mattresses for entrapment risk in any zones [specific areas around a hospital bed where a resident's head, neck, or chest can get wedged]. When a resident or their representative requested a side rail/grab bar, the therapy department would assess the resident using a checklist. The checklist did not contain resident risk for entrapment, any interventions tried before the use of the side rail/grab bar, or indicate that the resident's consent for the use of the side rail/grab bar was needed. She thought that if a resident wanted a side rail/grab bar, they could request one, and one would be provided. Resident 14's bed was not locked, the bed was moved away from the wall, and the mattress slid away from the bed rail with minimal effort when pushed, which created a large gap of more than five inches. She confirmed that the bed did not have the mattress guards to hold the mattress in place and prevent the mattress from sliding when a side rail/grab bar was attached to the bed frame. Resident 6's bed did not have the mattress guard. She confirmed that resident 14 and resident 6's beds had potential risks for entrapment between the side rail/grab bar and the mattresses. 10. Review of the maintenance clipboard in the charting conference room revealed there were no resident beds or side rail repair requisitions from 3/18/26 through 5/28/26. 11. Interview on 6/1/26 at 11:56 a.m. with DON B revealed there was no documentation available related to when the side rails were installed on the residents' beds. 12. Interview and review of the maintenance Inspection of Bed Frame w[with]/Mattress and Side Rail Audit on 5/28/26 at 12:04 p.m., with CEO A revealed that the audit was dated 12/06 through 1/13. There was no documentation to identify the year the audit was completed. CEO A thought that maintenance supervisor GG was responsible for assessing the side rails/grab bars, beds, and mattresses for entrapment risk. CEO A stated that maintenance supervisor GG ended his employment on 5/27/26, and CEO A was unable to access information about the installation or inspection of the side rails/grab bars, beds, or mattresses on maintenance supervisor GG's computer. CEO A was unsure if maintenance supervisor GG had inspected the side rails/grab bars, beds, or mattresses, and stated that maintenance supervisor GG was unavailable for an interview. CEO A thought that former maintenance supervisor I completed the bed inspections. There was no maintenance staff member available to interview related to the installation or inspection of side rails/grab bars, beds, or mattresses. 13. Notice of immediate jeopardy (IJ) of F689 was given verbally and in writing on 5/28/26 at 12:45 p.m., to CEO A and DOB B regarding the resident's side rails not being securely attached and the mattresses on residents' beds not being assessed for entrapment risks. Observations made throughout the survey and throughout the long-term care facility from 5/27/26 through 5/28/26 revealed there were several safety concerns related to bedrail installation, maintenance, and bed zone assessments. Residents 17, 21, 25, and 26 had side rail(s)/grab bar(s) that were not securely attached, which created entrapment risks and risk for injury. Resident 25 had a five-inch gap between the top of his mattress and his headboard, which created entrapment risk and risk for injury. Residents 6 and 14 had mattresses that were not securely attached to the bed and created a gap between the side rail/grab bar and the mattress, which created entrapment risks and risk for injury. Resident 17 had a side rail/grab bar that was not indicated for use on that bed, and the side rail/ grab bar was loosely secured to the bed frame with a plastic strap, which allowed the side rail to move away from the mattress and bed frame, creating entrapment risks and risk for injury. The above concerns had the potential to cause serious harm, injury, impairment, or death for residents with side rails on their beds. A plan for the removal of the immediacy was requested at that time. 14. On 5/28/26 at 3:03 p.m., the provider submitted the following IJ removal plan for review, HOW IMMEDIATE JEOPARDY WAS CORRECTED FOR RESIDENTS IDENTIFIED: Immediate jeopardy was identified related to unsafe bed systems, including loose bedrails, gaps creating entrapment risks, and improperly secured mattresses. The facility took immediate action to protect resident safety: Resident #17: Bed was immediately removed and replaced with a bed equipped with appropriate, secure bedrails. Resident #21: Bedrails were removed as they were not clinically indicated. Residents #25 & #26: Bedrails were immediately tightened and secured to eliminate instability. Resident #25: A 5 inch gap between mattress and headboard was immediately corrected by placing a tightly rolled comforter/bolster (this is temporary) to eliminate the entrapment zone. Residents #6 & #14: Mattresses were secured using manufacturer approved metal corner brackets on all four corners, eliminating gaps between mattress and rails. Additionally: Bedrails were removed in four resident rooms where they were not needed for mobility or positioning. The Administrator, Director of Nursing (DON), and Maintenance conducted immediate room to room audits of all beds. All entrapment zones were assessed and measured, ensuring compliance with less than a 4.75 inches in total. Immediate corrective actions included: Installation of manufacturer approved brackets, Temporary gap reduction (rolled comforters/bolsters) until permanent fixes completed, Ordering manufacture [manufacturer] approved corner brackets, Brackets will be installed as soon as they arrive to the facility by maintenance, no later then [than] July 6th, 2026. 2. HOW THE FACILITY IDENTIFIED OTHER RESIDENTS AT RISK: A[n] audit of all beds and mattresses in the facility was completed by: Administrator, Director of Nursing, Maintenance staff. All residents with: Bedrails, Assistive devices, Specialty mattresses were evaluated for: Entrapment zones (Zones 1–7 where applicable), Mattress fit and stability, Rail security. 3. MEASURES PUT IN PLACE / SYSTEMIC CHANGES: The facility implemented the following systemic changes. Equipment & Environment: Only manufacturer approved bedrail and mattress systems will be used. All beds must have: Securely attached rails (if used), Properly fitted mattresses, No gaps exceeding allowable limits, Metal corner brackets required for mattress stabilization where applicable. 4. MONITORING SYSTEM: The facility will implement the following monitoring: Weekly audits x [for] 4 weeks, then; Monthly audits x 3 months, then; Quarterly thereafter. Audit includes: Bedrail stability, Mattress fit and securement, Entrapment zone measurements. Audits will be completed by: Maintenance or designee. Results will be reviewed through: QAPI [quality assurance and performance improvement] Committee. 5. STAFF EDUCATION: All staff (nursing, maintenance, and leadership) will be educated on: Bed safety and entrapment policy will be review [reviewed] with immediate staff by DON/Administrator. All staff will be educated prior to start of next shift. Weekend staff will be educated by Administrator or DON. Proper installation of bedrails and mattress systems, Side rail policy reviewed, Identification of entrapment zones, Immediate reporting and correction process. Education will be completed: Immediately upon IJ identification, During annual competency validation, For all new hires. 15. The immediacy was removed on 5/28/26 at 5:25 p.m. after the survey team verified on-site that the provider had implemented their removal plan through observation, document review, and staff interviews. After the removal of the IJ, the scope and severity of the noncompliance remained at an E. Current census was 27 residents. 16. Review of the provider's revised 1/6/25 Side Rail policy revealed Quarter rails and bed canes [grab bars] that are approved for the beds can be used that are affixed to the bed and evaluated for safety and functioning by maintenance.Maintenance will be notified with side rail evaluations and prn [as needed] for an inspection of the side rail, how it fits the bed, tightness, and to evaluate the mattress for wear and distance from the rail. 17. Review of the provider's undated Bed Safety and Entrapment Prevention Policy revealed that the purpose was To ensure a safe sleeping environment by preventing bed related accidents, including entrapment, falls, and injury related to bedrails, mattresses, and bed systems. The facility is committed to maintaining all beds, mattresses, and assistive devices in a safe condition. Bed systems will be assessed, maintained, and used in a manner that minimizes the risk of entrapment and injury, in accordance with CMS [Centers for Medicare and Medicaid Services] F689 requirements and FDA [Food and Drug Administration] bed safety guidance. Bedrails will not be used as restraints and will only be utilized when clinically indicated and safe. All beds must: Be in good working condition, Have securely attached side rails or assistive devices (if used), Have a properly fitted mattress, Be compatible with all components (no mixing of incompatible parts), Be free of excessive gaps. All gaps must measure ≤ [less than or equal to] 4.75 inches where applicable. Special attention is given to: Space between mattress and rail, Mattress and headboard/footboard, Split rails and joints. Bedrails will: Only be used when clinically necessary. Require: Assessment prior to use, Care plan documentation, Be removed when: Not used for mobility or positioning, Risk outweighs benefit. Mattresses must: Fit securely within the bed frame, Not slide, shift, or leave gaps, Be secured using: Manufacturer approved systems (e.g., corner brackets or stops), Be replaced if worn or incompatible. Initial and Routine Assessments The following will be completed: On admission, With change in condition, Quarterly and annually, After any bed or mattress change. Assessment includes: Bedrail necessity, Mattress fit and stability, Entrapment zone measurement. Staff Responsibilities: All Staff: Assess need for bedrails, Monitor for signs of entrapment risk, Report hazards immediately. Maintenance: Ensure all beds are properly assembled, Perform repairs and installations, Maintain approved equipment only, Monthly audits on all beds. Administration: Ensure policy compliance, Monitor through [the] QAPI process. B. Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), record review, interview, and observation, the provider failed to ensure the safety of one of one sampled resident (5) who was not assessed for her ability to safely drink hot liquids and spilled hot tea on her lap and sustained a hot liquid burn injury, and one of one sampled resident (10) who was not assessed for her ability to safely use her personal coffee maker in her room. Findings include: 1. Review of the provider's 12/23/25 SD DOH FRI report revealed that on 11/19/25, it was reported that resident 5 spilled her hot tea in the dining room, which resulted in a 0.25 centimeter (cm) blister on her right inner thigh, and both inner thighs were red. Bacitracin (an antibiotic ointment) was applied to the blister, and it was covered with a bandage. Resident 5 told a family member that a staff member spilled the hot tea on her. On 12/22/25, resident 5's family member told registered dietitian (RD) H that she thought that a staff member spilled the hot tea on resident 5. On 12/22/25, CEO A and DON B interviewed resident 5, and resident 5 provided inconsistent information about who spilled the hot tea. An unidentified certified nursing assistant (CNA) was interviewed and stated that resident 5 was holding her teacup while the CNA added honey to the hot tea, and then the resident [5] tipped over the cup, into her lap. The unidentified CNA stated she immediately used cloth clothing protectors to absorb the hot tea, took resident 5 to her room, assisted an unidentified nurse to remove resident 5's pants, and cool packs were applied. An unidentified nurse, who the report identified as no longer working at the facility, was interviewed, and there was no change in the above information provided by the unidentified CNA. Dietary manager (DM) G interviewed an unidentified dietary aide who worked on 11/19/25, and the unidentified dietary aide recalled hearing resident 5 cry out, and did not see how the spill occurred. The provider determined that resident 5 spilled her hot tea on her leg. DM G implemented a lid policy, and resident 5 was to have a little water or ice added to her hot beverages, and a lid was to be on the cup when the cup of hot tea was served to resident 5. All hot drinks were to be served with a lid to all residents. The resident or a CNA, upon request by the resident, was the only one that can remove the lid. The lids were not allowed to be removed by the dietary staff members. The temperature on the hot water/coffee machine was not monitored on 11/19/25. The staff were to be trained by 1/5/26 to monitor the temperature of the hot water/coffee machine daily. The temperature of the hot water/coffee machine was monitored after the incident on 11/19/25, and that temperature was in the range of 125-140 degrees Fahrenheit (F). The hot water/coffee machine was inspected and serviced by the coffee company's representative/technician. The provider contacted an unidentified person at the Department of Health and was told that a maximum temperature for hot drinks was not determined by any regulation. Resident 5's blister healed with no residual effect or infection, and her care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was updated to reflect the need for a lid to be used on her hot beverages, and ice was to be added to her tea. The provider determined the incident was not the result of abuse or neglect. The report indicated that the provider, family, and DON were notified of the incident. 2. Review of resident 5's EMR revealed she admitted to the facility on [DATE]. Her 5/19/26 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated her cognition was intact. She had a diagnosis of Alzheimer's Disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions). An 11/19/25 nursing progress note revealed Staff reported that resident [5] was in the dining room when she spilled hot tea in her lap. Resident [5] was taken to her room and [her] pants [were] removed immediately. Cool packs [were] applied. Resident [5] has a 0.25 cm blister on [her] right inner thigh. Both inner thighs are red. Bacitracin applied to [the] blister covered with Telfa [a bandage]. [The] provider and family and DON [were] notified. There was an 11/19/25 physician's order for cool packs, Bacitracin, and a bandage to be applied to resident 5's right inner thigh. Resident 5's Skin Observations revealed that on 11/24/25, she had a blister on her right inner thigh that measured 1.5 cm by 0.75 cm, and the leg was tender to touch. On 12/1/25, the Burns spots on [her] inner thighs are peeling. Wound bed [was] pink, no drainage [was] noted. Areas [were] left open to air. On 12/8/25, there were no new skin issues noted.normal skin color, warm to touch. No documentation indicated when the hot liquid burn injury healed. A 12/23/25 progress note written by RD H revealed that she was at the facility on 12/22/25, and resident 5's family member came to her office for follow up regarding the hot liquids in the dining room as discussed during her [resident 5's] care conference on 12/9/25. RD H informed resident 5's family member that DM G adjusted and was monitoring the temperature of the hot water/coffee machine, that the staff members were instructed to add ice to resident 5's hot liquids to cool them, and resident 5 was to have a lid for her hot liquids to reduce the risk of burning herself. RD H reported the conversation to assistant DON C, licensed social worker (LSW) E, and social services designee (SSD) F on 12/22/25 and to DON B and the interdisciplinary team (ADT) at the IDT meeting that morning on 12/23/25. Resident 5's updated 3/10/26 care plan had a focus area that indicated on 11/19/25, resident 5 spilled hot tea on herself, and had a 0.25 cm blister on her right inner thigh. Interventions included that she was able to feed herself after set-up assistance was provided, she had a burn issue with hot tea in the dining room in November 2025, and that she was to have ice added to her hot liquids and a white lid on her cup to decrease the risk of burning herself by hot liquids. There was no documentation that a hot liquid assessment was completed. 3. Observation and interview on 5/27/26 at 8:13 a.m. with resident 5 revealed she had her breakfast of bacon, eggs, toast, and a bowl of oatmeal in front of her. Her hot tea did not have a lid. She answered questions with, yes or no and indicated that she did not have ice in her tea and did not like a lid on her tea. 4. Observation and interview on 5/27/26 at 10:52 a.m. with DM G revealed the water in the hot water/coffee machine was 164 degrees F. She was unsure what the temperatures of the hot water/coffee would have been in November 2025 because they did not monitor the temperatures until 12/24/25, after resident 5 sustained a hot liquid burn injury from her hot tea. She expected the temperature of the hot water/coffee to be under 180 degrees F for it to be safe to serve to residents. There was no hot beverage policy until December 2025. All residents were served their hot beverages in an open hot beverage cup until the hot beverage policy was implemented. All of the residents who were served a hot beverage by a dietary staff person must have a lid on that hot beverage. The lids were used to prevent a hot liquid burn injury, not to keep the beverage hot. The CNAs were not required to serve all residents their hot beverages with a lid because the CNAs knew which residents needed a lid and which residents did not need a lid. The residents could remove the lid once the hot beverage was served by a dietary staff member, or a CNA could remove the lid if the resident asked that the lid be removed. Some residents did not need the lids, but she did not know who they were. She educated the dietary staff about the use of the lids on the hot beverage cups and the new policy, but did not keep documentation of when that education was provided or who she educated. She did not work on 11/19/25 when resident 5 spilled her tea and was burned. She was not notified that resident 5 received a hot liquid burn injury until a few weeks after it occurred. 5. Phone interview on 5/27/26 at 4:34 p.m. with resident 5's family member regarding resident 5's 11/19/25 hot liquid burn injury revealed she visited resident 5 on 11/24/25 and was told by resident 5, they burned me, and resident 5 showed her the inner thigh area. She was resident 5's emergency contact, and no notification was provided to her or the other listed emergency contact. While at the facility on 11/24/25, she spoke with a nurse (she was unable to recall who) about the incident and was told that the documentation in resident 5's EMR said that resident 5 spilled her own coffee in her lap and that the resident's emergency contact was notified. She stated that resident 5 was coherent, and repeated several times, they burned me, and that she believed resident 5. She told the nurse that she thought a staff member caused resident 5's burn injury and that she was upset that she and the resident's other emergency contact person were not notified. Resident 5's family member attended resident 5's 12/9/25 care conference meeting and told the staff that she was concerned that a staff member caused resident 5's burn injury, and that she and the resident's other emergency contact person were not notified. She recalled that RD H was present at that care conference and said she would check into it. On 11/23/25, she stopped to visit with RD H because she was not provided any additional information about what happened when resident 5 was burned or what the facility was doing about it. She was told the hot water machine was over-temperature, the staff members were to put ice in resident 5's hot tea, and resident 5 was to drink her tea out of a cup with a lid. Resident 5's family member was upset because resident 5 did not like the lid on her cup, and she felt that resident 5 was safe to drink hot liquid out of a cup without a lid. She felt resident 5 did not spill her hot tea on herself and should be allowed to drink her tea without ice or a lid. She was not aware if or when the hot liquid burn injury healed. She stated that she hoped that an incident like this would not happen again or happen to anyone else. 6. Review of resident 5's 12/9/25 Care Conference Assessment revealed that resident 5, her family member, RD H, assistant DON C, and social services designee (SSD) F attended that care conference. Resident 5's family member discussed her concerns about resident 5's burn injury from her hot tea. 7. Observation and interview on 5/27/26 at 5:11 p.m. in the dining room with resident 5 and contracted travel CNA S revealed resident 5 had a plastic cover on her hot tea. Contracted travel CNA S stated that no residents received ice in their hot beverages, but she would put ice in their hot beverages to cool them, if they asked. All residents were served their hot beverages in a cup with a lid, and the resident or the staff could remove the lid for the resident after it was served. 8. Interview on 6/1/26 at 12:17 p.m. with DON B regarding resident 5's 11/19/25 hot liquid burn injury revealed that she was notified on 12/22/25 that resident 5's family member was stating that resident 5 was burned by a hot liquid and that she thought that a staff member caused the burn injury. DON B was not notified on 11/19/25 that resident 5 received a hot liquid burn injury, and did not expect to be notified because the hot liquid burn injury was not serious enough to require a visit to the emergency room, and the staff thought that resident 5 had spilled her hot tea on herself. CEO A and DON B began their investigation into resident 5's 11/19/25 hot liquid burn injury on 12/23/25. The results of their investigation were entered into the SD DOH reporting system, and then the information was shredded. The provider determined that resident 5 spilled her hot tea on her lap, causing the hot liquid burn injury. Hot liquid safety assessments were not completed on any residents. DM G initiated a policy that all residents were to have lids on their hot tea or coffee, and resident 5 was to have ice added to her hot beverages. Those interventions were added to resident 5's care plan. She was unaware that resident 5 was not provided ice in her hot tea, but resident 5 was allowed to remove the lid from her hot tea. 9. Phone interview on 6/1/26 at 3:53 p.m. with contracted travel CNA U regarding resident 5's 11/19/25 hot liquid burn injury revealed she worked during the evening meal that day. Resident 5 held her teacup up in the air, indicating that she wanted more hot tea and honey. Contracted travel CNA U refilled resident 5's cup and then set it on the table. After she walked away, she heard resident 5 scream that she spilled her hot tea in her lap. She felt that it was a few seconds after she walked away that resident 5 spilled the hot tea. Contracted travel CNA U stated the hot tea pooled in resident 5's lap, she used cloth clothing protectors to soak up the hot liquid, and pushed resident 5 quickly out of the dining room and back to her room to change her pants. She did not think that anyone was near resident 5 when her hot tea spilled. The facility implemented a new policy that all residents were to be served their hot beverages in cups with a plastic lid. They did not use the hot beverage cup lids before the 11/19/25 incident with resident 5. All residents were allowed to have hot beverages, and all residents were required to use the plastic lids. There was no list of residents who were allowed to have the covers removed, but she knew that some residents could remove the lids themselves or ask the nursing staff members to remove the lid for them. 10. Interview on 6/2/26 at 8:25 a.m. with RD H regarding resident 5's 11/19/25 hot liquid burn injury revealed she learned of the injury during resident 5's 12/9/25 care conference. The hot water/coffee machine was serviced by the distributor to ensure the temperature was safe. A hot beverage assessment was considered for resident 5, but the provider's current EMR system did not have one, so that assessment was not completed. Resident 5 was to have ice added to all of her hot beverages, and the use of plastic lids on all hot beverages was implemented. CNAs were allowed to remove the lids for residents who requested them removed. There were no residents who were not served hot beverages due to the risk of hot liquid burn injuries. The need for ice to be added to resident 5's tea was not on resident 5's meal ticket, but she thought that the staff knew that she needed it. RD H was unaware that ice was not being provided in resident 5's hot beverage, but resident 5 could have the hot beverage cup lid removed from her cup by a nursing staff member when she requested it removed. The temperature of the hot water/coffee machine was not monitored until 12/24/25. She thought that it was determined that resident 5 spilled her own hot tea. 11. Multiple attempts were made throughout the survey to interview resident 5. She answered simple yes-or-no questions, but when as

Based on the South Dakota Department of Health (SD DOH) Facility Reported Incident (FRI), interview, record review, and policy review, the facility failed to protect one of one resident's (13) right to be free from physical abuse by contracted travel certified nursing assistant (CNA) BB who used physical force while providing care to resident 13 who subsequently had a skin tear and bruising to her arms. Findings include:1. Review of the provider's 2/25/26 SD DOH FRI revealed on 2/24/26, at around 6:00 a.m., an unidentified CNA entered resident 13's room to assist her with her morning care. The CNA noted that resident 13 had bruises on both her arms and a skin tear on her right arm. The CNA reported her findings to the on-duty contracted travel registered nurse (RN) T. The nurse assessed resident 13 and confirmed that she had bruises on both arms and a skin tear on her right arm. Resident 13 told the CNA and RN that a girl from the night shift was mean, grabbed her arm, and wanted her to get out of bed to go to the bathroom. Resident 13 told the staff member no and said she had already gone to the bathroom, but the staff member made her get up out of bed. The incident, along with resident 13's bruising and skin tear, was reported to director of nursing (DON) B when she arrived at work that same day. On the evening of 2/24/26, DON B and the chief executive officer (CEO) A met with contracted travel CNA BB, to discuss resident 13's abuse allegation. Contracted travel CNA BB explained that she was assisting resident 13 in getting ready for bed on the evening of 2/23/26. While helping resident 13 stand, resident 13 began to fall, contracted travel CNA BB grabbed resident 13 by both forearms to steady her, which may have caused the bruising. When contracted travel CNA BB went in to assist resident 13 with care early the next morning on 2/24/26, resident 13 was combative, but contracted travel CNA BB said she was able to reason with resident 13 and left her room when resident 13 told her to. Contracted travel CNA BB wrote a statement about the incident and was placed on administrative leave pending the investigation. CEO A and DON B interviewed resident 13 regarding her allegation following the meeting held with contracted travel CNA BB, and resident 13's account of the incident did not differ from her previous explanations. DON B said that a witness statement was obtained by the unidentified CNA, which documented the bruising and skin tear on resident 13's arms the morning of 2/24/26. The unidentified CNA's witness statement was provided by DON B for review and revealed that the unidentified CNA's findings were written on a sheet of paper that contained no date or signature and contained another witness statement from an unidentified staff member with no date or signature. The statement for the unidentified CNA explained the findings regarding resident 13's bruising and skin tear on the morning of 2/24/26, and the statement by an unidentified staff member explained resident 13's mood and behavior from the previous evening, 2/23/26. Law Enforcement was notified by the facility on 2/25/26 at approximately 9:30 a.m. about the abuse allegation and began an investigation. The investigation's conclusion indicated that CNA BB's contracted travel employment at the facility was terminated on 2/25/26, and her travel employment agency was notified that she was no longer permitted on the facility's premises. Resident 13's power of attorney (POA, a trusted person to act on your behalf regarding financial, legal, or medical matters), DON, administrator, and physician were notified of resident 13's injuries and the investigation. The Department of Human Services (DHS) and the SD DOH were both notified on 2/25/26. 2. On 5/26/26, a request for the facility's investigation documentation for 2/25/26 was made, and on 5/27/26 at 8:12 a.m., CEO A reported that the facility did not have any investigation documentation to provide. 3. Review of resident 13's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 12/30/25 Brief Interview of Mental Status (BIMS) assessment score was 4, and her 3/24/26 BIMS assessment score was 7, both of which indicated her cognition was severely impaired. Resident 13 was discharged on 4/2/26 due to her death in the facility. A 2/24/26 6:35 a.m. nursing progress note documented by contracted travel RN T revealed that staff reported to this writer that resident [13] had 3 large purple bruises on the right forearm. The bruise closest to the wrist has a small skin tear. One purple bruise on [the] left forearm. Left side of lip has a small cut. Resident states, 'She grabbed my arm and twisted it.' DON, ADON [assistant DON] notified. Resident 13's 2/24/26 12:57 p.m. skin assessment indicated that she had 3 large purple bruises on her right forearm. The bruise closest to the wrist has a small skin tear. One purple bruise on her left forearm, and the left side of her lip has a small cut. Denies having pain, Turgor [the skin's elasticity used to check the body's hydration level] is > [greater than] 3 seconds. A 2/24/26 3:37 p.m. progress note indicated that contracted travel RN T was unable to reach resident 13's first emergency contact person but was able to reach her second emergency contact person by phone, and he would try to notify resident 13's first emergency contact person. A 2/25/26 1:16 p.m. progress note indicated that DON B attempted to call resident 13's first emergency contact to Follow up on [her] bruises, No answer, will try again later. There was no other documentation in resident 13's EMR that indicated resident 13's first emergency contact was notified of the abuse allegation on 2/24/26 that resulted in physical harm. A 3/8/26 physician's order indicated to observe bruising to bilateral forearms until healed, two times a day. Review of resident 13's most recent care conference summary was completed on 3/25/26, but no care conference signature form was available to review. There was no documentation in resident 13's EMR that the allegation of abuse with physical harm was reviewed with her family and the IDT team. Resident 13's care plan, dated 7/10/25 and revised on 3/30/26, did not address interventions that helped ensure her safety from abuse related to her cognitive or behavioral status. Incident tracking reports in the facility's electronic system (PCC) showed that no incident report for the abuse incident had been completed in the risk management report section from 2/16/26 through 3/16/26, as required by the facility's policy. 4. Review of the facility's staff schedules and timecards from 2/23/26 through 2/24/26 revealed that contracted travel CNA BB was assigned to resident 13 during the night shift on 2/23/26 at 5:17 p.m. through the morning of 2/24/26 at 6:21 a.m. 5. Review of contracted travel CNA BB's personnel file revealed that she was hired in January 2024 through a contracted travel agency. She completed abuse training through another facility on 4/13/23 and elder physical abuse and managing resident behaviors training with the provider on 9/8/25. No disciplinary actions or allegations of abuse and neglect were documented or found in former contracted travel CNA BB's file. 6. Interview on 5/27/26 at 3:37 p.m. with licensed social worker (LSW) E revealed the incident reports were completed by CEO A and DON B, and that she was not aware of resident 13's allegation of abuse on 2/24/26. LSW E did not believe she was notified of the incident involving resident 13 on 2/24/26 and acknowledged that she did not complete any documentation regarding the incident in resident 13's EMR. 7. Phone interview with resident 13's first emergency contact was attempted on 5/27/26 at 4:08 p.m.; a message was left for a return call. No return call was received during the survey. 8. Interview on 5/28/26 at 4:50 p.m. with CEO A revealed that CEO A acknowledged that no audits or education were provided to staff regarding resident abuse, and that no further follow-up was conducted with other residents to determine whether they were harmed by staff or felt safe at the facility. He said that resident incidents were routinely discussed in the Quality Assurance Performance Improvement (QAPI) and board meetings, and did not provide any further information on what those meetings determined regarding the incidents. 9. Interview on 6/1/26 at 12:08 p.m. with DON B revealed that she or CEO A initiated incident investigations. DON B acknowledged that no other residents were interviewed as a part of their investigation to assess additional concerns of abuse or neglect, no additional education on abuse prevention was provided to staff, and no audits related to the resident interviews and staff education were completed after the 2/24/26 incident involving resident 13. DON B further stated that approximately two weeks prior to resident 13's abuse allegation, she spoke to contracted travel CNA BB about toileting residents upon their requests, as it had been reported to her by staff that contracted travel CNA BB had told a resident, whom DON B could not recall, that she could not use the bathroom. DON B said she spoke with contracted travel CNA BB about that allegation, and contracted travel CNA BB denied it. DON B said she reported the information to the contracted travel CNA BB's travel staffing company to inform them that the discussion about the resident's situation had been identified as a disciplinary matter involving contracted travel CNA BB. 10. Review of the provider's revised June 2021 job description for the long-term care (LTC) Certified Nurse Assistant (CNA) revealed that The CNA assists in the provision of nursing care of the residents as directed by the charge nurse. Care skills include but are not limited to: comfort and safety measures, personal hygiene, assisting with activities of daily living, and simple nursing procedures. The CNA's duties include: Assisting residents with activities of daily living (ADLs) such as bathing, dressing, and grooming, responding to patient call lights and anticipating resident needs, maintaining a safe and orderly environment, following established health and safety standards, and coordinating with nurses and other healthcare professionals to ensure comprehensive and consistent patient care. CNAs will Demonstrate knowledge of the principles of growth and development over the life span and the skills necessary to provide age-appropriate care. Demonstrate appropriate lifting, repositioning, and moving of residents. Reports resident concerns, and promotes a safe and hazard-free resident care environment. 11. Review of the provider's reviewed December 2021 Abuse Prohibition policy revealed that the facility was To utilize the abuse prohibition investigative protocol to be in compliance with federal regulations. Documentation is required for all suspicious injuries, bruises, skin tears, fractures, and injuries of unknown origin. The primary RN or DON will complete necessary documentation surrounding the injury using the Injury Assessment form. Abuse, involuntary seclusion, and misappropriation of property will be reported to the primary registered nurse (RN) and then to the director of nursing (DON) or social worker who will be responsible for initial investigation of the incident. Document the investigation by using the Grievance Complaint Investigation form, and place it with the investigation report. 12. Review of the undated admission packet revealed that The facility will notify the resident or representative when an accident or injury occurs. Complaints of abuse, harassment, or mistreatment will be immediately investigated and you [the resident or resident's representative] will receive a written and/or verbal report of the findings, and/or corrective actions taken within five working days of filing the report.

Based on observation, interview, record review, and policy review, the provider failed to ensure the facility was operated and administered by chief executive officer (CEO) A and director of nursing (DON) B in a manner that ensured quality of life and overall well-being for all 26 residents in the facility.Findings include:1. Observations, interviews, record reviews, and policy reviews throughout the survey from [DATE] through [DATE] and [DATE] through [DATE] revealed CEO A and DON B did not ensure the management, safety, quality of life, and overall well-being of all the residents who lived at the facility.Those were evidenced by a widespread system breakdown to ensure services provided met professional standards and the minimum requirements as it pertained to providing education to residents and residents' representatives to be able to make informed decisions regarding psychotropic medication use, the filing of grievances, the residents' right to be free from abuse and neglect, the right to be free from chemical restraints, investigating and reporting allegations to the South Dakota Department of Health within the required timeframe, resident baseline care plans (personalized plan that addresses a resident's care needs, goals, and interventions within the first 48 hours of admission) completed and offered to the resident or their representative, the updating of care plans to reflect the residents' current care needs, accident hazards identification and mitigation related to entrapment risks for bed side rail use and hot liquid injury, the timeliness of physician visits and complete documentation of the visit, the accountability and securement of controlled medications (medications with risk for abuse and addiction), the pharmacist's medication regimen review, medication accessibility, the removal of expired supplies from use, staff training, and a functioning and effective QAPI (quality assurance and performance improvement) program.2. Interview on [DATE] at 12:31 p.m. with CEO A revealed he had worked at the facility since [DATE]. He was the CEO for the long-term care facility, the clinic, and the attached hospital. He confirmed he was responsible for the daily operations of the facility.3. Review of the providers undated CEO job description revealed, The Chief Executive Officer (CEO) will be responsible for overall administrative management and operation of the hospital, clinics, long-term care program, and related entities under the health umbrella in [redacted name of the town].Leads in educational programs, participates as a teacher and preceptor. Monitors the adequacy and quality of the hospital, clinic, and long-term care medical activities through coordination with the board, management partners [with] the medical and nursing staffs, and enacts policies to assure excellent health care services.4. Review of the provider's undated director of nursing job description revealed The DON plans, organizes, develops, and directs the overall operation of the LTC [long-term care] Nursing Department. Works closely with the Medical Director, and interdisciplinary teams to ensure that a high degree of quality care is maintained in accordance with current federal and state guidance and regulations as well as established policies and procedures.Refer to F552, F585, F600, F605, F609, F655, F657, F689, F700, F712, F755, F756, F761, F865, F944, and F947.

Based on interview, record review, and policy review, the provider failed to ensure they identified, investigated, and corrected quality deficiencies, and to initiate or monitor performance improvement projects (PIPs) in response to known areas of concern within their Quality Assurance and Performance Improvement (QAPI) program.Findings include: 1. Interview on 5/28/26 at 5:00 p.m. with CEO A revealed that director of nursing (DON) B managed the facility's QAPI program. He did not routinely attend the long-term care (LTC) QAPI meetings because he was not required to be present. He received a copy of the LTC QAPI meeting minutes and provided that at the general QAPI meeting and again at the board meetings, where he reviewed them. Medical director L was a member of the LTC QAPI committee, attended the meetings when he was able to, and was involved in the policy and procedure process as much as his time allowed. 2. Interview on 6/2/26 at 10:01 a.m. with medical director L revealed that he attended the facility's QAPI meetings quarterly (meaning occurring every three months) when he was able. If he was not able to attend in person, he would attend online. He received a copy of the meeting minutes for review every quarter. 3. Interview on 6/2/26 at 11:48 a.m. with DON B revealed that she was the QAPI Manager and led the QAPI meetings. The facility held quarterly QAPI meetings with committee members, and each committee member was expected to attend and present a report on the information they monitored. She tracked the committee members' attendance. The attendance tracker included the committee member's name, a column for Yes (meaning in attendance), and No (meaning did not attend). She placed a checkmark in the Yes column if the member attended, and a checkmark in the No column if the member did not attend. The QAPI committee implemented PIPs, and the staff were informed of them by their department managers. She acknowledged that potentially harmful systemic issues and concerns were not identified or corrected since the last survey. The staff did not receive training on the elements and goals of the facility's QAPI program. 4. Review of the provider's QAPI meeting attendance records revealed that on 11/23/25 and 3/24/26, CEO A and medical director L did not attend, and there were no other governing board members or facility owner present. On 1/27/26, the attendance record did not have any committee members marked as attending. 5. Review of the provider's QAPI documentation and meeting minutes revealed no PIPs were implemented to address concerns regarding resident safety and quality of care. 6. Interviews throughout the survey confirmed that the QAPI committee did not review or act on the problems that resulted in citations under F600, F605, F609, F689, F700, F755, and F761. There was no evidence that the facility collected safety data, conducted root cause analyses, or monitored corrective actions for the known issues. 7. Review of the provider's undated Chief Executive Officer (CEO) job description revealed that the CEO Leads in educational programs, monitors the adequacy and quality of the medical activities through coordination with the board, management partners, the medical and nursing staff, and enacts policies to assure excellent health care services. Ensures compliance with the regulations and the rules of accrediting bodies by continually monitoring the organization's service delivery and initiating changes as required. Communicates with staff and volunteers to improve service. 8. Review of the provider's revised June 2021 Director of Nursing (DON), Long Term Care (LTC) job description revealed that the DON plans, organizes, develops, and directs the overall operation of the LTC Nursing Department and works closely with the Medical Director, and interdisciplinary team to assure that a high degree of quality care is maintained in accordance with current federal and state guidelines and regulations as well as established policies and procedures of [Facility Name Redacted]. The DON has a primary role in the evaluation and improvement of nursing and other services provided. Provides effective onboarding, education, and training to assure staff competencies, and provides ongoing coaching, mentoring, and performance feedback for staff to succeed. 9. Review of the provider's reviewed October 2025 LTC Quality Assessment Performance Improvement (QAPI) Plan revealed that The QAPI Plan is designed to evaluate, improve, monitor, and measure every activity at [Redacted Facility Name] that affects resident care. The results should be measurable improvement in resident care and optimal utilization of [Redacted Facility Name] LTC Resources. Some goals included, Monitor and continuously improve resident care, find and correct problems in clinical care, improve resident and family satisfaction with services, provide education for staff on quality initiatives and their role, and assure accuracy of resident care documentation. The objectives included, Involve all departments in QAPI activities, and Document QAPI activities in departmental and committee meetings. The LTC QAPI shall be composed of the Administrator [CEO], Director of Nursing [DON], Medical Director (as available), LTC IDT, QAPI Manager, and Pharmacist. The Administrator [CEO] or Director of Nursing will ensure that assigned members of the medical and professional staff participate in the QAPI program and that recommendations for improvement from reports to the LTC QAPI Committee are implemented. The committee shall meet quarterly (more if needed) and shall be responsible for: Reviewing QAPI activities for adequacy and timely completion, Receiving and acting on the quarterly QAPI reports prepared by the QAPI Manager, Identifying opportunities for improvement; implementing initiatives to address problems and documenting follow-up and resolution of problems. The QAPI Manager shall report to the Director of Operations, attend all QAPI Committee meetings, and review reports of various activities. These reports include: quality indicator profiles, resident council, family council, pharmacy drug regimen reviews, family satisfaction surveys, resident abuse files, and incident reports. The QAPI Manager shall perform concurrent monitoring activities of the following: medication records, treatment sheets, incident reports, medication errors, and 24-hour nursing reports. The QAPI Manager will maintain records of all concurrent monitoring activities. Problems affecting resident care are brought to the attention of the QAPI Manager through safety reports, incident reports, survey reports, and resident council minutes. Data will be collected and recorded so that the degree of compliance with achievable goals can be measured. When the cause and scope of a problem are known, corrective action shall be implemented. Alternatives for corrective action include, but are not limited to: In-service Educational Problems, New or Revised Policies and Procedures, Staffing Changes, and Equipment or Facility Change. The QAPI Committee shall assign problem reassessment and monitoring responsibilities to determine if problems have been resolved or reduced to an acceptable level, and activities shall be documented and should demonstrate measurable improvement in quality of resident care. Refer to F600, F605, F609, F689, F700, F755, and F761.

Based on personnel record review, interview, and review of the director of nursing (DON)'s job description the provider failed to ensure yearly performance evaluations were completed on three of three sampled certified nursing assistants (CNAs) (S, U, and AA) and their in-service training was tailored to address areas of weakness as determined in the nurse aide's performance reviews and facility assessment. Findings include:1.Review of contracted travel CNA S's personnel record revealed she was hired on 3/19/24. There was no yearly performance review in her personnel record. 2. Review of contracted travel CNA U's personnel record revealed she was hired on 3/7/23. There was no yearly performance review in her personnel record. 3. Review of CNA AA's personnel record revealed she was hired on 1/15/08. Her last performance evaluation was on 4/2/25. 4. Interview on 6/2/26 at 10:31 a.m. with director of nursing (DON) B revealed she completed yearly performance evaluations on the provider's nursing staff. She stated that for the contracted travel CNAs, she provided feedback to their travel agency, and she expected the travel agency to complete their yearly performance evaluations. If a CNA was identified to need additional training in an identified area, that training could be added to the basic required training as needed. 5. Review of the provider's undated DON job description revealed, The DON has a primary roll in the evaluation and improvement of nursing and other services provided. Provides effective onboarding, education, and training to assure [ensure] staff competencies. Provides ongoing coaching, mentoring, and performance feedback for staff to succeed. 6. Review of the provider's 12/30/25 Facility Assessment revealed, Annual Evaluations- We have implemented an evaluation form that is easier for employees and directors to utilize. We have found it enables more substantial dialogue between the director and staff members.

Based on record review, interview, and policy review, the provider failed to ensure the staff received the required training regarding the elements and goals of the facility's Quality Assurance and Performance Improvement (QAPI) program for five of five employees reviewed (G, O, R, Y, and Z).Findings include:1. Review of employee personnel records revealed dietary manager G was hired on 7/28/25. Certified nursing assistant (CNA) O was hired on 2/15/26. Contracted travel CNA Z was hired on 4/6/26. Housekeeping aide Y was hired on 4/7/26. Contracted travel licensed practical nurse (LPN) was hired on 4/27/26. There was no documentation to support employees G, O, R, Y, and Z received training regarding the elements and goals of the facility's QAPI program. 2. Interview on 6/2/26 at 11:48 a.m. with director of nursing (DON) B revealed she managed the QAPI meetings. The staff were informed about any performance improvement plans (PIPS) developed in QAPI by their department manager. The staff did not receive any training regarding the elements and goals of the facility's QAPI program.3. Interview on 6/2/26 at 9:15 a.m. with human resources director J revealed she was responsible for assigning required training for the staff and the staff were not assigned training related to the QAPI program. She was not aware that the elements and goals of the facility's QAPI program was a required training topic.4. Interview on 6/2/26 at 12:31 p.m. with chief executive officer (CEO) A revealed he acknowledged there was required training that was not completed by the staff.5. Review of the provider's August 2018 Required Annual Training of Long-Term Care Healthcare Workers policy revealed that training was to be completed in accordance with state and federal regulations. The provider shall maintain a formal orientation program and an ongoing education program for all personnel.The elements and goals of the facility's QAPI program was not included as required staff training in the policy.

Based on observation, record review, interview, and policy review, the facility failed to ensure timely destruction of controlled medications (medications with risk for abuse and addiction) for six of six sampled residents (7,8,11,13, 32, and 100) and failed to ensure that the controlled medications awaiting destruction were stored with restricted access and maintained under proper accountability procedures in one of one medication storage room.Findings include:1. Observation and interview on 5/27/26 at 3:31 p.m. of the medication storage room with contracted travel registered nurse (RN) V revealed that the door was locked and that she used a key to enter. She stated that she held the key to the medication storage room for her shift and that every nurse had access to the medication room key during their shifts at the facility. The resident's medication refrigerator contained resident's personal beverages and their medications stored together. Resident 5's Trulicity 3mg/0.5ml syringe box was wet, as two boxes of opened, unlabeled wine boxes were stored above the medications. One box of wine was leaking from the spicket. Contracted travel RN V acknowledged that the cardboard medication container for resident 5's medication was wet. There was an unlabeled 12-pack of beer stored in the refrigerator as well. Additionally, a clear plastic bag containing three boxes of influenza vaccine Adjuvanted on the bottom shelf was wet. The following expired medications and supplies were stored on shelves in the medication storage room: Eight boxes of COVID 19 Antigen Rapid Tests (5 test kits), expired 9/2/25 One box (50 per box) Bionix lighted ear curettes, expired 11/7/25 Twenty four boxes of COVID 19 Antigen Rapid Tests (2 test kits), expired 11/11/25 Nine PureWick female external catheters, expired 4/28/26 Five syringes of Influenza vaccine adjuvanted lot #407253, expired 5/6/26 Eight syringes of Influenza vaccine adjuvanted lot #407257, expired 5/13/26 Contracted travel RN V acknowledged that the medications and supplies had expired and should have been removed from the medication storage room during the last monthly check. She acknowledged that residents' personal food and drinks should not be stored in the medication refrigerator due to the risk of contamination. She acknowledged that resident 5's medication container was compromised from the leaking wine spicket. Contracted travel RN V stated that controlled medications waiting to be destroyed were stored in the locked cupboard in the medication storage room. She was unsure of the medication destruction process. 2. Observation and interview on 5/27/26 at 4:14 p.m. with assistant director of nursing (ADON) C in the medication storage room revealed that outdated medications and supplies in the medication storage room were checked by night shift nurses the last day of the month, and nurses were expected to complete a fax request to the pharmacy to notify them that medications and supplies had expired and needed to be replaced. The resident medication refrigerator temperatures were to be monitored by the nurses every shift. She acknowledged that resident 5's cardboard medication container was wet from a leaking wine box stored above the medications. She was unsure if the resident's personal food and drinks could be stored in the medication refrigerator. ADON C acknowledged that two boxes of wine and a 12-pack of beer were not labeled with the resident's name or the date the wine boxes were opened. 3. Observation and interview on 5/27/26 at 4:19 p.m. with director of nursing (DON) B, in the medication storage room, revealed that temperatures should be monitored once or twice a day, but she was unsure. She acknowledged that no temperature log was maintained for May 2026. Temperature logs for February, March, and April 2026 were reviewed and revealed numerous missing temperature readings. She stated that the controlled medications were locked in a 2-door cupboard and that she, ADON C, and the scheduled working nurses had access to the key. DON B said that controlled medications were destroyed together by ADON C and licensed pharmacist M every one to two weeks. She said the controlled medications awaiting destruction were not counted each shift. 4. Review of the provider's resident medication refrigerator temperature log revealed that The temperature of patient medication refrigerators is to be monitored and documented daily. Store the medications under proper conditions as soon as possible and contact the pharmacy to determine if the potency of any of the medications has been affected, and recommendations for use or disposal. If pharmacy recommends, dispose of open multiple-use vials of medication. Defrost immediately if needed. Notify maintenance for recommendation regarding repair/maintenance/replacement. Document the actions taken in the space provided on the back of this sheet. The February 2026 temperature log had missing temperature documentation on days 2, 6-7, 11-15, 18, 20-21, and 24-27.The March 2026 temperature log had missing temperature documentation on days 4-7, 14, 18-21, and 26-28. The April 2026 temperature log was missing temperature documentation every day except days 5 and 6. 5. Interview on 5/28/26 at 8:40 a.m. with RN Q revealed she was concerned about the number of controlled medications awaiting destruction. She reported there were numerous controlled medications in the locked cupboard in the medication storage room awaiting destruction with licensed pharmacist M and ADON C. RN Q stated that the controlled medications had been in the cupboard for several weeks, waiting to be destroyed. 6. Observation and interview on 5/28/26 at 11:46 a.m. with ADON C in the medication storage room, and the controlled medications revealed that the controlled medications were locked in a cupboard in the medication storage room. Numerous controlled medications were stored in the cupboard, and the cupboard was disorganized and did not have a clear system of order. The controlled medication disposition forms were not stored with the medications, requiring ADON C to search through the cupboard to match each medication with its corresponding form. She stated that the controlled medications were to be counted and then destroyed at least every one to two weeks. ADON C stated that she and licensed pharmacist M were usually the ones who counted and destroyed the controlled medications together, and that they had not done so in over 2 weeks. She acknowledged that controlled medications awaiting destruction were not counted daily for their accountability, and multiple staff nurses having access to them was a potential risk for diversion. She stated that all medications were destroyed in the RX Destroyer (a liquid, ready-to-use chemical drug destruction product that begins deactivating drugs upon contact with it). Review of destruction logs revealed that she and licensed pharmacist M last counted together on 3/14/26. She acknowledged that the controlled medications had not been destroyed by her and licensed pharmacist M for over two months. The cupboard contained the following unreconciled controlled medications awaiting destruction for residents 7, 8, 11, 13, 32, and 100:Resident 7: Eight tablets of lorazepam 0.5 mg Six tablets of lorazepam 0.5 mg Six tablets of lorazepam 0.5 mg PRN 29 mL of lorazepam Intensol 2 mg/mL Two tablets of diazepam 10 mg 25 mL of morphine sulfate oral solution 20 mg/mLResident 8: 21 mL of lorazepam Intensol oral concentrate 2 mg/mL 75 tablets of hydromorphone 2 mg 26 mL of morphine sulfate 100 mg/5 mL 15 tablets of morphine sulfate ER 60 mg 15 tablets of morphine sulfate ER 60 mg Resident 11: One tablet of buprenorphine 2 mgResident 13: 15 tablets of hydrocodone/APAP 5-325 mg 26 tablets of tramadol 50 mg 22.5 mL of morphine sulfate 20 mg/mL Nine fentanyl 25 mcg/hr patchesResident 32: Three tablets of haloperidol 5 mg One tablet of lorazepam 1 mgResident 100: 28.5 mL of morphine sulfate oral solution 20 mg/mL Five fentanyl 25 mcg/hr patches 29.25 mL of lorazepam Intensol oral concentrate 2 mg/mLUnknown Two unidentified light-orange pills, stored in an unlabeled clear plastic medication cup. 7. Interview on 5/28/26 at 12:28 p.m. with ADON C revealed that DON B reported to her that DON B found medications on the floor in former resident 8's room, but she was unsure of the exact date. She stated that DON B said the medication was brought to resident 8 by a family member or friend. ADON C acknowledged that the medication was not documented on a controlled log sheet, was stored without identification, and that she had no record of it being stored in the medication room cupboard. 8. Interview on 5/28/26 at 1:45 p.m. with DON B in the medication storage room revealed that she acknowledged that resident 5's cardboard medication container was wet and that two boxes of unlabeled, opened wine above were likely what had leaked onto the medication. She removed both open boxes of wine, placed them in the sink, and stated she would discard them. She removed a 12-pack of beer from the door of the medication refrigerator that was not labeled with a resident's name. She acknowledged that residents' personal food and beverages should not be stored in the medication refrigerator but should be placed in the hospitality refrigerator behind the nurses' station. She expected nursing staff to complete a thorough check of the medication storage room for expired medications and supplies monthly and dispose of them. She acknowledged that controlled medications awaiting destruction were not counted each shift for accountability, that every nurse who worked a shift had access to the keys for both the medication storage room and the cupboard. She agreed that the controlled medications had not been destroyed by ADON C and licensed pharmacist M for over two months. Additionally, she said that maintenance had access to the medication storage room and acknowledged there was potential for drug diversion. , 9. Interview on 6/1/26 at 2:32 p.m. with licensed pharmacist M revealed she had been with the facility for one year and completed resident chart reviews, managed daily medication refills, and destroyed controlled medications with ADON C. She said that three months ago, she and ADON C changed to routinely destroying medications every other Tuesday to limit the number of controlled medications stored for destruction. Prior to that change, it was the facility contacting the pharmacy to come and destroy the controlled medications when needed. She said that RX Destroyer was used for the destruction of the controlled medications. Licensed pharmacist M was unsure whether another RN could destroy medications with her if ADON C was not available, and said she would have to ask DON B. She stated that she was at the facility frequently but did not have keys or access to the medication room or the locked cupboard that stored the controlled medications awaiting destruction. She was unsure if the controlled medications awaiting destruction were reconciled every shift until destroyed. She stated that there was concern for potential diversion when numerous people had access to keys. Licensed pharmacist M said that it was the nurses' responsibility to go through the medication room and carts for expired meds and supplies, and acknowledged that resident food and beverages should not be stored in the medication refrigerator. She acknowledged that waiting over 2 months to destroy controlled medications was not good practice and was a concern for potential drug diversion as well. She stated that she had not been involved in the facility's pharmacy policymaking. 10. Interview on 6/2/26 at 11:48 a.m. with DON B revealed that the unidentified medication that was stored in the locked cupboard in the medication room belonged to former resident 8 and was Dilaudid 2mg (an opioid medication used to treat moderate to severe pain) tablets that were brought in from home by his family or a friend. She acknowledged that the medication was not documented on a controlled log sheet, was stored in the cupboard unidentified, and she had no record of it being in the medication room cupboard. DON B didn't think about the medication being counted and destroyed because it was not a medication from the facility. She did not remember whether she documented the medication information in resident 8's EMR. 11. Interview on 6/2/26 at 12:31 p.m. with chief executive officer (CEO) A revealed that he expected nursing to go through the medication room monthly to check for expired medications and supplies and dispose of them. He stated that the controlled medications should be counted and then destroyed by licensed pharmacist M and ADON C when necessary. He was not aware that the controlled medications were not destroyed on a routine basis. He was not aware that the controlled medications had not been destroyed for over two months. He acknowledged that nursing staff have access to the keys to the medication storage room and the locked cupboard containing controlled medications awaiting destruction. He also confirmed that maintenance has a key and access to the medication storage room. 12. Medication storage, resident medication refrigerator, drug diversion, consultant pharmacist, and pharmacy services policies were requested between 5/27/26 and 6/2/26 during the survey; the facility did not have those policies for review. 13. Review of the provider's revised August 2018 Outdated Drug Control policy revealed that Outdated medications will not be dispensed for patient use or allowed to remain in the dispensing area of the pharmacy or in patient areas. Pharmacy personnel will check medications for dated items and remove all outdated packages from the shelves monthly. Nursing stations and medication stock areas will be checked monthly for outdated items and replaced. All outdated inventory will be removed and replaced by the pharmacy.14. Review of the provider's reviewed September 2018 Drug Disposition and Destruction policy defined the Procedure for proper disposition of medicines, which are discontinued because of the discharge or death of a resident; the drug is outdated; a drug is found that is not identifiable to a resident; the prescription is discontinued or changed; or destruction of a partial dose is required. Schedule II, III and IV drugs [controlled medications] (medications with risk for abuse and addiction) will be destroyed by a pharmacist and a registered nurse (RN). Discontinued medications (excluding Schedule II, III, and IV drugs) may be kept up to one month after the discontinued date. Destroy medications immediately if: resident was discharged or has expired. Discontinued Schedule II, III, and IV drugs will be secured, and then destroyed as soon as the pharmacist is available. Drugs with the exception of morphine oral solution and fentanyl patches, will be crushed and mixed in kitty litter in med room by the pharmacist and an RN and discarded. Morphine oral solution and fentanyl will be flushed down the toilet. Unless otherwise instructed, flush tablets, capsules, liquids, and contents of vials and ampules down the toilet. If a drug is found that cannot be readily identified to a resident, the drug will be taken to a pharmacist for identification. If the drug cannot be traced to a resident, it will be destroyed. An attempt will be made to identify the resident and why the drug was not properly administered. A documentation note will be written in the resident's medical record (Medication Reconciliation Form) by the person responsible for destroying the medications. The note will be signed by those persons destroying the medications. The drug disposition record must contain, as a minimum, the following information: date destroyed, name of the drug, dosage of drug, prescription number (if any), the quantity destroyed, method of destruction, and signatures of witnesses. Completed drug disposition records must be forwarded to medical records for the resident's medical record.15. Review of the provider's undated admission Packet revealed that with food and beverages, Family and friends may bring in food and non-alcoholic beverages as approved by the physician's ordered diet. Please report any food and beverages brought in. Alcoholic beverages are permitted only with a doctor's order and are kept in the medication room. Refrigerator space is available for small food and drink items in the facility nourishment room.

Based on record review, interview, and policy review, the provider failed to have a system in place to identify medication irregularities, report those irregularities to the physician, and for the physician to address the identified irregularities for four of four sampled residents (3, 6, 21, and 32) on psychotropic medications (drugs that affect brain activities associated with mental processes and behavior). Findings include:1. Review of resident 3's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 5/15/26 Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and dementia (a group of symptoms affecting memory, thinking, and social abilities) with behavioral disturbance. She had a 12/23/25 physician's order for haloperidol 5 milligrams (mg) (an antipsychotic medication; a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions), one tablet to be administered as needed for agitation. The physician's order did not have an end date, and she needed to be seen by a physician to have this reordered on 1/6/26. She had a 12/23/25 physician's order for Seroquel 50 mg (an antipsychotic medication) one tablet to be administered at bedtime for behaviors. The behaviors the Seroquel was ordered to treat were not identified. 2. Review of resident 3's 1/1/25 through 5/1/26 monthly medication reviews and gradual dose reduction (GDR; systematic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) recommendations revealed there were no recommendations made by the pharmacist to resident 3's physician regarding resident 3's haloperidol physician's order did not have an end date on the order or that the physician's order for Seroquel did not have a diagnosis or an identified behavior for which it was prescribed to treat. 3. Review of resident 32's EMR revealed she was admitted to the facility on [DATE]. Her 4/22/26 BIMS assessment score was 14, which indicated her cognition was intact. Her diagnoses included dementia with agitation. She had a 4/16/26 physician's order for mirtazapine 7.5 mg (an antidepressant medication) one tablet to be administered at bedtime for depression. Resident 32 did not have a diagnosis of depression. She had a 4/17/26 physician's order for lorazepam 1 mg (an anti-anxiety medication) one tablet to be administered every eight hours as needed for anxiety. There was no end date on that physician's order. She had a 4/21/26 physician's order for lorazepam 1 mg one tablet to be administered two times per day. There was no diagnosis or indication for use identified for this medication. She had a 4/21/26 physician's order for olanzapine 10 mg (an antipsychotic medication) one tablet to be administered two times per day for dementia with agitation and a 4/25/26 physician's order for quetiapine 50 mg (an antipsychotic medication) administer one tablet in the afternoon for agitation. Olanzapine and quetiapine were in the same drug class. A 4/21/26 progress note from medical director L indicated he had spoken with an on-call psychiatrist about resident 32's suicidal ideations and that psychiatrist recommended transitioning away from scheduled Seroquel (quetiapine) and switching to scheduled olanzapine. 4. Review of resident 32's 5/29/26 monthly medication review revealed licensed pharmacist M documented, There are no medication-related concerns at this time. The monthly medication review identified that the physician ordered psychotropic medications as mirtazapine 7.5 mg at bedtime, olanzapine 10 mg two times per day, lorazepam 1 mg two times per day, and quetiapine 25 mg three times per day as needed. Quetiapine will require 2 GDR [gradual dose reduction] attempts prior to 4/27 (Jul, Nov). PRN [as needed] use should be limited to 14 days and will require reassessment. Therapy changed to Olanzapine 10 mg BID [two times a day] given with lorazepam 1 mg BID per geriatric psychiatry recommendation. The monthly medication review did not address that the indication for use of mirtazapine was depression and resident 32 did not have a diagnosis of depression in her EMR. It did not address the as needed lorazepam that did not have an end date on the physician's order or the scheduled lorazepam not having a diagnosis on the physician's order. It identified quetiapine as being ordered to be given three times per day as needed, and the physician's order was for it to be administered daily in the afternoon. The monthly medication review did not identify the duplicate therapy of olanzapine and quetiapine or the psychiatrist recommended a transition from quetiapine to olanzapine. 5. Review of resident 21's EMR revealed he was admitted to the facility on [DATE]. His 4/21/26 Brief Interview of Mental Status (BIMS) assessment score was 3, which indicated his cognition was severely impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation and behavioral disturbance, and neurocognitive disorder with Lewy Bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells that affects thinking, memory, movement, sleep, and behavior), and obstructive sleep apnea (a disorder when your breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). He had a 10/23/25 physician's order for temazepam 15 milligrams (mg), a sedative-hypnotic medication that helps the brain relax, making it easier to fall asleep, one tablet by mouth every 24 hours PRN (as needed) at bedtime for insomnia (a sleep disorder with trouble falling asleep, staying asleep, or waking too early). Resident 21's EMR did not document a 14-day stop date from initiation and did not document a physician evaluation with a rationale for continuing resident 21's temazepam beyond 14 days. No physician response was documented for a GDR for that medication. He had a 10/23/25 physician's order for trazodone 100 mg (an antidepressant medication), one tablet by mouth at bedtime for insomnia. Resident 21's EMR did not document a physician evaluation with a rationale for continuing resident 21's trazodone, and no physician response was documented for a GDR for that medication. He had physicians' orders dated 10/24/25 for lorazepam Intensol oral concentrate 0.25 milliliters (mL) (an antianxiety medication) by mouth every two hours PRN (as needed) for agitation and for 0.5 mL by mouth every two hours PRN for agitation. Resident 21's EMR did not document 14-day stop dates from the initiation of both doses, nor did it document evaluations by the physician with rationales for continuing Resident 21's lorazepam doses beyond their 14-day limits. Licensed pharmacist M completed monthly Drug Regimen Reviews (DRRs) on 1/26/26, 2/27/26, 3/30/26, 4/29/26, and 5/29/26. A request to evaluate resident 21's lorazepam orders was suggested on 1/26/26 by licensed pharmacist M. The 5/29/26 review note completed by licensed pharmacist M indicated that resident 21's lorazepam was discontinued by the physician. A 1/30/26 order note for resident 21 indicated that a physician's order was received to discontinue his lorazepam. Review of resident 21's active orders revealed that resident 21 continued his lorazepam Intensol oral concentrate 0.25 mL by mouth every two hours PRN and lorazepam 0.5 mL by mouth every two hours PRN, both for agitation, and remained active since 10/24/25. No documentation was found indicating that the lorazepam doses were discontinued on 1/30/26. He had physicians' orders dated 4/2/26 for sertraline 100 mg (an antidepressant medication), 1 tablet by mouth in the morning and 50 mg (1/2 tablet) at bedtime for depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). He did not have a diagnosis of depression. 6. Review of resident 6's EMR revealed he was admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 5, which indicated his cognition was severely impaired. His diagnoses included type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood sugar), peripheral vascular disease (a circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels outside of the heart and brain), chronic kidney disease (loss of the kidneys' ability to filter waste and excess fluid from the blood), cerebral infarction (stroke), repeated falls, weakness, and tremor (involuntary, rhythmic shaking or trembling movement). He had an 11/13/25 physician's order for Sertraline HCl oral tablet 100 mg (an antidepressant medication used to treat mental health conditions like major depressive disorder), give 100 mg by mouth in the morning for depression. Resident 6 had a 1/23/26 physician's order for Haldol 5 mg (an antipsychotic medication; a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions): give 10 mg by mouth every 6 hours as needed for agitation. That physician's order did not have an end date, and he needed to be seen by a physician to have this reordered on 2/8/26. There was no diagnosis for use identified for this medication. He had a 2/20/26 physician's order for Seroquel 25 mg (an antipsychotic medication), one tablet by mouth two times a day for agitation. The behaviors that Seroquel was ordered to treat were not identified. There was no diagnosis for use identified for this medication. Review of resident 6's 11/17/25 through 5/29/26 DRRs and gradual dose reduction recommendations revealed that on 11/17/25, the DRR did not address that he took an antidepressant medication and did not have a diagnosis of depression in his EMR. On 12/29/25, the DRR indicated there were no medication-related concerns at this time. The DRR did not address that he took antidepressant medication and did not have a diagnosis of depression in his EMR. On 1/28/26, the DRR indicated there were no medication-related concerns at this time. The DRR did not address that he took antidepressant and antipsychotic medication and did not have a diagnosis of depression, or another mental health disorder, agitation, or anxiety in resident 6's EMR. On 2/27/26, the pharmacist's recommendation included The following medication-related concern has been identified: 1) Evaluation of PRN psychotropic medication: [Resident 6] has an active orders for Haloperidol 10 mg Q6H [every six hours] PRN agitation/anxiety. Per CMS [Centers for Medicare & Medicaid Services] guidelines, non-pharmacological interventions are prioritized and use of PRN psychotropic medications is limited to 14 days. Evaluation by a physician is required to extend use beyond 14 days. Provider contacted to complete the risk-benefit evaluation for ongoing use. The DRR did not address that resident 6 took antidepressant and antipsychotic medication, and he did not have a diagnosis of depression, or another mental health disorder, agitation, or anxiety in his EMR. There was no documentation that the provider followed up on the pharmacist's recommendation. On 3/30/26, the pharmacist's recommendation included The following medication-related concern has been identified: 1) Gradual Dose Reduction: [Resident 6] is currently taking Sertraline 100 mg QAM [every morning] for depression. Per CMS guidelines, this medication requires GDR attempts with the intent of utilizing [the] lowest possible effective/optimal dose. Provider contacted to complete a Gradual Dose Reduction Risk-Benefit Evaluation. There was no documentation that the provider followed up on the pharmacist's recommendation. The 3/30/26 DRR did not address that he took antidepressant and antipsychotic medication, and he did not have a diagnosis of depression, or another mental health disorder, agitation, or anxiety in his EMR. The DRR did not address the as-needed Haldol that did not have a supporting diagnosis or end date on the physician's order. On 4/29/26, the pharmacist's recommendation included that there were no medication-related concerns identified at this time. The DRR did not address that he took antidepressant and antipsychotic medication and did not have a diagnosis of depression, or another mental health disorder, agitation, or anxiety in his EMR. The DRR did not address the as-needed Haldol that did not have a supporting diagnosis or end date on the physician's order, or the need for a GDR of the scheduled Sertraline. On 5/29/26, The following medication-related concern has been identified: 1) Gradual Dose Reduction: [Resident 6] is currently taking Sertraline 100 mg QAM [every morning] for depression. Per CMS guidelines, this medication requires GDR [gradual dose reduction] attempts with the intent of utilizing [the] lowest possible effective/optimal dose. Provider contacted to complete a Gradual Dose Reduction Risk-Benefit Evaluation. This was noted, and the physician declined the GDR. The DRR did not address that he did not have a diagnosis of depression, or another mental health disorder, agitation, or anxiety in his EMR. The DRR did not address the as-needed Haldol that did not have a supporting diagnosis or end date on the physician's order. 7. Interview on 5/27/26 at 2:43 p.m. with director of nursing (DON) B revealed the provider did not have a policy related to psychotropic medications. 8. Interview and EMR review on 6/1/26 at 2:33 p.m. with licensed pharmacist M revealed she reviewed the residents' medication regimen monthly and was responsible for completing the residents' monthly medication review and making recommendations to the physician for the required gradual dose reduction. During her reviews she looked for psychotropic medications that were prescribed as needed to be sure the medication had an end date. If there was no end date, she would send a recommendation to the physician to place an end date on those medications. She acknowledged haloperidol was an antipsychotic and could not be ordered to be administered as needed for longer than 14 days without being seen by a physician and a new physician's order obtained. When she completed the residents' monthly medication reviews, she reviewed the medications to be sure there was a diagnosis associated with the medication. She did not review the residents' diagnoses list in the EMR to be sure the diagnosis assigned to the medication was a diagnosis that resident had. She verified resident 32 did not have a diagnosis of depression but her physician's order for mirtazapine indicated it was being used for depression. Licensed pharmacist M was aware resident 32 had duplicate therapy related to her antipsychotic medications. She thought the duplicate therapy was the recommendation of the geriatric psychiatrist, according to medical director L's 4/21/26 progress note. After reviewing the progress note, licensed pharmacist M stated she had read the progress note wrong previously and medical director L had documented that resident 32 was to be transitioning from quetiapine and switching to olanzapine. She had not made the recommendation to continue with the transition from quetiapine to olanzapine in her monthly medication reviews. 9. Interview on 6/2/26 at 10:01 a.m. with medical director L revealed he received the monthly medication reviews and the gradual dose recommendations from licensed pharmacist M in a secure envelope each month. When he receives the monthly medication reviews and gradual dose recommendations, he reviews them and responds to them if needed. If he had a question related to the monthly medication review or gradual dose reduction recommendation he would talk with pharmacist M in person. If the monthly medication review or the gradual dose recommendation required a new prescription, he would submit the new prescription electronically to the pharmacy and the provider. Medical director L acknowledged he had not responded to a gradual dose reduction recommendation submitted by licensed pharmacist M for resident 6. He expected that if he missed a monthly medication review or gradual dose recommendation, licensed pharmacist M or someone in the nursing department would immediately notify him that it was missed. He expected licensed pharmacist M and someone in the nursing department to review the monthly medication reviews and the gradual dose reduction recommendations to ensure they are completed each month. 10. Interview and EMR review on 6/2/26 at 11:30 a.m. with DON B revealed the provider did not review the risk versus benefit of psychotropic medications, educate on alternatives to the psychotropic medications, or have consent forms signed by the resident's representative prior to starting or changing resident 21's psychotropic medications. There was no documentation that resident 21's representative was notified when he was started on his psychotropic medications. DON B was aware of the regulation related to the consent for the use of psychotropic medications, but had not implemented a process for the review of risk versus benefits, review of alternative treatments or interventions, and consent for psychotropic medications. 11. Interview on 6/2/26 at 12:31 p.m. with CEO A revealed that he was aware the facility lacked a process for residents' use of psychotropic medications, was unaware that consent forms were not being completed for their use, and was unaware that appropriate diagnoses were not consistently documented. He was unaware that licensed pharmacist M's recommendations were not reaching medical director L, and, as a result, the provider did not implement them for several months. He acknowledged that resident diagnoses were not consistently documented in resident records, pharmacy recommendations regarding psychotropic medication management were not implemented in a timely manner, and residents or their representatives were not informed about their psychotropic medication treatment, including risks, benefits, alternatives, and consent prior to initiation or continuation of their medications. 12. Review of the provider's revised November 2024 Drugs: Review of Orders For Discontinuation policy revealed that A procedure whereby the dosage and schedule of medications will be reviewed by physicians. The timeframe for review of orders for continuation or discontinuation will apply to the following categories: a. Controlled Substances =30 days. b. Antibiotics = 7 days. c. Anticoagulants = 30 days. d. Colchicine for acute gout attack = 48 hours e. Ketorolac (Toradol) = 5 days. f. All other drugs not otherwise ordered for a specific time or number of doses = 60 days. The medication needing review will not automatically discontinue and will remain active until discontinued by the physician. The physician will have three options under this activity: 1. Review – this will reset the review date for the medication. 2. Discontinue – this will discontinue the medication. 3. Modify – this will modify the medication order and reset the review date. Psychotropic medications were not included in the policy to include PRN (as needed) orders and their 14-day stop dates. 13. Review of the provider's 1/12/26 Behavioral Health Management policy revealed, Staff will proactively assess, monitor, and manage behavioral symptoms using individualized, nonpharmacological and clinically appropriate interventions while ensuring resident dignity, safety, and regulatory compliance. The use of psychotropic medications, Must comply with CMS [Center for Medicare and Medicaid Services] regulations (gradual dose reductions, indications). Use only when clinically necessary and not for staff convenience. Requires: Documented clinical indication, provider order, and monitoring for effectiveness and side effects. 14. Review of the provider's 12/30/25 Facility Assessment Tool revealed, Our facility has an excellent consultant that does thorough chart reviews, makes appropriate suggestions, he is instrumental in helping with medication audits and accuracy. 15. A Monthly Medication Review and a Gradual Dose Reduction policy were requested on 6/2/26 at 9:20 a.m. and was not received by the end of the survey.

Based on observation, interview, record review, and policy review, the provider failed to ensure proper medication storage practices for one of one resident medication refrigerators in one of one medication storage room. Specifically, expired medications and supplies were not discarded as required; temperatures in the resident medication refrigerator were not consistently monitored and documented; and unlabeled resident beverages were stored in the resident medication refrigerator with resident medications. Findings include: 1. Observation and interview on 5/27/26 at 3:31 p.m. of the medication storage room with contracted travel registered nurse (RN) V revealed that the door was locked and that she used a key to enter. She stated that she held the key to the medication storage room for her shift and that every nurse had access to the medication room key during their shifts at the facility. The resident's medication refrigerator contained the resident's personal beverages and their medications stored together. Resident 5's Trulicity 3mg/0.5ml syringe box was wet, as two boxes of opened, unlabeled wine boxes were stored above the medications. One box of wine was leaking from the spicket. Contracted travel RN V acknowledged that the cardboard medication container for resident 5's medication was wet. There was an unlabeled 12-pack of beer stored in the refrigerator as well. Additionally, a clear plastic bag containing three boxes of influenza vaccine Adjuvanted on the bottom shelf was wet. The following expired medications and supplies were stored on shelves in the medication storage room: Eight boxes of COVID 19 Antigen Rapid Tests (5 test kits), expired 9/2/25 One box (50 per box) Bionix lighted ear curettes, expired 11/7/25 Twenty four boxes of COVID 19 Antigen Rapid Tests (2 test kits), expired 11/11/25 Nine PureWick female external catheters, expired 4/28/26 Five syringes of Influenza vaccine adjuvanted lot #407253, expired 5/6/26 Eight syringes of Influenza vaccine adjuvanted lot #407257, expired 5/13/26 Contracted travel RN V acknowledged that the medications and supplies had expired and should have been removed from the medication storage room during the last monthly check. She acknowledged that residents' personal food and drinks should not be stored in the medication refrigerator due to the risk of contamination. She acknowledged that resident 5's medication container was compromised from the leaking wine spicket. Contracted travel RN V stated that controlled medications waiting to be destroyed were stored in the locked cupboard in the medication storage room. She was unsure of the medication destruction process. 2. Observation and interview on 5/27/26 at 4:14 p.m. with assistant director of nursing (ADON) C in the medication storage room revealed that outdated medications and supplies in the medication storage room were checked by night shift nurses the last day of the month, and nurses were expected to complete a fax request to the pharmacy to notify them that medications and supplies had expired and needed to be replaced. The resident medication refrigerator temperatures were to be monitored by the nurses every shift. She acknowledged that resident 5's cardboard medication container was wet from a leaking wine box stored above the medications. She was unsure if the resident's personal food and drinks could be stored in the medication refrigerator. ADON C acknowledged that two boxes of wine and a 12-pack of beer were not labeled with the resident's name or the date the wine boxes were opened. 3. Observation and interview on 5/27/26 at 4:19 p.m. with director of nursing (DON) B, in the medication storage room, revealed that temperatures should be monitored once or twice a day, but she was unsure. She acknowledged that no temperature log was maintained for May 2026. Temperature logs for February, March, and April 2026 were reviewed and revealed numerous missing temperature readings. She stated that the controlled medications were locked in a 2-door cupboard and that she, ADON C, and the scheduled working nurses had access to the key. DON B said that controlled medications were destroyed together by ADON C and licensed pharmacist M every one to two weeks. She said the controlled medications awaiting destruction were not counted each shift. 4. Review of the provider's resident medication refrigerator temperature log revealed that The temperature of patient medication refrigerators is to be monitored and documented daily. Store the medications under proper conditions as soon as possible and contact the pharmacy to determine if the potency of any of the medications has been affected, and recommendations for use or disposal. If pharmacy recommends, dispose of open multiple-use vials of medication. Defrost immediately if needed. Notify maintenance for recommendation regarding repair/maintenance/replacement. Document the actions taken in the space provided on the back of this sheet. The February 2026 temperature log had missing temperature documentation on days 2, 6-7, 11-15, 18, 20-21, and 24-27.The March 2026 temperature log had missing temperature documentation on days 4-7, 14, 18-21, and 26-28. The April 2026 temperature log was missing temperature documentation every day except days 5 and 6. 5. Interview on 5/28/26 at 8:40 a.m. with RN Q revealed she was concerned about the number of controlled medications awaiting destruction. She reported there were numerous controlled medications in the locked cupboard in the medication storage room awaiting destruction with licensed pharmacist M and ADON C. RN Q stated that the controlled medications had been in the cupboard for several weeks, waiting to be destroyed. 6. Observation and interview on 5/28/26 at 11:46 a.m. with ADON C in the medication storage room, and the controlled medications revealed that the controlled medications were locked in a cupboard in the medication storage room. Numerous controlled medications were stored in the cupboard, and the cupboard was disorganized and did not have a clear system of order. The controlled medication disposition forms were not stored with the medications, requiring ADON C to search through the cupboard to match each medication with its corresponding form.She stated that the controlled medications were to be counted and then destroyed at least every one to two weeks. ADON C stated that she and licensed pharmacist M were usually the ones who counted and destroyed the controlled medications together, and that they had not done so in over 2 weeks. She acknowledged that controlled medications awaiting destruction were not counted daily for their accountability, and multiple staff nurses having access to them was a potential risk for diversion. She stated that all medications were destroyed in the RX Destroyer (a liquid, ready-to-use chemical drug destruction product that begins deactivating drugs upon contact with it). Review of destruction logs revealed that she and licensed pharmacist M last counted together on 3/14/26. She acknowledged that the controlled medications had not been destroyed by her and licensed pharmacist M for over two months. The cupboard contained the following unreconciled controlled medications awaiting destruction for residents 7, 8, 11, 13, 32, and 100:Resident 7: Eight tablets of lorazepam 0.5 mg Six tablets of lorazepam 0.5 mg Six tablets of lorazepam 0.5 mg PRN 29 mL of lorazepam Intensol 2 mg/mL Two tablets of diazepam 10 mg 25 mL of morphine sulfate oral solution 20 mg/mLResident 8: 21 mL of lorazepam Intensol oral concentrate 2 mg/mL 75 tablets of hydromorphone 2 mg 26 mL of morphine sulfate 100 mg/5 mL 15 tablets of morphine sulfate ER 60 mg 15 tablets of morphine sulfate ER 60 mg Resident 11: One tablet of buprenorphine 2 mgResident 13: 15 tablets of hydrocodone/APAP 5-325 mg 26 tablets of tramadol 50 mg 22.5 mL of morphine sulfate 20 mg/mL Nine fentanyl 25 mcg/hr patchesResident 32: Three tablets of haloperidol 5 mg One tablet of lorazepam 1 mgResident 100: 28.5 mL of morphine sulfate oral solution 20 mg/mL Five fentanyl 25 mcg/hr patches 29.25 mL of lorazepam Intensol oral concentrate 2 mg/mLUnknown Two unidentified light-orange pills, stored in an unlabeled clear plastic medication cup 7. Interview on 5/28/26 at 12:28 p.m. with ADON C revealed that DON B reported to her that DON B found medications on the floor in former resident 8's room, but she was unsure of the exact date. She stated that DON B said the medication was brought to resident 8 by a family member or friend. ADON C acknowledged that the medication was not documented on a controlled log sheet, was stored without identification, and that she had no record of it being stored in the medication room cupboard. 8. Interview on 5/28/26 at 1:45 p.m. with DON B in the medication storage room revealed that she acknowledged that resident 5's cardboard medication container was wet and that two boxes of unlabeled, opened wine above were likely what had leaked onto the medication. She removed both open boxes of wine, placed them in the sink, and stated she would discard them. She removed a 12-pack of beer from the door of the medication refrigerator that was not labeled with a resident's name. She acknowledged that residents' personal food and beverages should not be stored in the medication refrigerator but should be placed in the hospitality refrigerator behind the nurses' station. She expected nursing staff to complete a thorough check of the medication storage room for expired medications and supplies monthly and dispose of them. She acknowledged that controlled medications awaiting destruction were not counted each shift for accountability, that every nurse who worked a shift had access to the keys for both the medication storage room and the cupboard. She agreed that the controlled medications had not been destroyed by ADON C and licensed pharmacist M for over two months. Additionally, she said that maintenance had access to the medication storage room and acknowledged there was potential for drug diversion. , 9. Interview on 6/1/26 at 2:32 p.m. with licensed pharmacist M revealed she had been with the facility for one year and completed resident chart reviews, managed daily medication refills, and destroyed controlled medications with ADON C. She said that three months ago, she and ADON C changed to routinely destroying medications every other Tuesday to limit the number of controlled medications stored for destruction. Prior to that change, it was the facility contacting the pharmacy to come and destroy the controlled medications when needed. She said that RX Destroyer was used for the destruction of the controlled medications. Licensed pharmacist M was unsure whether another RN could destroy medications with her if ADON C was not available, and said she would have to ask DON B. She stated that she was at the facility frequently but did not have keys or access to the medication room or the locked cupboard that stored the controlled medications awaiting destruction. She was unsure if the controlled medications awaiting destruction were reconciled every shift until destroyed. She stated that there was concern for potential diversion when numerous people had access to keys. Licensed pharmacist M said that it was the nurses' responsibility to go through the medication room and carts for expired meds and supplies, and acknowledged that resident food and beverages should not be stored in the medication refrigerator. She acknowledged that waiting over 2 months to destroy controlled medications was not good practice and was a concern for potential drug diversion as well. She stated that she had not been involved in the facility's pharmacy policymaking. 10. Interview on 6/2/26 at 11:48 a.m. with DON B revealed that the unidentified medication that was stored in the locked cupboard in the medication room belonged to former resident 8 and was Dilaudid 2mg (an opioid medication used to treat moderate to severe pain) tablets that were brought in from home by his family or a friend. She acknowledged that the medication was not documented on a controlled log sheet, was stored in the cupboard unidentified, and she had no record of it being in the medication room cupboard. DON B didn't think about the medication being counted and destroyed because it was not a medication from the facility. She did not remember whether she documented the medication information in resident 8's EMR. 11. Interview on 6/2/26 at 12:31 p.m. with chief executive officer (CEO) A revealed that he expected nursing to go through the medication room monthly to check for expired medications and supplies and dispose of them. He stated that the controlled medications should be counted and then destroyed by licensed pharmacist M and ADON C when necessary. He was not aware that the controlled medications were not destroyed on a routine basis. He was not aware that the controlled medications had not been destroyed for over two months. He acknowledged that nursing staff have access to the keys to the medication storage room and the locked cupboard containing controlled medications awaiting destruction. He also confirmed that maintenance has a key and access to the medication storage room. 12. Medication storage, resident medication refrigerator, drug diversion, consultant pharmacist, and pharmacy services policies were requested between 5/27/26 and 6/2/26 during the survey; the facility did not have those policies for review. 13. Review of the provider's revised August 2018 Outdated Drug Control policy revealed that Outdated medications will not be dispensed for patient use or allowed to remain in the dispensing area of the pharmacy or in patient areas. Pharmacy personnel will check medications for dated items and remove all outdated packages from the shelves monthly. Nursing stations and medication stock areas will be checked monthly for outdated items and replaced. All outdated inventory will be removed and replaced by the pharmacy.14. Review of the provider's reviewed September 2018 Drug Disposition and Destruction policy defined the Procedure for proper disposition of medicines, which are discontinued because of the discharge or death of a resident; the drug is outdated; a drug is found that is not identifiable to a resident; the prescription is discontinued or changed; or destruction of a partial dose is required. Schedule II, III and IV drugs [controlled medications] (medications with risk for abuse and addiction) will be destroyed by a pharmacist and a registered nurse (RN). Discontinued medications (excluding Schedule II, III, and IV drugs) may be kept up to one month after the discontinued date. Destroy medications immediately if: resident was discharged or has expired. Discontinued Schedule II, III, and IV drugs will be secured, and then destroyed as soon as the pharmacist is available. Drugs with the exception of morphine oral solution and fentanyl patches, will be crushed and mixed in kitty litter in med room by the pharmacist and an RN and discarded. Morphine oral solution and fentanyl will be flushed down the toilet. Unless otherwise instructed, flush tablets, capsules, liquids, and contents of vials and ampules down the toilet. If a drug is found that cannot be readily identified to a resident, the drug will be taken to a pharmacist for identification. If the drug cannot be traced to a resident, it will be destroyed. An attempt will be made to identify the resident and why the drug was not properly administered. A documentation note will be written in the resident's medical record (Medication Reconciliation Form) by the person responsible for destroying the medications. The note will be signed by those persons destroying the medications. The drug disposition record must contain, as a minimum, the following information: date destroyed, name of the drug, dosage of drug, prescription number (if any), the quantity destroyed, method of destruction, and signatures of witnesses. Completed drug disposition records must be forwarded to medical records for the resident's medical record.15. Review of the provider's undated admission Packet revealed that with food and beverages, Family and friends may bring in food and non-alcoholic beverages as approved by the physician's ordered diet. Please report any food and beverages brought in. Alcoholic beverages are permitted only with a doctor's order and are kept in the medication room. Refrigerator space is available for small food and drink items in the facility nourishment room.

Based on record review, interview, and admission packet review, the provider failed to ensure that residents were seen by a physician at least once every 30 days for the first 90 days after admission for two of four sampled residents (3 and 6), and at least once every 60 days thereafter for one of four sampled residents (9). Findings include:1. Review of resident 9's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Resident 9's January 2025 through May 2026 physician's visit documentation revealed she was seen by medical director L on 1/14/25 and then not seen by a physician in the facility until 4/18/15. There were 94 days between the two physician's visits. After the 4/18/25 physician's visit she did not have a physician's visit until 8/14/25. There were 118 days between the two physician's visits. On 10/16/25 resident 9 was seen by medical director L, there were no signed physician's orders for that visit. She had physician's visit with medical director L on 12/12/25 and then did not have another physician's visit until 4/21/26. There were 130 days between those two physician's visits. 2. Review of resident 3's EMR revealed she was admitted to the facility on [DATE]. Resident 3's January 2025 through May 2026 physician's visit documentation revealed she was not seen by a physician until 3/18/25, 96 days after she was admitted to the facility. 3. Review of resident 6's EMR revealed he was admitted to the facility on [DATE]. Review of resident 6's November 2025 through May 2026 physician's visit documentation revealed he was seen by medical director L on 12/12/25, 1/22/25, 3/24/25, and 5/13/26. There were 61 days between his 1/22/25 and 3/24/25 physician visits. 4. Interview on 6/2/26 at 10:01 a.m. with medical director L revealed his physician rounds schedule was organized by director of nursing (DON) B and assistant DON C and he saw the residents according to the schedule that DON B and assistant DON C made for him. Each physician visit he completed he signed a physician's order and completed a progress note for that resident's visit. He was aware that a newly admitted resident needed to be seen by a physician every 30 days for the first 90 days and then every 60 days after that. 5. Interview and EMR review on 6/2/26 at 11:12 a.m. with DON B resident 9 was not seen in March 2025 because she had been in the hospital from [DATE] through 3/4/25. March physician's rounds were on 3/11/25, and she thought the hospitalization replaced resident 9's physician visit. She verified that resident 9 had not been seen by a physician from April 2025 through August 2025, in December 2025, or April 2026. She acknowledged that the time between those physician's visits did not meet the required every 60-day physician visits. There was no documentation to support resident 3 was seen after she was admitted to the facility on [DATE] until she was seen on 3/18/25. She acknowledged resident 3 was not seen every 30 days for the first 90 days after her admission to the facility to meet the required physician visits. 6. A policy related to physician visits was requested on 6/2/26 at 9:20 a.m. from DON B and was not received by the end of the survey. 7. Review of the provider's undated admission Packet revealed, Physician Services During the first ninety (90) days after the resident's admission to the facility, a physician must see the resident at least every thirty (30) days. After that, a physician will see the resident at least once every sixty (60) days.

Based on observation, interview, record review, and policy review, the provider failed to ensure physician's orders, in accordance with the provider's policy, were obtained before bed rails/grab bars (bars attached to the bed) were installed for two of ten sampled residents (6 and 26), alternatives to the bed rails/grab bars were attempted before the bed rails/grab bars were installed, the risks versus benefits of bed rails/grab bars were reviewed with the resident, or the resident's representative, entrapment zone assessments were completed, and a consent for the bed rails/grab bars were obtained for seven of ten (6, 14, 17, 21, 22, 25, and 26) who had bed rails/grab bars on their bed. Findings include:1. Observation and interview on 5/26/26 at 3:39 p.m. with resident 22 revealed she had a scoop mattress (a mattress designed with raised, contoured edges and a lower, scooped center) and bed rails/grab bars (bars attached to the bed) on both sides of her bed. She stated that she fell out of bed about a year ago. She could get in and out of bed without assistance, did not use the grab bars, and was unsure why the scoop mattress remained on her bed. 2. Review of resident 22's electronic medical record (EMR) revealed she admitted on [DATE]. Her 3/10/26 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. There was a 4/22/24 physician's order for a Pressure Reducing Mattress: Check Q [each] Week to Ensure Proper Functioning and Placement on Bed at bedtime every Sun[day], and a 4/23/24 physician's order for Bilateral bed rails for repositioning and safety while in bed. There was no documentation to indicate when resident 22's side rail/grab bars or scoop mattress were installed on her bed. There was no documentation that alternatives were attempted before the recommendation or installation of the side rail/grab bars or scoop mattress, that the risks versus benefits of side rail/grab bars or scoop mattress were reviewed with the resident or the resident's representative, or a consent for the side rail/grab bars or scoop mattress was obtained before the installation of the side rail/grab bars or scoop mattress on resident 22's bed. There was no documentation that resident 22's safety for the use of the scoop mattress, or the risk for entrapment, had been assessed. The quarterly side rail/grab bar assessments completed did not assess for resident 22's risk of entrapment. 3. Interview on 6/1/26 at 2:18 p.m. with DON B regarding resident 22's scoop mattress and bed rails/grab bars revealed that no assessment for resident 22's safe use of the scoop mattress had been completed, the use of the scoop mattress was not included in resident 22's care plan, and the provider did not have a policy for the use of the scoop mattress. She did not think a policy or an assessment for the use of a scoop mattress was needed. Resident 22's use of a scoop mattress should have been included in the care plan. DON B thought that the scoop mattress and bed rails/grab bars were placed on resident 22's bed last year after she fell, at the request of a family member of resident 22. 4. Observation on 5/27/26 at 9:53 a.m., with resident 6 and resident 14 in their shared room revealed that both of their beds had right-side side rails/grab bars. The mattresses were not securely attached to the beds and created a gap between the side rail/grab bar and the mattress when the mattresses moved. The gap between resident 14's bed and the side rail/grab bar measured four and a half inches when the mattress slid to the wall when touched. 5. Review of resident 6's EMR revealed he was admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 5, which indicated his cognition was severely impaired. There was no documentation that a physician's order was obtained for the use of a side rail/grab bar on his bed, when the side rail/grab bar was installed on his bed, that alternatives were attempted before the recommendation or installation of the side rail/grab bar, that the risks versus benefits of side rail/grab bars were reviewed with the resident or the resident's representative, or that a consent for the use of the side rail/grab bar was obtained before the installation of the side rail/grab bar on resident 6's bed. Quarterly side rail assessment documentation started on 11/17/25. The 2/20/26 quarterly assessment was completed on 5/27/26, and the 5/12/26 quarterly assessment was completed on 5/28/26. The completed quarterly side rail/grab bar assessments did not assess for resident 6's risk of entrapment. 6. Review of resident 14's EMR revealed he was admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 13, which indicated his cognition was intact. He had a 2/24/26 physician's order OK for side rails. There was no documentation of when the side rail/grab bar was installed on his bed, that alternatives were attempted before the recommendation or installation of the side rail/grab bar, that the risks versus benefits of side rail/grab bars were reviewed with the resident or the resident's representative, or that a consent for the use of the side rail/grab bar was obtained before the installation of the side rail/grab bar on resident 14's bed. The quarterly side rail/grab bar assessments completed did not assess for resident 14's risk of entrapment. 7. Observation on 5/27/26 at 9:53 a.m. with resident 17 revealed that she had a side rail on the left side of her bed, which was the side of the bed that was up against a wall in her room. The side rail loose and could be pulled away from the bed. It was not properly attached to the bed and was held in place with a zip tie. The side rail was not appropriate for use on that bed. The bar to which the side rail was attached was not attached to the frame of the bed, was loose and unsecured under the mattress, and could move around. 8. Review of resident 17's EMR revealed she was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated her cognition was intact. Her diagnoses included contracture, cerebral palsy, weakness, and dependence on a wheelchair. There was an 8/7/19 physician's order for side rails for positioning, and a 3/5/24 physician's order for left-side quarter bed rail for repositioning and safety. Resident 17 had an Alarm/Side Rail/Restraint Consent for Use dated 9/9/22 on file; it was signed by a former DON, but the consent was not signed by resident 17. A Side Rail Use Assessment was completed on 3/16/19, but it was not signed by resident 17. Quarterly side rail assessments were completed on 10/6/25, 1/20/26, and 4/1/26. No other quarterly assessments were provided prior to the 10/6/25 side rail assessment. There was no documentation to indicate when resident 17's side rail was installed on her bed. There was no documentation that alternatives were attempted before the recommendation or installation of the side rail, that the risks versus benefits of the side rail were reviewed with the resident or the resident's representative, as the consent dated 9/9/22 was not signed by resident 17 to indicate she received the information prior to the installation of the side rail on resident 17's bed. There was no documentation that resident 17's safety for the use of the siderail or the risk for entrapment had been assessed. The quarterly side rail assessments completed did not assess for resident 17's risk of entrapment. 9. Observation on 5/27/26 at 9:54 a.m., with resident 26 in his room, revealed he had side rails/grab bars on both sides of his bed. The right-side side rail/grab bar was loose and moved approximately four inches away from the mattress when touched. 10. Review of resident 26's EMR revealed he admitted to the facility on [DATE]. His BIMS assessment score was 1, which indicated his cognition was severely impaired. There was no documentation that a physician's order was obtained for the use of a side rail/grab bars on his bed, when the side rail/grab bars were installed on his bed, that alternatives were attempted before the recommendation or installation of the side rail/grab bar, that the risks versus benefits of side rail/grab bars were reviewed with the resident or the resident's representative, or that a consent for the use of the side rail/grab bars was obtained before the installation of the side rail/grab bars on resident 26's bed. Quarterly side rail assessment documentation started on 6/9/21. The 12/3/25 and 3/25/26 quarterly assessments were completed on 5/27/26. The quarterly side rail/grab bar assessments completed did not assess for resident 26's risk of entrapment. 11. Observation and interview on 5/27/26 at 9:58 a.m. with resident 25 in his room revealed he had bilateral side rails on his bed. The right-side rail was loose and pulled away from the bed. Resident 25 was lying in bed with his head resting against the left side rail. He stated he did not use the side rails for transferring in or out of bed or repositioning while he was in bed. 12. Review of resident 25's EMR revealed he was admitted to the facility on [DATE]. He had a BIMS assessment score of 15, which indicated his cognition was intact. His diagnoses included alcohol induced dementia (a group of symptoms affecting memory, thinking, and social abilities caused by excessive prolonged use of alcohol), and an eye movement disorder. His 5/28/26 care plan indicated resident 25 was unable to see out of his left eye. Resident 25's 1/9/24 side rail and safety screen indicated bilateral side rails were recommended to be installed by occupational therapy due to: [Resident 25 was using bed rails in [the] hospital. Without them he requires increased assistance. Recommending Bilateral rails. The physician signed the recommendation for bilateral side rails on 1/25/24. This assessment did not document if there were alternatives attempted prior to the recommendation or installation of the side rails. There was a 3/6/24 physician's order for the use of bilateral side rails to optimize independence and safety. There was no documentation to indicate when resident 25's side rails were installed on his bed. There was no documentation that the risks versus benefits of side rails were reviewed with the resident or the resident's representative and a consent for the side rails was obtained prior to the installation of the side rails on resident 25's bed. Quarterly side rail assessment documentation started on 1/10/25, one year after the bilateral side rails were recommended and continued until 9/8/25. There were no quarterly assessments completed in December 2025 or March 2026. The quarterly assessments did not assess for resident 25's entrapment risk. 13. Observation on 5/27/26 at 12:05 p.m. with resident 21 out of his bed, revealed that he had a half-rail on the right side of his bed, and the left side of his bed was up against the wall. The half-rail on the bed was loose. The gap between the loose right half-rail and his mattress measured five inches when the mattress was pushed to the wall, and the loose rail was pulled out from the bed. There was a 4.5-inch gap between his headboard and the head of the mattress when the mattress was pushed to the foot of the bed. 14. Review of resident 21's EMR revealed he was admitted to the facility on [DATE]. His 4/21/26 BIMS assessment score was 03, which indicated his cognition was severely impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation and behavioral disturbance, and neurocognitive disorder with Lewy Bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells that affects thinking, memory, movement, sleep, and behavior), and obstructive sleep apnea (a disorder when your breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). There was a 12/22/25 physician's order for Siderails and fall mat for safety and to promote independence. Quarterly side rail assessments were completed on 10/31/25 and 4/20/26. No quarterly side rail assessment was completed in January 2026, and no other quarterly side rail assessments were provided prior to the 10/31/25 side rail assessment. There was no documentation indicating that consent to install the side rail for resident 21 was obtained. There was no documentation to indicate when resident 21's side rail was installed on his bed. There was no documentation that alternatives were attempted before the recommendation or installation of the side rail, that the risks versus benefits of the side rail were reviewed with the resident or the resident's representative. There was no documentation that resident 21's safety for the use of the siderail or the risk for entrapment had been assessed. The quarterly side rail assessments completed did not assess for resident 21's risk of entrapment. 15. Interview on 5/28/26 at 10:05 a.m., with DON B revealed she was unaware that the side rail/grab bars and mattresses needed to be assessed for entrapment risks. She was unsure if maintenance assessed the rails or mattresses for entrapment risk in any zones. She stated that when a resident or their representative requested a side rail/grab bar, the therapy department would assess the resident using a checklist, which did not contain resident risk for entrapment, interventions tried, or obtain resident consent for the use of the side rail/grab bar. She thought that if a resident wanted a side rail/grab bar, they could request one, and one would be provided. She expected the nurse assigned to the resident that day to obtain a physician's order and complete a quarterly assessment when it was due to be completed. 16. Interview on 6/1/26 at 11:56 a.m. with DON B revealed there was no documentation available related to when the side rails were installed on residents' beds. 17. Review of the provider's undated Bed Safety and Entrapment Prevention Policy revealed: The policy did not indicate when it was developed, reviewed, or approved. The purpose was To ensure a safe sleeping environment by preventing bed related accidents, including entrapment, falls, and injury related to bedrails, mattresses, and bed systems. The facility is committed to maintaining all beds, mattresses, and assistive devices in a safe condition. Bed systems will be assessed, maintained, and used in a manner that minimizes the risk of entrapment and injury, in accordance with CMS F689 requirements and FDA bed safety guidance. Bedrails will not be used as restraints and will only be utilized when clinically indicated and safe. All beds must: Be in good working condition, Have securely attached side rails or assistive devices (if used), Have a properly fitted mattress, Be compatible with all components (no mixing of incompatible parts), Be free of excessive gaps. All gaps must measure ≤ 4.75 inches where applicable. Special attention is given to: Space between mattress and rail, Mattress and headboard/footboard, Split rails and joints. Bedrails will: Only be used when clinically necessary. Require: Assessment prior to use, Care plan documentation, Be removed when: Not used for mobility or positioning, Risk outweighs benefit. Mattresses must: Fit securely within the bed frame, Not slide, shift, or leave gaps, Be secured using: Manufacturer approved systems (e.g., corner brackets or stops), Be replaced if worn or incompatible. Initial and Routine Assessments The following will be completed: On admission, With change in condition, Quarterly and annually, After any bed or mattress change. Assessment includes: Bedrail necessity, Mattress fit and stability, Entrapment zone measurement. Staff Responsibilities: All Staff: Assess need for bedrails, Monitor for signs of entrapment risk, Report hazards immediately. Maintenance: Ensure all beds are properly assembled, Perform repairs and installations, Maintain approved equipment only, Monthly audits on all beds. Administration: Ensure policy compliance, Monitor through QAPI process. 18. Review of the provider's revised 1/6/25 Side Rail policy revealed Quarter rails and bed canes that are approved for the beds can be used that are affixed to the bed and evaluated for safety and functioning by maintenance. A side rail assessment will be completed by therapy and/or nursing when there is a desire expressed by the resident or [a] need [is] reported by the nursing staff. Physicians['] orders will be obtained prior to placing the side rail on the bed. A side rail assessment form will be completed quarterly and prn [as needed] by the MDS [minimum [NAME] set] coordinator or designee. and prn for use or desired change. Resident and/or family education is provided with new orders received from [the] physician for side rail use.Maintenance will be notified with side rail evaluations and prn for an inspection of the side rail, how it fits the bed, tightness, and to evaluate the mattress for wear and distance from the rail. Continued use of the side rail will be reviewed with the family quarterly and prn [with] changes in condition. The Director of Nurses or designee will be contacted when there is a determination that a side rail order is being requested.

Based on observation, interview, record review, and policy review, the provider failed to ensure the residents' care plans (personalized plan that addresses a resident's care needs, goals, and interventions) were reviewed and revised to reflect the current care needs for nine of thirteen sampled residents (3, 5, 6, 9, 14, 18, 21, 22 and 32). Findings include:1. Observation on 5/26/26 at 1:22 p.m. in resident 18's room revealed a nebulizer machine on her bedside table, with a mask and tubing attached and stored on top of the machine. 2. Review of resident 18's electronic medical record (EMR) revealed she was admitted to the facility on [DATE]. Her 3/10/26 Brief Interview of Mental Status (BIMS) assessment score was 05, which indicated her cognition was severely impaired. She had diagnoses included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe (COPD), type 2 diabetes mellitus (a condition involving disruptions in how the body regulates blood sugar), chronic kidney disease (a condition involving the kidneys that are permanently damaged and can't properly filter waste and extra fluid from the blood), and weakness. Resident 18 had 3/10/26 physician orders for Budesonide inhalation suspension 0.5 milligram (mg)/2 milliliters (mL), two times a day, and Combivent Respimat inhalation aerosol solution 100 micrograms (mcg)/act ipratropium-Albuterol, before meals and at bedtime, both for her COPD. Resident 18's comprehensive care plan dated 3/23/26 did not document that she required the use of respiratory treatment and did not indicate her documented diagnosis of COPD. No interventions, measurable objectives, or monitoring related to her COPD, such as respiratory treatments, medications, and cleaning of her nebulizer equipment, were addressed in her care plan. 3. Observation on 5/26/26 at 3:26 p.m. resident 9 was yelling out that she needed to use the restroom. Contracted travel certified nursing assistants (CNA) U and CNA AA brought in a stand aide lift (a manual lift used to assist from a seated to a standing position), assisted resident 9 out of her bed, into the stand aide lift, and rolled the stand aide lift into the bathroom so resident 9 could use the bathroom. 4. Review of resident 9's EMR revealed she was admitted to the facility on [DATE]. Her 2/27/26 Brief Interview of Mental Status (BIMS) assessment score was 3, which indicated her cognition was severely impaired. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation, and a stroke (blood flow to the brain is interrupted) resulting in weakness or paralysis of the left side of her body. She had a 9/5/25 physician's order for lorazepam 2 milligrams per milliliter (mg/ml) (an anti-anxiety medication) to be administered 0.25 milliliters (ml) every two hours as needed for agitation or anxiety. The physician's order did not have an end date. Her 5/27/26 care plan did not indicate she had agitation or anxiety or identify any non-pharmacological interventions for agitation or anxiety. Her care plan did not indicate how she transferred out of bed, it did not indicate if she walked or used a wheelchair, and it did not indicate if she required assistance with dressing, bathing, or eating. 5. Observation on 5/26/26 at 3:30 p.m. of resident 32 in her room revealed she was seated in Broda chair (a specialized, ergonomic medical wheelchair or recliner) in a semi-reclined position. 6. Review of resident 32's EMR revealed she was admitted to the facility on [DATE]. Her 4/22/26 BIMS assessment score was 14, which indicated her cognition was intact. Her diagnoses included dementia with agitation and a stroke resulting in weakness or paralysis affecting the left side of her body. She had been placed on frequent checks and was referred to psychiatry due to her expressions of suicidal thoughts. She had 4/24/26 occupational therapy evaluation completed by occupational therapist DD. It was recommended at that time resident 32 use a Broda chair for positioning. She had a 4/16/26 physician's order for mirtazapine 7.5 milligrams (mg) (an antidepressant medication) one tablet to be administered at bedtime for depression; a 4/17/26 physician's order for lorazepam 1 mg (an anti-anxiety medication) one tablet to be administered every eight hours as needed for anxiety; a 4/21/26 physician's order for lorazepam 1 mg one tablet to be administered two times per day; a 4/21/26 physician's order for olanzapine 10 mg (an antipsychotic medication) one table to be administered two times per day for dementia with agitation; and a 4/25/26 physician's order for quetiapine 50 mg (an antipsychotic medication) administer one tablet in the afternoon for agitation. Her 5/28/26 care plan had a focus area of uses psychotropic medications r/t [related to] depression, anxiety, and behavioral management. There were no non-pharmacological interventions identified within that focus area. Her care plan indicated she had displayed significant aggressive behaviors, and the intervention was to provide one to one care for her if she poses a risk to herself or others. Potential triggers for her aggressive behavior were not identified. Her history of suicidal thoughts was not identified on her care plan nor triggers or interventions for those thoughts. Resident 32's use of a Broda chair to optimize positioning was not identified on her care plan. 7. Observation and interview on 5/26/26 at 3:39 p.m. with resident 22 revealed she had a scoop mattress (a mattress designed with raised, contoured edges and a lower, scooped center) and bed rails/grab bars (bars attached to the bed) on both sides of her bed. She stated that she fell out of bed about a year ago. She could get in and out of bed without assistance, did not use the grab bars, and was unsure why the scoop mattress remained on her bed. 8. Review of resident 22's EMR revealed she was admitted on [DATE]. Her 3/10/26 BIMS assessment score was 15, which indicated her cognition was intact. There was a 4/22/24 physician's order for a Pressure Reducing Mattress: Check Q [each] Week to Ensure Proper Functioning and Placement on Bed at bedtime every Sun[day]. Her 3/11/26 minimum data set (MDS) assessment (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) indicated that she was independent with bed mobility, transfers, and toileting. Her 3/30/26 care plan indicated she required assistance by staff to turn and reposition in Bed., that she used a walker with one assist to go to and from activities and that she required assistance by staff for toileting. There was no documentation in resident 22's care plan that she required the use of a scoop mattress, the level of assistance that she required to complete bathing and dressing tasks, transfers, or mobility in her room. 9. Interview on 6/1/26 at 2:18 p.m. with DON B regarding resident 22's scoop mattress revealed that no assessment for resident 22's safe use of the scoop mattress had been completed, the use of the scoop mattress was not included in resident 22's care plan, and the provider did not have a policy for the use of the scoop mattress. She did not think a policy or an assessment for the use of a scoop mattress was needed. DON B stated that resident 22's use of a scoop mattress should have been included in the care plan. The scoop mattress was placed on resident 22's bed last year after she fell, at the request of a family member of resident 22. 10. Observation on 5/27/26 at 9:36 a.m. with resident 6 and resident 14 in their shared room revealed that resident 6 was seated upright in a Broda (a specialized, ergonomic medical wheelchair or recliner) chair. Resident 14 was seated in a Broda chair in a semi-reclined position. 11. Review of resident 6's EMR revealed he was admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 5, which indicated his cognition was severely impaired. He had an 11/13/25 physician's order for Sertraline HCl oral tablet 100 mg (an antidepressant medication used to treat mental health conditions like major depressive disorder), give 100 mg by mouth in the morning for depression, a 1/23/26 physician's order for Haldol 5 mg (an antipsychotic medication; a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions): give 10 mg by mouth every 6 hours as needed for agitation, and a 2/20/26 physician's order for Seroquel 25 mg (an antipsychotic medication), one tablet by mouth two times a day for agitation. There was no documentation in resident 6's 5/20/26 care plan that he received antidepressant and antipsychotic medication. There was a focus area where he had a behavior of inappropriate touching to [of] female staff. There were no behavior management or non-pharmacological interventions for those behaviors. There was no documentation that he had a mental health diagnosis or a severe behavioral disorder. There was no documentation in that care plan that he required the use of a Broda chair, nor the level of assistance that he required to complete bathing, dressing, transfers, and toileting tasks. 12. Review of resident 14's EMR revealed he was admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 13, which indicated his cognition was intact. There was no documentation in resident 14's 4/15/26 care plan that he required the use of a Broda chair, nor the level of assistance that he required to complete bathing, dressing, transfers, and toileting tasks. 13. Observation on 5/28/26 10:30 a.m. with resident 5, certified nursing assistant (CNA) AA, and CNA EE revealed that resident 5 was transferred from her wheelchair to the bathroom with a stand aid lift (a mechanical lift used to assist from a seated to a standing position), and there were no side rails/grab bars (bars attached to the bed) on her bed. 14. Review of resident 5's EMR revealed she was admitted on [DATE]. There was a 3/19/25 physician's order side rails to promote independence and increase safety, and a physician's order Ok to use Purwick catheter system [a non-invasive, external urine management system] due t[o] incontinence, which was discontinued on 12/12/25. Her 3/10/26 care plan indicated she was able to transfer with supervision, that she required the use of a full body lift with staff assistance for her safety, and that restorative therapy was working on resident 5's request to use a stand lift. Her care plan also indicated that she used side rails/grab bars on her bed for her safety, and she used a Purwick catheter system due to incontinence. Her 5/19/26 MDS assessment indicated her BIMS assessment score was 13, which indicated her cognition was intact, and that she was dependent with toileting tasks, and required substantial/maximal assistance with bathing and dressing. There was no documentation in resident 5's care plan that indicated the level of assistance she required to complete bathing, dressing tasks or toileting tasks. 15. Review of resident 21's EMR revealed he was admitted to the facility on [DATE]. His 4/21/26 BIMS assessment score was 03, which indicated his cognition was severely impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation and behavioral disturbance, neurocognitive disorder with Lewy Bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells that affects thinking, memory, movement, sleep, and behavior), and obstructive sleep apnea (a disorder when your breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). He had a 10/23/25 physician's order for donepezil 10 milligram (mg) one tablet by mouth in the morning for his dementia. Resident 21's care plan, dated 10/23/25, had an intervention with the incorrect dose for that medication. The intervention listed the medication as Donepezil HCL 100 Mg PO BID. The dose on the care plan had an extra zero, indicating it was 100 mg instead of the physician's ordered 10 mg, and the care plan reflected that he should receive it twice daily rather than once daily. He had physicians' orders dated 10/24/25 for lorazepam Intensol oral concentrate 0.25 milliliters (mL) (an antianxiety medication) by mouth every two hours PRN (as needed) for agitation and for 0.5 mL by mouth every two hours PRN for agitation. Resident 21's care plan, dated 10/23/25, had an intervention with the incorrect dose for that medication. The intervention listed the medication as Lorazepam 0.5 mg-1 mg Q [every] 2 HRS [hours] PRN. He had physicians' orders dated 3/6/26 for Risperdal 1mg (an antipsychotic medication that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions), give 1.5 mg (1.5 tablets) by mouth in the morning for agitation and 2 mg by mouth every 24 hours PRN, may give at bedtime for agitation or anxiety. Resident 21's care plan, dated 10/23/25, had an intervention with the incorrect dose for that medication. The intervention listed the medication as Risperdal 2 Mg PO [by mouth] at HS [bedtime]. He had physicians' orders dated 4/2/26 for sertraline 100 mg (an antidepressant medication), 1 tablet by mouth in the morning and 50 mg (1/2 tablet) at bedtime for depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). Resident 21's care plan, dated 10/23/25, had an intervention with the incorrect dose for that medication. The intervention listed the medication as Sertraline 100 Mg BID [twice daily]. He did not have a diagnosis of depression. Resident 21's care plan dated 10/23/25 continued to include interventions and referral to hospice services, despite the resident's hospice services being discontinued on 1/16/26. The facility did not update the care plan to reflect resident 21's current status and needs, and did not address goals and interventions to include the risks associated with psychotropic medication use. Resident 21's 10/23/25 care plan was not individualized or person centered related to his psychotropic medications. 16. Review of resident 3's EMR revealed she was admitted to the facility on [DATE]. Her 5/15/26 BIMS assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included anxiety disorder (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability), and dementia with behavioral disturbance. She had a 7/29/25 physician's order for alprazolam 0.5 milligrams (mg) (an anti-anxiety medication), one tablet to be administered as needed for anxiety. The physician's order did not have an end date. She had a 12/23/25 physician's order for haloperidol 5 mg (an antipsychotic medication; a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions), one tablet to be administered as needed for agitation. The physician's order did not have an end date, and she needed to be seen by a physician to have this reordered on 1/6/26. She had a 12/23/25 physician's order for Seroquel 50 mg (an antipsychotic medication), one tablet to be administered at bedtime for behaviors. The behaviors that the Seroquel was ordered to treat were not identified. Her 5/28/26 care plan had a focus area stating she received psychotropic medication related to behavior management. That focus area did not identify what her behaviors were or non-pharmacological interventions for those behaviors. A focus area stated she had hallucinations and indicated she was taking olanzapine (an antipsychotic medication) for anxiety, agitation, and psychosis (a state of losing touch with reality). She did not have a physician's order for this medication. She did not have a diagnosis of psychosis or hallucinations, and there were no non-pharmacological interventions for these symptoms identified in her care plan. 17. Interview and EMR review on 5/28/26 at 9:17 a.m. with registered nurse (RN) Q revealed she would expect the care needs of each resident to be in their care plan. The care plans should include the assistance the resident requires for transfers, dressing, eating, and toileting. The nurses charted resident behaviors on the residents' medication administration record (MAR) or treatment administration record (TAR). The certified nursing assistants (CNA)s would notify the nurse if a resident had displayed a behavior. She did not know how the CNAs would identify what behaviors the residents had or what the non-pharmacological intervention for that behavior was. She acknowledged some of the residents' behaviors and interventions were identified in their care plans, but others did not. 18. Interview on 6/1/26 at 11:38 a.m. with CNA S revealed that she knew the level of assistance that a resident needed to complete bathing, dressing, and transfers because that information was on the resident's care plan in the EMR. She expected a resident's care plan to contain information about a resident's behaviors and interventions or solutions to manage those behaviors. She indicated that a resident's care plan had all the information she needed to care for the residents, including their cognitive status, if the resident required special equipment for transfers and positioning. There was also a note on each residents bathroom door that indicated how a resident transferred. She thought that DON B or assistant DON C updated the care plan if there was a change in how she was to care for or transfer a resident. 19. Interview on 6/1/26 at 12:17 p.m. with DON B revealed that the facility used an external Minimum Data Set (MDS) company to complete resident care plans when MDS assessments (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) were completed. She stated that the company was responsible for updating the resident's care plan. She was unaware that the care plans for residents 3, 5, 6, 9, 14, 18, 21, 22, and 32 were neither person-centered nor up to date with those residents' individual needs. DON B said she would email the external MDS company if she became aware that something needed to be added to or updated on a resident's care plan. DON B and ADON C were responsible for updating resident care plans. DON B stated that the care plans should have contained information on the resident's physical ability or the level of assistance they require to complete bathing, dressing, toileting, and transfer tasks She expected the CNAs to use the residents' care plan to know what care each resident required. The CNA's daily assignment sheet also included information on the level of assistance and equipment needed to transfer a resident. She expected the residents' use of a Broda chair and side rails to be included in the care plan. She expected monitoring for the use of antidepressant and psychotropic medications, the resident's behaviors, and non-pharmacological approaches to be included in the resident care plan. 20. Review of the provider's revised February 2020 Care Plans: Preliminary, Comprehensive and Reviews policy revealedAn interdisciplinary team, in coordination with the resident and his/her family or representative (sponsor), develops and maintains a comprehensive care plan for each resident. Each discipline enters their portion of the comprehensive care plan into PointClickCare EMR [an electronic medical record] and works with the interdisciplinary team members to maintain a care plan for each resident. PointClickCare shall always have the most updated care plan for each resident. Care plans are revised as changes in the resident's condition dictates and reviewed at least quarterly. The Comprehensive Care Plan is designed to: Incorporate identified problem areas and risk factors. Enhance the optimal functioning of the resident. CNA [certified nursing assistant] staff, Day/Night, shall be responsible for reviewing and revising their drop sheets to reflect care. Changes in the resident's condition must be reported to the RN [registered nurse] MDS [minimum data set] coordinator so that a review of the resident's assessment and care plan can be made. Daily care and documentation must be consistent with the resident's care plan. The Care Planning Committee/Team is responsible for keeping care plans on a current status and for periodic review and updating of care plans. 21. Review of the provider's 1/12/26 Behavioral Health Management policy revealed, Staff will proactively assess, monitor, and manage behavioral symptoms using individualized, nonpharmacological and clinically appropriate interventions while ensuring resident dignity, safety, and regulatory compliance. Each resident with behavioral health needs must have: -An individualized care plan addressing behaviors -Identified triggers and early warning signs -Specific interventions and staff approaches Staff must prioritize non-drug approaches

Based on record review, interview, and policy review, the facility failed to protect the residents' rights to be free of unnecessary medications, specifically psychotropic medications (drugs that affect brain activities associated with mental processes and behavior), for five of five sampled residents (3, 6, 9, 21, and 32) who were administered psychotropic medications without usage order stop dates or documented reasoning for continuation of use of as needed psychotropic medications beyond fourteen days, completed risk versus benefit evaluations for informed consent for use, documented diagnoses for use, documented and physician responses to pharmacy recommendations. Findings include: 1. Review of resident 9's electronic medical record (EMR) revealed she admitted to the facility on [DATE]. Her 2/27/26 Brief Interview of Mental Status (BIMS) assessment score was 3, which indicated her cognition was severely impaired. Her diagnoses included dementia (a group of symptoms affecting memory, thinking, and social abilities) with agitation. She had a 9/5/25 physician's order to be given 0.25 milliliters (mL) of lorazepam 2 milligrams per milliliter (mg/ml) (an anti-anxiety medication) every two hours as needed (PRN) for agitation or anxiety (anticipation of future danger or misfortune with feelings of distress and/or sadness and symptoms such as restlessness or irritability). The physician's order did not have a usage end date. Resident 9 did not have a diagnosis of anxiety. Her 5/27/26 care plan (personalized plan that addresses a resident's care needs, goals, and interventions)did not indicate she had agitation or anxiety and did not identify any non-pharmacological (without medication) interventions to help her manage agitation or anxiety. 2. Review of resident 3's EMR revealed she admitted to the facility on [DATE]. Her 5/15/26 BIMS assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included anxiety disorder and dementia with behavioral disturbance. She had a 12/23/25 physician's order to be given one 5mg tablet of haloperidol (an antipsychotic medication that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) as needed for agitation. The physician's order did not have a usage end date. She had a 12/23/25 physician's order to be given one tablet of 50 mg Seroquel, (an antipsychotic medication) at bedtime for behaviors. The behaviors that Seroquel was to treat were not identified in that order. Her 5/28/26 care plan had a focus area that indicated she received a psychotropic medication related to behavior management. That focus area did not identify what her behaviors were or non-pharmacological interventions for those behaviors. A focus area indicated she had hallucinations and took the antipsychotic medication olanzapine for anxiety, agitation, and psychosis (a state of losing touch with reality). There were no non-pharmacological interventions for the symptoms of hallucinations, anxiety, agitation, or psychosis. 3. Review of resident 21's electronic medical record (EMR) revealed he admitted to the facility on [DATE]. His 4/21/26 BIMS assessment score was 3, which indicated his cognition was severely impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia with agitation and behavioral disturbance, and neurocognitive disorder with Lewy Bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells that affects thinking, memory, movement, sleep, and behavior), and obstructive sleep apnea (a disorder when your breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). He had a 10/23/25 physician's order to be given one tablet of 15 mg temazepam, a sedative-hypnotic medication that helps the brain relax, making it easier to fall asleep, by mouth every 24 hours as needed at bedtime for insomnia. Resident 21's temazepam order did not indicate a 14-day stop date or include a physician's evaluation with a rationale for continuing the PRN temazepam beyond 14 days. He had 10/24/25 physicians' orders to be given 0.25 ml of lorazepam Intensol oral concentrate, an antianxiety medication, by mouth every two hours PRN for agitation and to be given 0.5 ml of lorazepam by mouth every two hours PRN for agitation. Those orders did not include 14-day stop dates or physician evaluations with rationales for continuing resident 21's lorazepam PRN doses beyond 14 days. Licensed pharmacist M reviewed resident 21's chart and medication list on 1/26/26 and suggested his lorazepam orders be evaluated by his physician. Licensed pharmacist M indicated in a 5/29/26 review note that resident 21's lorazepam was discontinued by the physician. A 1/30/26 order note for resident 21 indicated that a physician's order was received to discontinue his lorazepam. Review of resident 21's active physician orders indicated that resident 21 continued to be administered his 0.25 ml and 0.5 ml lorazepam Intensol oral concentrate PRN doses as ordered by the physician on 10/24/25. No documentation indicated that the lorazepam doses were ordered to be discontinued on 1/30/26. He had 3/6/26 physicians' orders to be given 1.5 tablets of 1 mg Risperdal, an antipsychotic medication, by mouth in the morning for agitation and 2 mg by mouth every 24 hours PRN, that may be given at bedtime for agitation or anxiety. Resident 21's Risperdal order did not indicate a 14-day stop date, and did not include an evaluation by the physician with a rationale to continue resident 21's PRN Risperdal beyond 14 days. He had a 4/2/26 physicians' orders to be given one tablet of 100 mg sertraline, an antidepressant medication, (1 tablet) by mouth in the morning and 50 mg (one-half tablet) at bedtime for depression. He did not have a diagnosis of depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). 4. Review of resident 6's EMR revealed he admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 5, which indicated his cognition was severely impaired His diagnoses included type 2 diabetes mellitus, peripheral vascular disease (a circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels outside of the heart and brain), chronic kidney disease (loss of the kidneys' ability to filter waste and excess fluid from the blood), cerebral infarction (stroke), repeated falls, weakness, and tremor (involuntary, rhythmic shaking or trembling movement). He had a 2/20/26 physician's order to be given one tablet of 25 mg Seroquel by mouth two times a day for agitation. He had a 1/23/26 physician's order to be given 10 mg of haloperidol by mouth every 6 hours as needed for agitation. That physician's order did not have an end date. He did not have a diagnosis of schizophrenia (a chronic and severe brain disorder that affects how a person thinks, feels, and acts), bipolar disorder (a mental health condition characterized by extreme, recurring shifts in mood, energy, and activity levels), anxiety, depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), or a severe behavioral disorder, There was no documentation in resident 6's 5/20/26 care plan that he received an antidepressant or a psychotropic medication. There was a focus area that indicated that he had a behavior of inappropriate touching to [of] female staff. There were no behavior-management or nonpharmacological interventions for those behaviors included in his care plan. 5. Review of resident 32's EMR revealed she admitted to the facility on [DATE]. Her 4/22/26 BIMS assessment score was 14, which indicated her cognition was intact. Her diagnoses included dementia with agitation. She had a 4/16/26 physician's order to be given one tablet of 7.5 mg mirtazapine (an antidepressant medication) at bedtime for depression. Resident 32 did not have a diagnosis of depression. She had a 4/17/26 physician's order to be given one tablet of 1mg lorazepam every eight hours as needed for anxiety. There was no end date included for that PRN medication order. She had a 4/21/26 physician's order to be given one tablet of 1 mg lorazepam two times per day. There was no diagnosis or indication for use identified for that medication. She had a 4/21/26 physician's order to be given one tablet of 10 mg olanzapine two times per day for dementia with agitation and a 4/25/26 physician's order to be given one tablet of 50 mg quetiapine (an antipsychotic medication) administer one tablet in the afternoon for agitation. Olanzapine and quetiapine were in the same drug class. A 4/21/26 progress note from medical director L indicated he spoke with an on-call psychiatrist about resident 32's suicidal ideations who recommended transitioning away from scheduled Seroquel (quetiapine) and switching to scheduled olanzapine. Her 5/28/26 care plan had a focus area of uses psychotropic medications r/t [related to] depression, anxiety, and behavioral management. There were no non-pharmacological interventions identified for that focus area. Her care plan indicated she displayed significant aggressive behaviors, and the intervention was for staff to provide one to one care for her if she poses a risk to herself or others. Potential triggers for her aggressive behavior were not identified. Her history of suicidal thought tiggers or interventions for those thoughts were not identified in her care plan. On 5/21/26, resident 32 had a 2:30 p.m. appointment with a mental health provider related to her prior suicidal thoughts. During that appointment, it was documented that she was, unable to participate in the session due to being asleep and unresponsive to verbal prompting. Review of her May 2026 medication administration record (MAR) indicated that on 5/21/26 at 12:34 p.m. she was administered 5 mg of oxycodone (controlled pain medication with risk fir addiction and abuse) with a reported pain level of three and one tablet of lorazepam 1 mg for agitation. Resident 32 did not have any documented behaviors on 5/21/26. 6. Interview on 5/28/26 at 9:17 a.m. with registered nurse (RN)(space)Q revealed the nurses were to chart resident behaviors on the residents' MARs or treatment administration records (TAR). The certified nursing assistants (CNAs) would notify the nurse if a resident displayed a behavior. She did not know how the CNAs would know what behaviors the residents had or what the non-pharmacological interventions for those behaviors were. Some of the residents' behaviors and interventions were identified on their care plans, but others were not. 7. Interview on 6/1/26 at 2:33 p.m. with licensed pharmacist M revealed she reviewed the residents' medication regimens monthly. During her reviews, she looked for PRN psychotropic medication orders to check if those medication orders had an end date. If there were no end date, she would send a recommendation to the physician to order an end date for those medications. When she made a recommendation, she sent a copy to the physician and DON B. If the physician did not address her recommendation, she did not include it in the following month's review, since she had already mentioned it. She acknowledged resident 9's PRN lorazepam order did not have an end date. She stated resident 9 was on hospice services previously(comma) and that the medication order was a hospice order. Licensed pharmacist M was unaware of the regulation on end dates for hospice residents. She verified resident 9 was no longer receiving hospice services, but the medication remained on her medication list. She acknowledged haloperidol was an antipsychotic medication that was not to be ordered to be administered PRN for longer than 14 days without being seen and evaluated by a physician and obtaining a new physician's order for that medication. When she completed the residents' monthly medication reviews, she reviewed the medications for each diagnosis and the use of each medication. She did not review the residents' diagnosis list in the EMR to ensure that the diagnosis assigned to the medication was an active diagnosis for that resident. She verified resident 32 did not have an active diagnosis of depression(comma), but her physician's order for mirtazapine indicated it was being used for depression. Licensed pharmacist M was aware that resident 32 had duplicate antipsychotic medication therapy (define). She thought the duplicate therapy was the recommendation of the geriatric psychiatrist, according to medical director L's 4/21/26 progress note. After reviewing that progress note, she stated she previously read the progress note wrong, and medical director L indicated that resident 32 was to be transitioned from quetiapine to olanzapine. She did not recommend continuing that transition in her monthly medication review for resident 32. She acknowledged that resident 21 did not have a diagnosis for depression but was being treated with an antidepressant. 8. Interview on 6/2/26 at 10:01 a.m. with medical director L revealed that he received recommendations from the pharmacist after she reviewed resident charts for gradual dose reductions (GDRs) and monthly medication reviews (MMRs). He reviewed and discussed the recommendations with the pharmacist, then submitted an electronic prescription that reflected the medication changes. Medical director L expected that if he failed to respond to a GDR recommendation, licensed pharmacist M, director of nursing (DON) B, or assistant director of nursing (ADON) C would address that with him in person immediately. He stated that the nursing staff and the pharmacist should review the GDRs and MMRs to ensure the orders and reviews were completed. If a medication lacked a diagnosis, he expected the nurse to address the missing diagnosis with their supervisor to obtain the appropriate diagnosis from him. 9. Interview on 6/2/26 at 11:30 a.m. with DON B revealed the provider did not review the risk versus benefits, educate on alternatives to the psychotropic medications with the resident or the resident's representative, document that informed consent was obtained, or have written consent forms signed by the resident or the resident's representative before starting or changing resident 21's psychotropic medications. The provider did not have a policy related to psychotropic medications that addressed their use, risks, benefits, alternatives, non-pharmacological interventions, GDRs, PRN use limits, the ongoing need for the medications, and monitoring and safety. DON B acknowledged that there was no documentation that resident 21's representative was notified before he was started on his psychotropic medications. DON B did not implement a process for reviewing risks versus benefits, alternative treatments, or interventions, and obtaining informed or written consent from the resident or their representative for the use of psychotropic medications. 10. Review of the provider's 1/12/26 Behavioral Health Management policy revealed, Staff will proactively assess, monitor, and manage behavioral symptoms using individualized, nonpharmacological and clinically appropriate interventions while ensuring resident dignity, safety, and regulatory compliance. Each resident with behavioral health needs must have an individualized care plan addressing behaviors, identified triggers and early warning signs, specific interventions and staff approaches, and staff must prioritize non-drug approaches. The use of psychotropic medications, Must comply with CMS [Center for Medicare and Medicaid Services] regulations (gradual dose reductions, indications). Use only when clinically necessary and not for staff convenience. Requires: Documented clinical indication, provider order, and monitoring for effectiveness and side effects. 11. Review of the provider's revised November 2024 Drugs: Review of Orders For Discontinuation policy revealed that A procedure whereby the dosage and schedule of medications will be reviewed by physicians. The timeframe for review of orders for continuation or discontinuation will apply to the following categories: Controlled Substances will be discontinued in 30 days, Antibiotics will be discontinued in 7 days, Anticoagulants will be discontinued in 30 days, Colchicine for acute gout attacks will be discontinued in 48 hours, Ketorolac (Toradol) will be discontinued in 5 days, and all other drugs not otherwise ordered for a specific time or number of doses will be discontinued in 60 days. The medication needing review will not automatically discontinue and will remain active until discontinued by the physician. The physician will have three options under this activity, that includes Review, which will reset the review date for the medication, Discontinue, which will discontinue the medication, and Modify, which will modify the medication order and reset the review date. Psychotropic medications were not included in the policy to include PRN (as needed) orders and their 14-day stop dates.

Based on record review, interview, and policy review, the provider failed to ensure the staff educated the resident or the resident's representative of the risks versus benefits of medications or of alternative treatments to make an informed decision for the consent for the use of psychotropic medications (drugs that affects brain activities associated with mental processes and behavior) before they were administered to four of four sampled residents (3, 6, 21, and 32). Findings Include:1. Review of resident 21's EMR revealed he admitted to the facility on [DATE]. His 4/21/26 BIMS assessment score was 3, which indicated his cognition was severely impaired. His diagnoses included Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions), dementia with agitation and behavioral disturbance, and neurocognitive disorder with Lewy Bodies (a progressive brain disorder caused by abnormal protein clumps that damage nerve cells that affects thinking, memory, movement, sleep, and behavior), and obstructive sleep apnea (a disorder when your breathing repeatedly stops and starts during sleep because the throat muscles relax, causing the airway to collapse and block airflow). He had a 10/23/25 physician's order to be given one tablet of 15 mg temazepam, a sedative-hypnotic medication that helps the brain relax, making it easier to fall asleep, by mouth every 24 hours as needed at bedtime for insomnia. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 21. He had a 10/23/25 physician's order for trazodone 100 mg (an antidepressant medication), one tablet by mouth at bedtime for insomnia. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 21. He had 10/24/25 physicians' orders to be given 0.25 ml of lorazepam Intensol oral concentrate, an antianxiety medication, by mouth every two hours PRN for agitation and to be given 0.5 ml of lorazepam by mouth every two hours PRN for agitation. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 21. Licensed pharmacist M reviewed resident 21's chart and medication list on 1/26/26, and suggested his lorazepam orders be evaluated by his physician. Licensed pharmacist M indicated in a 5/29/26 review note that resident 21's lorazepam was discontinued by the physician. A 1/30/26 order note for resident 21 indicated that a physician's order was received to discontinue his lorazepam. Review of resident 21's active physician orders indicated that resident 21 continued to be administered his 0.25 ml and 0.5 ml lorazepam Intensol oral concentrate PRN doses as ordered by the physician on 10/24/25. No documentation indicated that the lorazepam doses were ordered to be discontinued on 1/30/26. He had 3/6/26 physicians' orders to be given 1.5 tablets of 1 mg Risperdal, an antipsychotic medication, by mouth in the morning for agitation and 2 mg by mouth every 24 hours PRN, that may be given at bedtime for agitation or anxiety. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 21. He had 4/2/26 physicians' orders to be given one tablet of 100 mg (1 tablet) sertraline, an antidepressant medication, by mouth in the morning and 50 mg ( one-half tablet) at bedtime for depression. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or provided their consent for that medication to be administered to resident 21. He did not have a diagnosis of depression (a mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities). 2. Review of resident 6's EMR revealed he admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 5, which indicated his cognition was severely impaired. He did not have a diagnosis of schizophrenia (a chronic and severe brain disorder that affects how a person thinks, feels, and acts), bipolar disorder (a mental health condition characterized by extreme, recurring shifts in mood, energy, and activity levels), anxiety, depression (a serious mood disorder that causes persistent feelings of sadness, emptiness, and a loss of interest in activities), or a severe behavioral disorder. He had an 11/13/25 physician's order for Sertraline HCl oral tablet 100 mg to be administered by mouth in the morning for depression. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 6. He had a 1/23/26 physician's order for Haldol 5 mg (an antipsychotic medication; a drug that alters neurotransmitter activity in the brain to reduce symptoms of mental health conditions) give 10 mg by mouth every 6 hours as needed for agitation. That physician's order did not have an end date, a diagnosis for use, and resident 6 needed to be seen by a physician to have that medication reordered on 2/8/26. No documentation indicated that the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 6. He had a 2/20/26 physician's order for Seroquel 25 mg (an antipsychotic medication), one tablet to be administered by mouth two times a day for agitation. The behaviors that Seroquel was ordered to treat were not identified. There was no diagnosis for use identified for that medication. 3. Review of resident 3's EMR revealed she admitted to the facility on [DATE]. Her BIMS assessment score was 11, which indicated her cognition was moderately impaired. Her diagnoses included anxiety disorder and dementia with behavioral disturbance. She had a 7/29/25 physician's order for alprazolamv0.5 mg (an anti-anxiety medication), one tablet to be administered as needed for anxiety. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 3. She had a 5/23/25 physician's order for escitalopram 20 mg (an antidepressant medication), one tablet to be administered every morning for anxiety. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 3. She had a 12/23/25 physician's order for haloperidol 5 mg one tablet to be administered as needed for agitation. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 3. She had a 12/23/25 physician's order for Seroquel 50 mg, one tablet to be administered at bedtime for behaviors. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 3. She had an 8/7/25 physician's order for trazadone 50 mg, one tablet to be administered at bedtime for sleep. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 3. 4. Review of resident 32's EMR revealed she admitted to the facility on [DATE]. Her 4/22/26 BIMS assessment score was 14, which indicated her cognition was intact. Her diagnoses included dementia with agitation. She had a 4/17/26 physician's order for lorazepam 1 mg (an anti-anxiety medication), one tablet to be administered every eight hours as needed for anxiety. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 32. She had a 4/21/26 physician's order for lorazepam 1 mg, one tablet to be administered two times per day. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 32. She had a 4/16/26 physician's order for mirtazapine 7.5 mg (an antidepressant medication), one tablet to be administered at bedtime for depression. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 32. She had a 4/25/26 physician's order for quetiapine 50 mg (an antipsychotic medication), one tablet to be administered in the afternoon for agitation and dementia with behaviors. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided consent for that medication to be administered to resident 32. She had a 4/21/26 physician's order for olanzapine 10 mg (an antipsychotic medication), one tablet to be administered two times per day for dementia with agitation. No documentation indicated that the resident or the resident's representative was informed of the risks versus benefits of that medication, alternative treatment options, or that they provided their consent for that medication to be administered to resident 32. 5. Interview and EMR review on 6/2/26 at 11:30 a.m. with director of nursing (DON) B revealed the provider did not review the risk versus benefit, educate on alternatives to the psychotropic medications, or have consent forms signed by the resident or the resident's representative before starting or changing resident 21's psychotropic medications. The provider did not have a policy related to psychotropic medications. There was no documentation that resident 21's representative was notified when resident 21 was started on his psychotropic medications. There was no documentation that resident 32's representative was notified when she was started on the lorazepam as needed for anxiety, the mirtazapine, or the quetiapine, because he was difficult to reach by phone. DON B was aware of the regulation related to obtaining the residents' or the residents' representatives' consent for the use of psychotropic medications, but did not implement a process for the review of risks versus benefits, review of alternative treatments or interventions, and obtaining consent for psychotropic medications. 6. Interview on 6/1/26 at 2:33 p.m. with licensed pharmacist M revealed she expected the resident or the resident's representative to be informed of the risks versus benefits of taking a psychotropic medication before the medication was administered or changed. When she made a recommendation, she sent a copy to the resident's physician and DON B. If the physician did not address her recommendation, she did not include it in the following month's review, since she had already mentioned it. Licensed pharmacist M reviewed medication-related diagnoses to ensure that medications had appropriate diagnoses. She acknowledged that residents 21 and 32 did not have a diagnosis for depression but were being treated with an antidepressant. 7. Interview on 6/2/26 at 10:01 a.m. with medical director L revealed that he received resident recommendations from the pharmacist after she reviewed resident charts for gradual dose reductions (GDRs) and monthly medication reviews (MMRs). He reviewed and discussed them with the pharmacist, then submitted an electronic prescription reflecting the changes. Medical director L expected that if he failed to respond to a GDR recommendation, licensed pharmacist M, DON B, or assistant DON C would address him in person immediately. Both the nursing staff and the pharmacist should review the GDRs and MMRs to ensure the orders and reviews were complete. If a medication lacked a diagnosis, he expected the nurse to address the missing diagnosis with their supervisor to obtain the appropriate diagnosis. 8. Interview on 6/2/26 at 12:31 p.m. with chief executive officer (CEO) A revealed he was aware that consent forms were not being completed for psychotropic medications, and that appropriate diagnoses were not documented for resident medications. He was unaware that licensed pharmacist M's recommendations were not reaching medical director L, and, as a result, the provider did not implement them for several months. He acknowledged that pharmacy recommendations regarding psychotropic medication management were not implemented promptly, and residents or their representatives were not informed about their psychotropic medication treatment, including risks, benefits, alternatives, and providing their consent before initiation or continuation of the resident's medications. 9. Review of the provider's 1/12/26 Behavioral Health Management policy revealed, Staff will proactively assess, monitor, and manage behavioral symptoms using individualized, nonpharmacological and clinically appropriate interventions while ensuring resident dignity, safety, and regulatory compliance. The resident's family was to be notified of significant behavioral changes. Residents have the right to participate in care decisions (as able).

Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, document review, record review, and policy review, the provider failed to report within the required time frame to the SD DOH for two of two sampled residents' (5 and 13) allegations of potential resident abuse or neglect. Findings include:1. Review of the provider's 12/23/25 SD DOH FRI report revealed that on 11/19/25, it was reported that resident 5 spilled her hot tea in the dining room, which resulted in a 0.25 centimeter (cm) blister on her right inner thigh, and both inner thighs were red. Bacitracin (an antibiotic ointment) was applied to the blister, and it was covered with a bandage. Resident 5 told a family member that a staff member spilled the hot tea on her. On 12/22/25, resident 5's family member told registered dietitian (RD) H that she thought that a staff member spilled the hot water on resident 5. On 12/22/25, chief executive officer (CEO) A and director of nursing (DON) B interviewed resident 5, and resident 5 provided inconsistent information about who spilled the hot water for her tea. The provider determined the incident was not the result of abuse or neglect. The report indicated that the provider, family, and DON were notified of the incident. 2. A request was made to CEO A on 5/27/26 at 9:00 a.m. for the provider's reporting and investigating policies and incidents subject to reporting. A request was made to DON B on 5/27/26 at 3:00 p.m. for the provider's incident reporting guidelines and abuse and neglect policies. 3. Interview on 5/27/25 at 2:20 p.m. with licensed social worker (LSW) E and social services designee (SSD) revealed SSD F read about resident 5's 11/19/25 hot liquid burn injury the following day (11/20/25) in the nurse's progress note. At that time, it was documented that resident 5 spilled her coffee in her lap. She could not recall when she learned that resident 5's daughter stated that she thought the hot liquid burn injury was caused by a staff member. She could not recall when she learned that resident 5's daughter stated that she thought the hot liquid burn injury was caused by a staff member. LSW E became aware of resident 5's family members' concern that resident 5 received a hot liquid burn injury and that resident 5's family member thought that a staff member caused that burn injury on 12/23/25. LSW E was unaware when resident 5's family member first shared the concern that the hot liquid injury was caused by a facility staff member. She expected that if resident 5's family member shared a concern that she thought that a staff member caused resident 5's burn injury, that concern would have been reported to CEO A and DON B immediately, and CEO A or DON B would have reported the incident to the SD DOH. She expected that CEO A and DON B would have been responsible for filing a report, investigating the incident of concern, and sharing the outcome of their investigation with the family member for a family member's concern that was required to be reported to SD DOH. 4. Continued interview on 5/27/26 at 3:37 p.m. with LSW E revealed that she completed the SD DOH FRI investigation and reports until she began working remotely about two years ago and now CEO A and DON B were responsible for reporting and investigating incidents. She worked at the facility two days per month. She recalled that DON B called her several weeks after resident 5 received a hot liquid burn injury from her tea, because a family member complained to the RD H that staff spilled coffee on resident 5. That incident was originally documented on 11/19/25 by the nurse that resident 5 spilled her hot beverage on herself, and an investigation was not completed. LSW E advised DON B to report the 11/19/25 hot liquid burn injury incident to the SD DOH. 5. Phone interview on 5/27/26 at 4:34 p.m. with resident 5's family member regarding resident 5's 11/19/25 hot liquid burn injury incident revealed she visited resident 5 on 11/24/24 and was told by resident 5, they burned me, and resident 5 showed her the inner thigh area. She was resident 5's emergency contact, and no notification was provided to her or the other listed emergency contact. It had been about a week since that incident occurred. While at the facility on 11/24/25, she spoke with a nurse (she was unable to recall who she spoke with) about the incident and was told that the documentation in resident 5's EMR said that resident 5 spilled her own coffee in her lap and that the emergency contact was notified. She stated that resident 5 was coherent, repeated several times, they burned me, and that she believed resident 5. She told the nurse that she thought a staff member caused resident 5's burn injury and that she was upset that she and the other emergency contact were not notified. Resident 5's family member attended the 12/9/24 care conference meeting and told the staff members that she was concerned that a staff member caused resident 5's burn, and that she and the emergency contact were not notified. She recalled that RD H was present at that care conference and said she would check into it. On 11/23/25, she stopped to visit with RD H because she was not provided any additional information about what happened when resident 5 was burned or what the facility was doing about it. She was frustrated that the facility did not follow up with her about her concerns and stated that she hoped that an incident like this would not happen again or happen to anyone else. 6. Review of resident 5's 12/9/25 Care Conference Assessment revealed that resident 5, her family member, RD H, assistant DON C, and SSD F attended that care conference. Resident 5's family member discussed her concerns about resident 5's burn injury from her hot tea. 7. A request was made to DON B on 5/28/26 at 8:30 a.m. for the provider's accident hazards policy. The provider provided their reviewed December 2021 Abuse Investigating policy and their revised January 2020 Accidents and Incidents policy. 8. Interview on 6/1/26 at 12:17 p.m. and again on 6/2/25 at 11:31 a.m. with DON B regarding resident 5's 11/19/25 hot liquid burn injury revealed that she was notified on 12/22/25 that resident 5's family member was stating that resident 5 was burned by hot liquid and that she thought that a staff member caused the burn injury. She was not notified on 11/19/25 that resident 5 received a hot liquid burn injury, and did not expect to be notified because it was not serious enough to require a visit to the emergency room, and staff thought that she had spilled her hot tea on herself. She expected the staff in attendance at resident 5's care conference on 12/9/25 would have notified her immediately after resident 5's family member expressed concern that resident 5 was burned by a staff member, so she could have investigated and reported the incident to the SD DOH. Due to the staff not immediately reporting the incident to her, there was a delay in the investigation and reporting of resident 5's hot liquid spill that resulted in a burn, which required treatment. DON B reported resident 5's 11/19/25 hot liquid burn injury to the SD DOH on 12/23/25. She thought allegations of resident abuse or neglect needed to be reported within 24 hours and that her investigation needed to be completed within 5 days. She was not aware that an allegation of resident abuse or neglect needed to be reported within 2 hours. 9. Interview on 6/2/26 at 8:25 a.m. with RD H regarding resident 5's 11/19/25 hot liquid burn injury revealed she learned of the injury during resident 5's 12/9/25 care conference. Resident 5's family member was concerned that resident 5 was burned by hot tea in the dining room, thought that a staff member spilled the hot tea on resident 5, wanted to know more about how the incident occurred, and what steps were taken to prevent it from happening again. RD H stated that she followed up with dietary manager (DM) G, SSD F, and DON B by email after the care conference about the actions that DM G was taking. On 12/23/25, resident 5's family member came to her office, and RD H told her about the implemented interventions. She was unaware whether the incident had been investigated and reported to the SD DOH. 10. Interview on 6/2/26 at 9:48 a.m. with SSD F revealed that she attended resident 5's 12/9/25 care conference and was aware that resident 5's family member was concerned about how resident 5 was burned by her hot tea, but it was documented that resident 5 spilled her tea on herself. She was unsure if a report should have been made to the SD DOH. She was unaware that resident 5's family member had more concerns about resident 5's hot liquid burn injury or how it happened. 11. Review of the SD DOH Facility Reported Incident dated 2/25/26 revealed an allegation of staff abuse by a former contracted travel certified nursing assistant (CNA), BB, against former resident 13 on 2/24/26. On the morning of 2/24/26, at around 6:00 a.m., an unidentified CNA entered resident 13's room to assist her with her morning care. The CNA noted that resident 13 had bruises and a skin tear to her right forearm. The CNA reported her findings to the on-duty unidentified registered nurse. The nurse assessed resident 13 and confirmed that she had bruises on both arms and a skin tear on her right arm. Resident 13 told the CNA and RN that a girl from the night shift was mean, grabbed her arm, and wanted her to get out of bed to go to the bathroom. Resident 13 told the girl (from the night shift) that she had already gone to the bathroom and said no, but the girl had made her get up out of bed. The incident, along with the noted bruising and skin tear, was reported to director of nursing (DON) B upon her arrival at work that same day. On the evening of 2/24/26, DON, B, and the chief executive officer (CEO) A met with the contracted travel CNA BB, to discuss resident 13's abuse allegation. Contracted travel CNA BB explained that she was assisting resident 13 in getting ready for bed on the evening of 2/23/26. While helping resident 13 stand, resident 13 began to fall, contracted travel CNA BB grabbed resident 13 by both forearms to steady her, which may have caused the bruising. Contracted travel CNA BB also stated that when she went in to assist resident 13 with care early the next morning on 2/24/26, resident 13 was combative, but contracted travel CNA BB said she was able to reason with resident 13 and left her room when resident 13 told her to. Contracted travel CNA BB wrote a statement about the incident and was placed on administrative leave pending the investigation. CEO A and DON B interviewed resident 13 regarding her allegation following the meeting held with contracted travel CNA BB, and resident 13's account of the incident did not differ from her previous explanations. A witness statement was obtained by the unidentified CNA that noted the bruising on resident 13's arms the morning of 2/24/26. Law Enforcement was notified by the facility on 2/25/26 at approximately 9:30 a.m. about the abuse allegation and began an investigation. The investigation's conclusion indicated that contracted travel CNA BB was terminated on 2/25/26 and that the facility notified the travel agency because she was no longer allowed on the facility's premises. The report indicated that resident 13's power of attorney (POA), DON, administrator, and physician were notified of resident 13's bruising and the investigation. The Department of Human Services (DHS) and the SD DOH were both notified on 2/25/26. 12. On 5/26/26, a request was made for review of resident 13's facility investigation report from 2/25/26, and on 5/27/26 at 8:12 a.m., CEO A reported that the facility did not have an investigation report to provide. 13. Review of resident 13's electronic medical record (EMR) revealed she was admitted on [DATE]. Her 12/30/25 Brief Interview of Mental Status (BIMS) assessment score was 4, and her 3/24/26 BIMS assessment score was 7, both of which indicated her cognition was severely impaired. However, she did not have a diagnosis of dementia, Alzheimer's disease, or other cognitive disorder. A nursing progress note dated 2/24/26 at 6:35 a.m. revealed that an unidentified staff member reported to an unidentified nurse that the resident had 3 large purple bruises on the right forearm. The bruise closest to the wrist has a small skin tear. One purple bruise on left forearm. Left side of lip has a small cut. Resident states, She grabbed my arm and twisted it. DON, ADON notified. Resident 13's skin assessment dated [DATE] at 12:57 p.m. revealed that she had 3 large purple bruises on her right forearm. The bruise closest to the wrist has a small skin tear. One purple bruise on her left forearm, and the left side of her lip has a small cut. Denies having pain. On 2/24/26 at 3:37 p.m., a progress note indicated that contracted travel RN T was unable to reach resident 13's first emergency contact but was able to reach her second emergency contact by phone, and he would try to notify resident 13's first emergency contact. On 2/25/26 at 1:16 p.m., a progress note indicated that DON B attempted to call resident 13's first emergency contact to Follow up on bruises, No answer, will try again later. There was no other documentation in resident 13's EMR indicating that resident 13's emergency contact had been notified of the abuse allegation on 2/24/26 that resulted in physical harm. A physician's order was received twelve days after the incident, on 3/8/26, to observe bruising to bilateral forearms until healed, two times a day. Review of resident 13's most recent care conference summaries revealed that summaries were completed on 1/5/26 and 3/25/26, but no care conference signature forms were available to review in resident 13's EMR for those dates, so it was unclear if a care conference meeting was conducted. A care conference signature form dated 2/10/26 was reviewed, and it indicated that a care conference had been conducted regarding resident 13's plan of care, but there was no care conference summary available to review in resident 13's EMR for that date. Resident 13's second emergency contact, ADON C, social services designee (SSD) F, activities director (AD) FF, registered dietitian (RD) H, and licensed social worker (LSW) E (by phone) attended that care conference on 2/10/26. There was no documentation in resident 13's EMR that the allegation of abuse with physical harm had been reviewed with the family and IDT team. Resident 13's care plan, dated 7/10/25 and revised on 3/30/26, did not address interventions that ensured she was safe from abuse, including safety measures, physical and emotional support, cognitive or behavioral status, nor did it address follow-up and monitoring. Incident tracking reports in the facility's electronic system (PCC) showed that no incident report for the abuse incident had been completed in the risk management report section, as required by the facility's policy. The dates reviewed to locate the incident were 2/16/26 through 3/16/26, and no documented incident report was found. 14. Review of the facility's working staff schedules and timecard from 2/23/26 through 2/24/26 confirmed that contract travel CNA BB was assigned to resident 13 during the incident period from the night shift of 2/23/26 at 5:17 p.m. through the morning of 2/24/26 at 6:21 a.m. Resident 13's injuries were observed by an oncoming unidentified day shift CNA on 2/24/26, per the facility's SD DOH FRI report. She had noted a skin tear, a cut on the left side of her lip, and significant bruising on both of her arms when she went to assist resident 13 with her morning care on 2/24/26. The unidentified CNA reported her findings to her nurse immediately, and the unidentified nurse responded and completed an assessment, per the facility's SD DOH FRI report. The unidentified nurse documented her findings in a progress note dated 2/24/26 at 6:35 a.m. 15. Review of former contracted travel CNA BB's personnel file revealed that she was hired in January 2024 through a contracted travel agency and that she had completed abuse training online with [contract nursing facility name] on 4/13/23 and also completed elder physical abuse and managing resident behaviors on 9/8/25 through the current facility. No disciplinary actions or allegations of abuse and neglect were documented or found in former contracted travel CNA BB's file. 16. Interview on 5/27/26 at 3:37 p.m. with LSW E revealed that she completed the SD DOH FRI investigation and reports until she began working remotely about two years ago. She worked at the facility two days per month. LSW E said that incident reports were completed by CEO A and DON B and that she was not aware of resident 13's allegation of abuse that resulted in bruising and a skin tear sustained from former contracted travel CNA BB on 2/24/26. LSW E stated she didn't believe she had been notified of the incident involving resident 13 on 2/24/26 and acknowledged that she had not completed any documentation regarding the incident in resident 13's EMR. She expected that CEO A and DON B would have been in charge of filing a report, investigating the incident of concern, sharing the outcome of their investigation with resident 13's first emergency contact and the physician, and reporting to the SD DOH within federal guidelines. 17. Interview on 5/28/26 at 4:50 p.m. with CEO A revealed that the provider's investigations for the FRI's were discarded after about 30 days if the SD DOH did not come to the facility to investigate the incident. He was unaware that some FRI's would be investigated more than 30 days after the incident. He was not aware of the two-hour report time to the SD DOH for abuse allegations. CEO A thought it was a 24-hour time frame to report to SD DOH and acknowledged that no investigation documents for resident 13 had been completed. CEO A stated, The employee was terminated, so there was no need for further follow-up. If documentation was completed, such as an incident report, CEO A stated, I get rid of them [incident reports] after they are sent [to SD DOH], and when the investigation is concluded. CEO A acknowledged that no audits or education were provided to staff, and that no further follow-up was conducted with other residents. He said that incidents were routinely discussed in the Quality Assurance Performance Improvement (QAPI) and board meetings. No incident investigation report from the facility was provided during the survey. 18. Interview on 6/1/26 at 12:08 p.m. with DON B revealed that she or CEO A initiated incident investigations and entered the reports into the state website. DON B said that no audits were completed after the incident involving resident 13 and former contracted travel CNA BB. She acknowledged that no other residents were interviewed to assess additional concerns of abuse or neglect and that no additional education on abuse prevention was provided to staff following the incident. DON B further stated that approximately two weeks prior to resident 13's abuse allegation, another resident (who was unidentified) reported that the same former contracted travel CNA BB had told a resident she could not use the bathroom. DON B said she spoke with the former contracted travel CNA BB, about that allegation, and the CNA denied it. DON B said she reported the information to former contracted travel CNA BB's travel staffing company, identifying the situation as a disciplinary matter. The conversation that DON B had with former contracted travel CNA BB two weeks prior to resident 13's abuse allegation was not found as documented in her personnel file as a disciplinary action or write-up. DON B said she was not aware of any prior abuse or neglect issues involving former contracted travel CNA BB before the incident involving resident 13, except for the above situation. She confirmed receiving a copy of the police report and that notifications were made to the Board of Nursing, Adult Protective Services (APS), and the Ombudsman. When asked about reporting timelines, DON B stated she was unaware that abuse or neglect allegations must be reported within 2 hours. She stated she believed the requirement was 24 hours, with 5 days to complete the investigation. No incident investigation report from the facility was provided during the survey. 19. A phone call was made to contact resident 13's first emergency contact on 5/27/26 at 4:08 p.m.; a message was left for a return call. No return call was received during the survey. 20. Resident 13 was unable to be interviewed as she was discharged on 4/2/26 due to death in the facility. 21. Review of the provider's reviewed August 2018 Incident Reporting policy revealed that all accidents or incidents occurring on our premises must be reported to the administrator. Regardless of how minor an accident or incident may be, it must be reported to the charge nurse immediately, and they will report the incident to the department supervisor. The charge nurse shall notify the medical director, attending physician, and the family of the accident or incident. A risk management report must be completed on the shift that the accident or incident occurred, and the charge nurse or the department director must conduct an immediate investigation of the accident or incident. The incident must be reported to the administrator and director of nursing services no later than twelve (12) hours after the occurrence of the accident or incident if any injuries occurred, or within 72 hours if no injuries. A risk management report is required for any occurrence or event that is out of the ordinary for the resident, or interrupts normal procedure. Ensure that the care plan is updated if a new intervention is put into place. Complete the form if any type of abuse occurred (physical, sexual, etc.). 22. Review of the provider's reviewed October 2021 Incident Reporting Guidelines policy revealed that Incidents of unusual nature, suspected abuse, medication error, drug reactions, or an accident that causes injury to a resident shall be recorded. The resident's physician and legal representative shall be notified within 24 hours. The facility must have evidence that all alleged violations of abuse are thoroughly investigated and prevent further potential abuse while [the] investigation is in progress. Nurse's notes shall document the incident in sufficient detail in the clinical record. Document the resident's and witnesses' statements in quotations. Maintain an incident report log in order to evaluate patterns such as number of incidents per shift or day of the week, types of accidents and injuries, and residents with multiple incidents. Incident reports must be reviewed by the director of nursing, the Quality Assurance Process Improvement (QAPI)/risk manager, administrator, and medical director. Incidents will be reported at the monthly LTC (long-term care) QAPI meetings. Incident reports are filed by time periods (monthly, quarterly, etc.) in SEPARATE FILES from clinical records. Incident reports are retained according to state statute of limitations and then destroyed according to the same procedures as clinical records. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, are reported immediately to the administrator of the facility and the state licensure agency. 23. Review of the provider's reviewed December 2021 Abuse Prohibition policy revealed that the facility was To utilize the abuse prohibition investigative protocol to be in compliance with federal regulations. Documentation is required for all suspicious injuries, bruises, skin tears, fractures, and injuries of unknown origin. The primary RN or DON will complete necessary documentation surrounding the injury using the Injury Assessment form. Abuse, involuntary seclusion, and misappropriation of property will be reported to the primary registered nurse (RN) and then to the director of nursing (DON) or social worker who will be responsible for initial investigation of the incident. Document the investigation by using the Grievance Complaint Investigation form, and place it with the investigation report. The facility is to notify the Department of Health within 24 hours of any alleged abuse, neglect, or misappropriation of a resident's property. The report may be faxed or called in by the administrator, DON, social worker, or other designated person. The administrator, DON, social worker, or other designated person has 5 working days to complete the investigation unless a verbal approval for an extension is obtained from the DOH. A copy of the completed investigation will be recorded on the Resident Abuse Investigation form and will be provided to the administrator, resident, or resident representative within 5 working days of the reported incident. The administrator, DON, social worker, or other designated person will provide a written report of the results of all abuse investigations and appropriate action taken to the state survey and certification agency within 5 working days of the reported incident, notify the local or state ombudsman of the occurrence, investigation, and corrective action, and invite them to participate in the investigation process. Corrective actions to be implemented and monitored by the administrator, DON, social worker, or other designated person. 24. Review of the undated admission packet revealed that The facility will notify the resident or representative when an accident or injury occurs. A resident, his or her representative, family member, visitor, or advocate may file a verbal or written grievance or complaint concerning treatment, abuse, neglect, harassment, or medical care. Complaints of abuse, harassment, or mistreatment will be immediately investigated and you will receive a written and/or verbal report of the findings, and/or corrective actions taken within five working days of filing the report. 25. Review of the provider's revised January 2020 Accidents and Incidents policy revealed .all accidents or incidents occurring on our premises must be reported to the administrator. Regardless of how minor an accident or incident may be, it must be reported to the department supervisor and an Accident or Incident Report Form must be completed on the shift that the accident or incident occurred. The Investigation Report Form must be submitted to the Director of Nursing Services no later than twelve (12) hours after the occurrence of the accident or incident. Submit the original copy of the Investigation Report and the Accident and Incident Report to the Administrator no later than 24 hours after the occurrence of the accident or incident. The policy did not address reporting timelines for reporting incidents, accidents, or suspicion or allegations of resident abuse or neglect to the SD DOH.

Based on interview, observation, and policy review, the provider failed to make information available on how to file a grievance, ensure the grievance forms were readily available to residents and their representatives, designate who the grievance official was, and follow their grievance process when one of one sampled residents' (5) representative expressed a concern about an injury. Findings Include:1. Observation on 5/27/26 at 8:10 a.m. revealed there were no grievance forms or information on how to file a grievance located in the resident care areas, at the nurses' station, near the dining room, or in the activities room. 2. Interview on 5/27/26 at 8:16 a.m. with social services designee (SSD) F revealed she thought that the grievance official was either licensed social worker (LSW) E or chief executive officer (CEO) A. SSD F was responsible for filing the grievances in a binder. She had not assisted any resident or family member in completing a grievance form.There was no grievance, concern, or complaint filed by resident 5's family member regarding the 11/19/25 incident when resident 5 received a hot liquid burn injury 3. Observation and interview on 5/27/26 at 2:12 p.m. with LSW E revealed she was the grievance official until she began working remotely about two years ago. She supervised SSD F and worked at the facility two days per month. SSD F was the grievance official and was responsible for ensuring that the grievances were investigated by the appropriate department, that follow-up occurred with the individual filing the grievance, and that the grievance form was filed and retained for several years.LSW E expected the grievance forms to be located in each hallway where there were resident rooms, outside of the director of nursing (DON) B's office, and outside of the social services office.She confirmed there were no grievance forms located outside DON B's office or in the 300 hallway. The grievance binder in the 200 hallways was located inside a clear file holder that also held trash bags. It was approximately five feet from the floor and did not contain grievance forms. She agreed that residents who required the use of a wheelchair would not have access to those grievance forms. There were grievance forms in a binder near the front door of the facility outside of the social services office. She confirmed that it was not a resident care area and most residents would not have known they were there. She thought that residents could file a grievance anonymously by sliding a form under SSD F's door or by placing it in the box near the front door.LSW E expected that SSD F would have been responsible for handling a family member's concern if it was not a concern that was required to be reported to the South Dakota (SD) Department of Health (DOH). 4. Interview on 5/27/25 at 2:20 p.m. and again at 3:37 p.m. with LSW E and SSD F revealed SSD F read about resident 5's 11/19/25 hot liquid burn injury the following day (11/20/25) in the nurse's progress note. At that time, it was documented that resident 5 spilled her coffee in her lap. She could not recall when she learned that resident 5's daughter stated that she thought the hot liquid burn injury was caused by a staff member. She was unsure if a grievance form should have been completed or if that hot liquid burn injury should have been reported to the SD DOH.LSW E became aware of resident 5's family members' concern that resident 5 received a hot liquid burn injury and that resident 5's family member thought that a staff member caused that hot liquid burn injury on 12/23/25 when DON B called her several weeks after resident 5 received a hot liquid burn injury from her tea, because a family member complained to the dietitian that staff spilled coffee on resident 5.LSW E was unaware when resident 5's family member first shared the concern that the hot liquid injury was caused by a facility staff member.LSW E expected that if resident 5's family member shared a concern with any staff member that she thought that a staff member caused resident 5's hot liquid burn injury, that a grievance form would have been completed, and that concern would have been reported to CEO A and DON B immediately. 5. Resident Council group interview on 5/27/26 at 2:45 p.m. revealed that three residents attended. The three residents who attended did not know how to file a grievance or where the grievance forms were located. Resident 20 stated that if she had a concern or a grievance, she would tell a nurse and hoped that the nurse would fix the problem. 6. Phone interview on 5/27/26 at 4:34 p.m. with resident 5's family member regarding resident 5's 11/19/25 hot liquid burn injury revealed she visited resident 5 on 11/24/24 and was told by resident 5, they burned me, and resident 5 showed her the inner thigh area. She was resident 5's emergency contact, and no notification was provided to her or the other listed emergency contact. It had been about a week since that incident occurred. While at the facility on 11/24/25, she spoke with a nurse (she was unable to recall who she spoke with) about the incident and was told that the documentation in resident 5's EMR said that resident 5 spilled her own coffee in her lap and that the emergency contact was notified.She stated that resident 5 was coherent, repeated several times, they burned me, and that she believed resident 5. She told the nurse that she thought a staff member caused resident 5's hot liquid burn injury and that she was upset that she and the emergency contact were not notified. She expected someone to follow up with her about her concerns.Resident 5's family member attended the 12/9/24 care conference meeting and told the staff members, again, that she was concerned that a staff member caused resident 5's hot liquid burn injury, and that she and the other emergency contact were not notified. She recalled that registered dietitian (RD) H was present at that care conference and said she would check into it.On 11/23/25, she stopped to visit with RD H because she was not provided any additional information about what happened when resident 5 was burned or what the facility was doing about it.She was frustrated that the facility did not follow up with her about her concerns and stated that she hoped that an incident like this would not happen again or happen to anyone else. 7. Interview on 6/1/26 at 12:17 p.m. and again on 6/2/25 at 11:31 a.m. with DON B regarding resident 5's 11/19/25 hot liquid burn injury revealed that she was notified on 12/22/25 that resident 5's family member was stating that resident 5 was burned by hot liquid and that she thought that a staff member caused the hot liquid burn injury. She was not notified on 11/19/25 that resident 5 received a hot liquid burn injury, and did not expect to be notified because it was not serious enough to require a visit to the emergency room, and staff thought that she spilled her hot tea on herself.She expected the staff in attendance at resident 5's care conference on 12/9/25 to have completed a grievance form when they were notified by resident 5's family member that she was concerned that resident 5 was burned by a staff member with a hot liquid. If a grievance form was filled out, DON B would have been notified, she would have begun an investigation, and would have had the information to follow up with resident 5's family member after the investigation was completed. 8. Interview on 6/2/26 at 8:25 a.m. with RD H regarding resident 5's 11/19/25 hot liquid burn injury revealed she learned of the injury during resident 5's 12/9/25 care conference. She was unsure if a grievance form was completed when resident 5's family member voiced that she was concerned that resident 5 was burned by a staff member with a hot liquid. RD H expected that SSD F would have completed a grievance form if it was appropriate and followed up with resident 5's family after the 12/9/25 care conference. She was surprised when resident 5's daughter visited her again on 12/23/25 and was still concerned about resident 5's 11/19/25 hot liquid burn injury. 9. Interview on 6/2/26 at 9:48 a.m. with SSD F revealed that she attended resident 5's 12/9/25 care conference and was aware that resident 5's family member was concerned about how resident 5 was burned by her hot tea, but it was documented that resident 5 spilled her tea on herself. She was unsure if a grievance should have been completed. She felt that if resident 5's daughter voiced a concern to a nurse on 11/24/25 or to RD H, they would have completed a grievance form if it was appropriate. Nursing or dietary would have been responsible for completing an investigation into those concerns. She was unaware that resident 5's family member had more concerns about resident 5's hot liquid burn injury or how the burn injury happened. After resident 5's 12/9/25 care conference, SSD F expected RD H to have followed up with resident 5's family member about what interventions the facility implemented.Resident 5 spilled her own tea, so she did not think that there was anything else to follow up with the family about. 10. Review of the provider's reviewed December 2021 Filing Grievances/Complaint policy revealed Our facility will assist residents, their representatives (sponsors), other interested family members, or advocates in filing grievances or complaints when such requests are made. It did not identify who the grievance official was. 11. Review of the Provider's undated Grievance/Concern Follow-up form revealed This form should be completed on any resident comment or criticism not resolved immediately, regarding their care or treatment in any of our facilities. This may come in the form of a resident satisfaction survey, a letter, a phone call, or a conversation with a resident/family member/visitor, etc. 12. Review of the provider's undated Long-Term Care Center Resident Grievance/Concern Procedure revealed .all residents and/or his/her representative have the right to voice grievances/concerns to the facility. Grievance/Concerns can be filed orally or written on the facilities grievance/concern form. (Located in the Grievance/Concern folder outside the social services office or at the end of each wing [hallway]). We want to ensure prompt resolution of all grievances regarding the resident's rights.The grievance official was listed as LSW E. SSD F's contact information was not included in that procedure.

Based on record review, interview, and policy review, the provider failed to ensure the resident's baseline care plan (personalized plan that addresses a resident's care needs, goals, and interventions) was completed, was reviewed with, and a copy was offered to the resident or the resident's representative within 48 hours of the resident's admission to the facility for three of four sampled newly admitted residents (3, 6, and 14). Findings include: 1. Review of resident 14's electronic medical record (EMR) revealed he was admitted to the facility on [DATE]. His 5/14/26 Brief Interview of Mental Status (BIMS) assessment score was 13, which indicated his cognition was intact. His diagnoses included hemiparesis (paralysis on one side of the body following cerebral infarction (stroke) affecting his right dominant side, adult failure to thrive, repeated falls, hypertension (high blood pressure), chronic ischemic heart disease (a long-term condition where the heart muscle receives insufficient blood and oxygen), and vitamin D and B deficiencies. His baseline care plan assessment was initiated on 2/19/26, but was not completed. There was no documentation that indicated his diagnoses, his diet, or that the social services section had been completed. There was no documentation that a copy of the baseline care plan was offered to or reviewed with the resident or his representative within 48 hours of his admission to the facility. 2. Review of resident 6's EMR revealed he was admitted to the facility on [DATE]. His 5/14/26 BIMS assessment score was 5, which indicated his cognition was severely impaired. His diagnoses included type 2 diabetes mellitus (a chronic metabolic condition characterized by high blood sugar levels), peripheral vascular disease (a circulation disorder characterized by the narrowing, blockage, or spasms of blood vessels outside of the heart and brain), chronic kidney disease (loss of the kidneys' ability to filter waste and excess fluid from the blood), cerebral infarction (stroke), repeated falls, weakness, and tremor (involuntary, rhythmic shaking or trembling movement).His baseline care plan assessment was completed on 11/17/26. There was no documentation that indicated his diagnoses, his bed-to-chair transfer status, or that the social services section had been completed. There was no documentation that a copy of the baseline care plan was offered to or reviewed with the resident or his representative within 48 hours of his admission to the facility. 3. Review of resident 5's EMR revealed she was admitted on [DATE]. Her 5/19/26 BIMS assessment score was 13, which indicated her cognition was intact. Her diagnosis included diverticulosis (a painful digestive condition that occurs when small, bulging pouches in the lining of your colon (called diverticula) become inflamed or infected), atrial fibrillation (a type of irregular heart beat), type 2 diabetes mellitus (a chronic metabolic condition characterized by high blood sugar levels), hypertension, low back pain, depressive episodes (a distinct period of at least two weeks characterized by a persistent low mood, sadness, or a complete loss of interest in activities), presence of cardiac pacemaker (a small, battery-operated medical device implanted in the chest or abdomen), Alzheimer's Disease (a progressive, irreversible brain disorder that slowly destroys memory and thinking skills), and dementia (a group of symptoms that negatively impact memory, thinking, and social abilities).Her baseline care plan assessment was completed on 3/11/25. There was no documentation that indicated her diagnoses, her code status, or that the social services section had been completed. There was no documentation that a copy of the baseline care plan was offered to or reviewed with the resident or his representative within 48 hours of his admission to the facility. 4. Interview on 6/1/26 at 12:17 p.m. with director of nursing (DON) B regarding baseline care plans revealed she expected the baseline care plan to be completed as soon as possible, within 48 hours after a resident admitted to the facility. She was unsure if the social services department contributed to the baseline care plan. The resident or the resident's representative was not offered or provided a copy of the baseline care plan. She was unaware that the regulation required the baseline care plan to be reviewed with the resident or their representative, and a copy was to be provided. 5. Review of the provider's revised February 2020 Care Plans: Preliminary, Comprehensive and Reviews policy revealed the provider assures each resident has a preliminary care plan developed at admission to address immediate care needs. Preliminary care plans are used until the Comprehensive Care plan has been completed and addressed the following areas of care for the resident: Problems , Strengths , Short/Long-ter Goals , Approach , Time Frame.

Based on South Dakota Department of Health (SD DOH) complaint report review, record review, and interview, the provider failed to ensure care plans were reviewed and revised to reflect the current care needs of two of two sampled residents (1 and 2): *One of one sampled resident (1) with verbally aggressive behaviors. *One of one sampled resident (2) vulnerable to verbal aggression from her roommate. Findings include: 1. Review of the 1/28/25 SD DOH complaint report revealed a resident with dementia (1) was physically aggressive with staff. *He had an alarm placed. -The report did not identify where, why, or what type of alarm had been placed. *An anonymous staff member was afraid that the alarm would not prevent the resident from going after other residents and staff. Review of resident 1's medical record revealed: *He was admitted on [DATE]. *His 4/7/25 Brief Interview of Mental Status (BIMS) assessment score was 1, which indicated he had severe cognitive impairment. *His diagnoses included: dementia, psychotic disturbance, mood disturbance, and anxiety. *His nurse progress notes indicated: -On 3/29/25, Resident was yelling at his [roommate]. -On 5/16/25 at 12:45 p.m., resident 1, while in his room, was cussing and yelling at a staff member. His roommate asked him to please stop cussing and allow staff to help him. Resident 1 told his roommate, Shut the hell up or I will slap . -On 5/16/25 at 6:11 p.m., resident 1 was very agitated, and he cussed at his roommate. *His current care plan reviewed on 5/20/25 did not include that: -He was verbally aggressive to his roommate or to staff. -He had any aggressive behaviors, or interventions for staff to implement to address his behaviors. 2. Review of resident 2's medical record revealed: *She was admitted on [DATE]. *Her 4/7/25 BIMS assessment score was a 13, which indicated her cognition was intact. *Her diagnoses did not include any mental health diagnoses. *Her nurse progress notes indicated that on 4/14/25 her roommate had been observed to holler at her on occasion. Her family was aware and had chosen not to move her to another room. *Her current care plan, reviewed on 5/20/25, did not include that she was vulnerable to verbal aggression by her roommate or any interventions for staff to implement to address or limit that vulnerability. 3. Interview on 5/20/25 at 4:30 p.m. with director of social services (DSS) C revealed: *The facility utilized a contracted service to complete the Minimum Data Set (MDS) assessment (used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) while a new MDS coordinator was being trained. *She confirmed that resident 1's care plan did not include his aggressive behaviors or interventions to address those behaviors. *She confirmed that resident 2's care plan did not include her vulnerability to verbal aggression from her roommate or any interventions to address that vulnerability. *She would absolutely expect to see those issues identified in resident 1 and resident 2's care plans. *She stated the care plans were not revised due to a lapse between me and the MDS nurse. 4. Interview on 5/21/25 at 11:33 a.m. with director of nursing (DON) B regarding care plans revealed: *She confirmed that resident 1's care plan did not reflect his aggressive behaviors. *She confirmed that resident 2's care plan did not address her vulnerability to verbal aggression from her roommate. *She stated that she and the MDS nurse shared responsibility for those care plans not having been revised to reflect residents' current care needs. *She agreed that care plans should reflect the residents' current needs and interventions to address those needs.

Based on observation, interview, record review, and policy review the provider failed to ensure side rail assessments were completed for safe and appropriateuse for three of seven sampled residents (1, 9, and 14) wh used them for repositioning. Findings include: 1. Observation and interview on 12/17/24 at 10:47 a.m. with resident 14 in her room revealed: *She was seated in her wheelchair. *Her bed hadside rails on the top half of each side (bilateral) of her bed. *She stated she used the side rails to move around in bed. Review of resident 14's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was 14, meaning she was cognitively intact. *She had diganoses of: -Nondisplaced comminuted fracture of left patella (kneecap). -Parkinson's disease. -Pneumonia. *An order dated 5/8/24 for her to use side rails to bilateral sides of the bed, to aid her in self mobility and repositioning while in bed. *A 1/4 rail and side rail rationale and safety screen was completed on 5/7/24. *No other safety screens or assessments were completed for the use of the side rails. 2. Observation and interview on 12/17/24 at 9:57 a.m. with resident 9 in her room revealed: *She was seated in her wheelchair. *The top half of her bed had bilateral side rails. *She stated she used the side rails and loved them. Review of resident 9's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 8, meaning she was moderately cognitively impaired. *A 1/4 rail and siderail rationale and safety screen was completed on 7/29/23. *She had a current physicians order for a side rail. *No other safety screens or assessments were completed for the use of the side rail. 3. Observation and interview on 12/17/10:22 a.m. with resident 1 in her room revealed: *She was seated in her motorized wheelchair. *The top half of her bed had a side rail on the left side of her bed. *She stated she used her side rail at night to help her turn. *She stated she had been living at the facility for seventeen years. Review of resident 1's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 15, meaning she was cognitively intact. *A side rail use assessment was completed on 3/6/2019. *She had a current physicians order for a side rail. *An alarm/side rail/restraint consent for use was signed on 9/9/2022. *No other safety screens or assessments were completed for the use of a side rail. Interview on 12/19/24 at 8:16 a.m. with assistant director of nursing (ADON) C regarding side rail assessments revealed the therapy department completed the assessments for the side rails. Interview on 12/19/24 at 8:39 a.m. with physical therapist L regarding side rail assessments revealed: *The therapy department did the initial assessments. *The nursing department was responsible for completing the quarterly assessments. Interview on 12/19/24 at 9:32 a.m. with director of nursing (DON) B regarding side rail assessments revealed: *She had identified the quarterly side rail assessments were an issue. *The therapy department completed the initial assessments. *The nursing department was responsible for the quarterly assessments. *She agreed the quarterly assessments were not being completed. Review of the provider's 6/2021 side rail policy revealed: *Each resident will maintain his/her highest practical level of well-being in an environment that prohibits the use of side rail for discipline or to restrict movement and limits side rail use to circumstances in which the resident has been evaluated for transfers and safety with use of side rails to enhance mobility. *10. A side rail assessment will be completed by therapy and/or nursing when there is a desire expressed by the resident or need reported by the nursing staff. *11. Physicians orders for type and number of side rails will be obtained prior to placing the side rail on the bed. *12. A side rail assessment form will be completed quarterly and prn by the MDS coordinator or designee in conjunction with OBRA MDS's and prn for use or desired change. 50916

Based on observation, interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (18) prior to pushing the resident in her wheelchair without placing foot pedals to elevate her feet off the floor, and that resulted in the resident falling out of the wheelchair and fracturing her left arm. Findings include: 1. Observation and interview on 8/22/23 at 10:25 a.m. with resident 18 revealed: *She had a cast on her left arm. *When asked about how she got the cast, she stated that she had fallen and broke her arm. *She winced in pain when moving her arm and stated it was quite painful at times. -She indicated she had just taken some pain medication and was waiting for it to start working. -The pain was manageable with the help of her pain medication. Interview on 8/24/23 at 10:35 a.m. with licensed practical nurse R about resident 18's fractured left arm revealed: *Resident 18 usually propelled herself throughout the building in her wheelchair. *She had not witnessed the fall, but she had received a report of the incident. Interview on 8/24/23 at 10:47 a.m. with CNA N about resident 18's fall revealed she: *Was not working when the incident occurred. *Confirmed that after the fall, therapy was consulted. *Therapy recommended a certain style of foot pedals for the wheelchair resident 18 was using. Interview on 8/24/23 at 10:56 a.m. with director of nursing B about resident 18's incident revealed: *Resident 18 was usually independent with propelling herself in her wheelchair, and that was the reason she had not been assessed for the use of wheelchair foot pedals. *The fall happened on 8/12/23. *On that day, CNA S noticed that resident 18 was taking longer than usual to propel herself back to her room after the evening meal. -CNA S asked the resident if she wanted a ride back to her room. -There were no foot pedals available for the resident to rest her feet on. -Resident 18 lifted her legs up so they would not drag on the floor. -While CNA S was pushing the resident back to her room, resident 18 suddenly put her feet down. -Resident 18's feet were pulled underneath the wheelchair, and she fell face-forward out of her wheelchair to the floor. -She braced herself with her arms. *After the fall, the staff had completed the following: -Assessed her using the fall protocol. -Confirmed she was not experiencing pain. -Contacted the resident's physician and family members. -Initiated neurological checks per protocol. *Several hours after the fall, staff noted that resident 18's left hand and forearm were swollen, and she experienced pain upon movement. -At that time, she was taken to the emergency room for assessment. *X-rays confirmed she had broken her arm. *DON B confirmed that prior to the incident, they had no policy regarding safety protocols when pushing a resident in a wheelchair. *She had since created a wheelchair foot pedal policy. *She ordered new bags to have been placed on the back of all wheelchairs to store the foot pedals when not in use. *She re-educated all staff during the daily huddles about the new policy, and what procedures staff had to do prior to pushing a resident in a wheelchair. *She had not documented who had attended the daily huddles to ensure each staff member was educated. *She had not initiated any audits to ensure staff were compliant with the new policy. Interview on 8/24/23 at 12:26 p.m. with DON B and social worker H about resident 18's incident revealed: *Occupational therapists (OT) would recommend types of foot pedals for a resident's wheelchair. *They confirmed resident 18 had not been assessed by OT prior to her accident because she had propelled herself independently in her wheelchair. -The staff had not wanted to always leave the foot pedals on her wheelchair due to the risk of residents or staff tripping over them or causing damage to walls. -They had no storage bags for all the resident's foot pedals but had ordered them for all the residents who used wheelchairs. *When asked how they were monitoring for compliance that all the residents had foot pedals in place when being pushed, they stated that resident 18 was the only one they were monitoring. Review of resident 18's electronic medical record revealed: *Her care plan had not been updated to include the use of foot pedals while assisting the resident with locomotion in her wheelchair. *Her most recent Brief Interview for Mental Status score was assessed at 4, indicative of severe cognitive impairment. *A progress note from 8/12/23 read, Per CNA assigned to resident, as resident was being pushed in wheelchair from supper, legs got caught under wheelchair and resident fell forward out of her chair. Abrasion to forehead and nose. VSS [vital signs stable], resident denied pain when asked. Neuro-checks initiated. MD [medical doctor] and DON notified. Attempted to contact POA [power of attorney] [name redacted] but no answer and voicemail full. *A progress note from 8/13/23 at 3:36 a.m. read, Resident has a edematous bruise on her L [left] hand at the middle finger. *Another progress note from 8/13/23 at 11:42 a.m. read, Resident with noted swelling to left wrist. Warm to to the touch and tender when palpated. Limited ROM [range of motion]. Call placed to on call provider in ER [emergency room ] and resident sent over for X-ray. *8/13/23 progress note from 2:07 p.m. read, X-ray revealed closed fracture of distal end of left radius . *There was a therapy note from 8/14/23 which read, OT put pedals on [resident 18's] w/c [wheelchair] this morning as unable to find any in her room. Pedals should always be used when pushing any resident. *Another therapy note from 8/18/23 read, OT placed a calf board on resident's w/c due to recent fall incident as she is having more difficulty keeping her feet on the pedals and putting her feet on the ground when being pushed was the cause of her fall. Will monitor response. Resident was very receptive to this change as she has not been propelling her own w/c due to the cast on her arm. Review of the provider's Department of Health Required Healthcare Facility Event Reporting revealed: *In the final report and investigation submitted, the provider indicated that the DON has educated [CNA S] and all staff regarding utilizing foot rests when transporting a resident. -Occupation Therapy added foot rests to [resident 18's] wheelchair .[Resident 18] did not usually have foot rests on her wheelchair as she self propels herself often. -[Resident 18's] care plan did not address the foot pedals. -There was a not a policy in place regarding wheelchair foot pedals prior to this incident, there is now a new policy moving forward that all residents need to have foot pedals on their wheelchair if they are pushed. Review of the provider's 8/22/23 Wheelchair Transports policy revealed: *The policy had not addressed: -The need for therapy to assess the resident for the type of foot pedal. -The use of the foot pedal storage bags. -The procedure for installing the foot pedals. -The procedure for ensuring resident safety prior to staff pushing the resident in a wheelchair. *The purpose of the policy was to provide safe transports via wheelchair. *Under the Equipment section: -1. Wheelchair -2. Footrest Pedals *Under the Procedure section: -1. When patients are being transported via wheelchair, foot pedals must be in place and utilized.

Based on observation, interview, and policy review, the provider failed to ensure one of one unlicensed assistive personnel (UAP) (B) in the special care unit provided care without mistreating one of one resident (18). Findings include: 1. Observation on 12/14/11 at 10:30 a.m. during care for resident 18 provided by UAP B revealed: *The UAP put gloves on her hands after she had washed them for less than 15 seconds. *She entered resident 18's room. *She told the resident she had eye drops to administer. *She opened the eye drop bottle and approached the resident. *The resident began calling out repetitively she was "going to die-don't-no", and she had shut her eyes tightly. *The UAP attempted to open the resident's right eye with her hands as the resident resisted by pushing away with her hands and saying no. *The resident's eye had remained closed, and the UAP applied an eye drop that landed on the resident's closed eyelids. *The UAP then pulled the resident's left lower eyelid down with her fingers, so the eyelashes touched the resident's skin under her eye. *The resident continued to resist as before. *The UAP then tried to put an eye drop in the resident's eye and jabbed the resident in the eye with the end of the eye drop applicator as the resident thrashed about trying to resist the eye drops. *The resident cried out "ouch" when that happened. *The UAP stated to the resident "Oh, you're okay." *The eye drop rolled down the resident's cheek. *The UAP then put down the eye drops and picked up a tube of [MEDICATION NAME] ointment. *With the same gloves applied that ointment to the resident's left heel. *She then put down the ointment, picked up a jar of [MEDICATION NAME] cream, used her gloved hand and removed cream, and applied it to the resident's left heel. *She then put that jar down and used a wet wipe to cleanse under the resident's breasts. *She picked up another jar of [MEDICATION NAME] cream, dipped her gloved fingers into that cream, and applied it under the resident's breasts. *The UAP changed her gloves without washing her hands. *She then dressed the resident's lower body while the resident was in bed. *She assisted the resident to a sitting position and placed a gait belt around the resident's waist. *She then transferred the resident to the wheelchair using the gait belt. *As she transferred the resident the resident's left leg was pushed against the edge of the wheelchair where the foot pedal would have attached to the wheelchair. The pedal had not been attached at that time. *The resident stood in a crouched position with her body bent at the knees and the waist. *The UAP pushed the resident's bottom towards the chair with her body, as she turned the resident towards the chair. *During the transfer the resident had cried out "Stop pushing me-you're pushing me-that hurts-you're hurting my leg." *The UAP had told the resident she was okay, and she had not hurt her. She had not checked the resident's leg after that transfer. *The UAP then wheeled the resident into the bathroom and transferred her to the toilet using the gait belt. The resident had not stood well, and the UAP pushed the resident's bottom over again during that transfer. *The UAP then removed the resident's soiled gown and placed it on the floor. *She then placed the resident's soiled incontinence products in the trash can. *She dressed the resident's upper body. *She had the resident stand holding onto the grab bar, as she cleansed the resident's bottom with wet wipes. *The UAP pulled the resident's slacks up and transferred her into the wheelchair. *She combed the resident's hair and put her glasses on her. *She removed her gloves and without washing her hands pushed the resident in her wheelchair out to the dining area. *She returned to the resident's room and gathered up the trash, soiled clothing, and medications she had used during the resident's care. *She placed the soiled laundry and trash in the soiled utility room. *She then entered the medication room and placed the medications in the medication cart. *After that she washed her hands for less than 15 seconds. Interview on 12/14/11 at 12:50 p.m. with registered nurse (RN) consultant L confirmed: *The UAP should not have forced the resident to have the eye drops applied. *The UAP should have notified the nurse if she was unable to apply the eye drops as ordered for the resident. *If giving resident 18's eye drops continued to be a struggle with the resident the physician should have been notified. *The UAP should have asked for assistance during the transfer, as it had been unsafe and had put the resident at increased risk for bruises. Interview and observation on 12/14/11 at 1:20 p.m. with (RN) consultant L confirmed: *Upon examination of resident 18's left lower leg two old yellow-green bruises were present. *They were at the height of the edges of resident 18's leg where it had been pushed against on the wheelchair during the transfer that morning. *The bruises could have happened during transfers into the wheelchair. Review of the provider's revised 2/17/06 Resident's Rights policy revealed: *"It is the policy of this facility to promote and protect the rights of residents residing in our facility." *The provider would ensure residents had always been treated with respect, kindness, and dignity. *It had included the ABCs of resident rights. *Under Choice in the ABCs it had stated the resident had the right to refuse treatment.

Based on record review and interview, the provider failed to ensure the Quality Assurance (QA) committee functioned in a manner to develop and implement appropriate plans of action to identify and correct quality deficiencies. Findings include: 1. Refer to F157, F226, F280, F281, F309, F323, and F356. 2. Interview on 10/5/11 at 11:30 a.m. with the administrator revealed: *The QA committee met on a quarterly basis. *The committee was comprised of the administrator, director of nursing, assistant director of nursing (ADON), other management staff, and the medical director. *Skin concerns were usually always discussed but not consistently documented. *The ADON was responsible to report bruises and any skin issues to QA. *They had always documented the number of bruises and skin problems they had. They would usually talk about specific residents at their daily stand-up meetings. *They usually talked about process and quality improvement, but that was often not reflected in the QA minutes. *He thought the medical director was aware of the multiple bruises of residents with unknown origin. He had no other specific intervention advice except having the residents wear protective arm sleeves. Review of the provider's 9/1/02 Quality Management/Improvement Plan policy and procedure revealed the purpose to be: *"A coordinated, systematic, multi-disciplining facility-wide approach will be followed to improve resident and patient care and health outcomes. *Minimize the probability of events that have an adverse physical or psychological effect on patients, residents, visitors, and staff. *To recommend action on identified or potential problems. *To determine priorities for multidisciplinary problems. *Identify the problems and establish goals. *Develop baseline measure tools to measure and analyze. *Identify all the causes of the problems and break down the causes and find out root cause. *Develop possible solutions and action plans to be able to monitor and measure changes to show others improvement. *Implement solutions and document who is going to do what. Communicate to let everyone know what is going on. *Measure performance and compare it with the base measurement. *Evaluate the results and evaluate what else should be done." Review of the provider's QA meeting notes for 5/16/11 through 9/22/11 revealed: *5/16/11- "Eight falls for the month of May thus far with no major injuries or suspected abuse. Ten bruises and three skin tears thus far for the month of May with no suspected abuse issues on these. All unwitnessed falls and bruises have been faxed into the state and social service departments. For the month of April, facility has seven falls, thirty five bruises noted with no suspected case of abuse." *8/15/11- "Five falls in June with no harm. Forty five bruises all with no harm. In July there were eight falls and 61 bruises and skin tears. A new committee is being formed to monitor bruises and skin tears. Forms will be used to document bruised areas and date and time of incident." *9/19/11- "Mandatory use of transfer belts initiated when transferring a resident who requires any hand-on assistance implemented to reduce the bruises of unknown origin. Nurses are conducting weekly skin checks on the resident's bath day and documenting the results." Further review of the above QA minutes revealed there was no documented evidence the provider had followed their plan for quality improvement. Review of the provider's 2011 incident tracking revealed the following number of abrasions/bruises: *January 2011-Twenty eight witnessed. None unwitnessed. *February 2011-Twenty six witnessed. None unwitnessed. *March 2011-Thirty five witnessed. None unwitnessed. *April 2011-Seventeeen witnessed. Twenty eight unwitnessed. *May 2011-Twenty witnessed. Twenty five unwitnessed. *June 2011-Nineteen witnessed. Twenty six unwitnessed. *July 2011-Twenty one witnessed. Forty unwitnessed. *August 2011-Twenty three witnessed. Fifteen unwitnessed.

Based on record review and interview, the provider failed to ensure the governing body monitored that policies and procedures were implemented for the overall management of the facility. Findings include: 1. Refer to F157, F226, F280, F281, F309, F323, F490, and F520. 2. Interview on 10/5/11 at 11:30 a.m. with the administrator revealed he: *Thought he had kept the governing board updated of any resident or staff concerns. *Would usually keep the chief executive officer (CEO) updated. He was a member of the governing board. *Had no record of anything he had informed the CEO of. *Had no record of anything the governing board had recommended regarding falls and bruises of unknown origin. *Thought the governing board thought they were doing everything they could to investigate bruises and falls of unknown origin. He could not remember any specific ideas they had to improve resident care. Review of the undated Governing Board of Directors Policies revealed: *The board's monthly agenda should have been prepared by the administrator in consultation with the board president with as much information mailed out ahead of the meeting as possible. *"There shall be an "open door" policy between the administrator and the board." Review of the provider's 9/1/02 Quality Management/Improvement Plan revealed: *"The Board of Directors has the overall responsibility for performance improvement and risk management. *The Board of Directors, Administration, and Medical Staff Officers have the responsibility and accountability for the quality of care and services provided."

Based on observation, record review, and interview, the provider failed to ensure: *Residents were free from neglect and accidents. *Investigations involving resident injuries of unknown origin had been thoroughly completed and reported. *Services were provided for residents to attain the highest practicable physical, mental, and psychosocial well being for the individual resident. *The quality assurance process had been utilized effectively to maintain the highest practicable physical, mental, and psychosocial well being of the residents. *Resident care plans were revised to reflect the current care needs of the residents. *Professional standards regarding investigations, a quality assurance process, and care plans were followed. Findings include: 1. Observation, record review, and interviews confirmed the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain and maintain the highest practicable physical, mental, and psychsocial well-being of each resident. Refer to F226, F280, F281, F309, F323, and F356. 2. Interview on 10/5/11 at 11:30 a.m. with the administrator revealed: *A stand-up meeting was held every morning (Monday through Friday) where the management staff "went over any unknowns or bruises." *He would expect the staff to notify him at home if a resident had a fracture or a death. "I want no surprises." *Regarding the bruises, they were handed to the appropriate person to follow through on. That was usually the responsibility of the unit managers. "I want to know what they think happened and how to prevent it from happening again." *"There were always investigations." *The facility had adequate staffing. He had compared it to another facility about the same size he had been at. *He would have to go back and check resident 2's chart for the specifics. He thought she had been periodically placed in the special care unit for her safety. He could not remember the specific incident when she had fractured her arm. *He was unaware the investigation into resident 2's wrist fracture had not been thoroughly investigated or reported. He acknowledged he had signed off on the incident. He had not recalled being part of the investigation himself. He had not given the assistant director of nursing any guidance on that investiation. *He confirmed it would not be normal protocol for a family member to investigate their own family member. He would usually assign another staff member to complete the investigation. *He felt some interventions had been put in place to decrease the large number of resident bruises of unknown origin. He was unsure if the amount of bruises had decreased with the interventions. "I would have to get the book and look." *He thought they had talked about bruises at Quality Assurance (QA). He confirmed the number of bruises was primarily what was talked about. The assistant director of nursing (ADON) was responsible to report at that meeting any skin/bruise issues to QA. *He had remembered hearing about resident 3 being injured after an improper transfer with the use of a mechanical lift. He was not aware all the temporary staff they had used had not received the appropriate training for the use of the mechanical lift and/or the stand lift. *He had not verified with either of the temporary staffing services they utilized that background checks had been completed on the staff that was provided to their facility. He had gone into the state registry web and had checked a few staff names a few weeks ago, and they had came back okay. *Was not aware of any staffing or resident concerns that staff had neglected to inform him of. He had came to work at the facility "with an open door policy." Did not believe staff were afraid to come to him. *Unable to recall any specific family concerns with any resident care. "They would have to be more specific." *Had a certified nursing assistant (CNA) come to one QA meeting, and staff had felt their imput was valuable. Unsure when that meeting was and why a CNA was never invited to the meeting again. *Was unsure why resident 2 was placed in the special care unit for several hours a day. "I know we did not have a bed available. I will have to look at her record." *Was unsure who made the decision for resident 2 to spend hours every day in the special care unit. It was likely to keep resident 2 safe.

Based on record review and interview, the provider failed to ensure the safety of two of two sampled residents (2 and 5). Findings include: 1. Review of resident 2's 8/31/11 nurse's progress notes revealed: *12:15 a.m. "Found by certified nursing assistant (CNA) when he heard a beeper going off down wing two and went to investigate. CNA found resident lying next to the stand lift which was in the hallway outside her room. The stand lift belt was lying next to her. She sustained a 1/4 centimeter (cm) skin tear to the left posterior elbow, a 2 cm reddened area on the right buttock, a 7 cm long by 1 cm wide area on the left mid-back, and a 10 cm reddened area to the right posterior elbow. Steri strips applied to the skin tear. Resident moved to special care unit where she could be monitored more closely." *3:45 a.m. "Redness on right buttock, left mid-back, and right posterior elbow is gone. Steri strip on skin tear located on left posterior elbow." 2. Review of resident 5's 9/3/11 2:08 p.m. nurse's progress notes revealed: *"Eloped from the facility. *Physician found him and brought him back to the facility. *He had Wanderguard on the wheelchair which was defective and did not sound. *Wanderguard on the right ankle was cut off since the morning check by resident. *Wanderguard and cut band were found in nightstand. *Wanderguard was placed on wheelchair and resident's right leg. *Family was notified. *Resident seems increasingly confused today and will be closely monitored." Review of resident 5's September 2011 weekly Wanderguard check revealed there was no documentation for 9/2/11 that resident 5's Wanderguard had been checked. 3. Interview on 10/6/11 at 9:00 a.m. with the interim director of nursing revealed: *The stand lift should not have been left outside resident 2's room. Resident 2 had significant dementia and was not aware of safety hazards. *The Wanderguard weekly checks in September 2011 were to have been done with the residents' bathes on a weekly basis by the bath aide. She confirmed there was no documentation on 9/2/11 the Wanderguard had been checked when resident 5 had his bath.

Based on record review, policy review, and interview, the provider failed to assess, monitor, and intervene in the individualized care and service to maintain the highest practical physical and psychosocial well being for: *One of one resident (3) with a fall from a mechanical lift during a transfer. *One of one resident (2) with a fracture of unknown origin. Findings include: 1. Review of resident 3's 4/12/11 revised care plan revealed she: *Had been at high risk for falls. *Required assistance with mobility and activities of daily living (ADL). *Required two assist with the full body mechanical lift to transfer. *Had little to no lower or upper body control due to her medical diagnosis. Review of resident 3's revised 2/22/11 falls care plan revealed: *The resident would be free from falls or fall related injuries. *A full body mechanical lift with the assistance of two staff was required during transfers. Review of resident 3's care sheet used on 7/28/11 revealed she required a full body lift for transfers with the assistance of two staff. Review of the nurse's notes dated 7/30/11 at 7:15 p.m. stated resident 3: *Had fell during a transfer by a certified nursing assistant using a full body lift from the resident 's wheelchair to the bed. *The resident had fallen to the floor. *She had hit her head which had caused an open area 1.0 by 3.0 by 0.5 centimeters on her head. *The resident complained of pain at the site of the injury. Review of the 8/4/11 abuse investigation report for resident 3 revealed: *A temporary staff agency CNA had not followed the care plan when transferring the resident with a mechanical lift. *That had resulted in a fall and a head injury. 2. Review of resident 2's 7/14/11 11:10 a.m. nurse's admission progress notes revealed she: *"Was admitted to the long-term care area of the facility. *Was confused to time and place. *Had dementia and [MEDICAL CONDITION]. *Was on the psychoactive medication [MEDICATION NAME]. *Wandered constantly at the noon meal. Wanderguard was placed on her left ankle. *Wandered in and out of other residents' rooms. *Refused to go to the bathroom and had a bowel movement accident in her pull-up. *Hit at the certified nursing assistants (CNAs) while being cleaned up and screamed. *Attempted to take her clothes off several times." Review of resident 2's nurse's progress notes revealed: *7/17/11 no time "Two centimeter raised area noted on left wrist-tender to touch." *7/18/11 2:00 p.m. "Resident's left wrist swollen and bruised. Painful to touch. X-ray taken at 9:30 a.m. X-ray showed fracture. Physician was notified and sent to hospital at 1:00 p.m. and scheduled for surgery at 3:00 p.m. Assistant director of nursing (ADON) and administrator notified. Also informed of behaviors (increase in hitting out with cares) and [MEDICATION NAME] was increased to 0.5 milligrams (mg) every morning." Review of resident 2's certified nursing assistant (CNA) 7/17/11 through 7/18/1 repositioning/toileting flow sheet revealed: *On 7/17/11 there was documentation she had been assisted with toileting at 2:00 a.m., 4:00 a.m., and 7:00 a.m. There was no documentation of any care provided from 8:00 a.m. through 12:00 p.m. There was documentation "special care unit (dementia unit) for 1:00 p.m. through 10:00 p.m." There was documentation resident 2 had been assisted to toilet and bed at 11:00 p.m. *On 7/18/11 there was documentation resident 2 had been assisted with toileting and returned to bed at 1:00 a.m., 3:00 a.m., and 5:00 a.m. There was documentation resident 2 had been assisted with a bath at 8:00 a.m. There was no documentation of any care provided from 8:00 a.m. until she left for the hospital at 2:00 p.m. Review of resident 2's nurses' 7/28/11 through 9/26/11 progress notes, resident incident reports, and investigations revealed: *7/28/11 3:00 p.m. "Noted 2 by 2 centimeter (cm) bruise on right hip after resident pulled her own pants up using one hand due to other arm in a cast. Refused to let the CNA help her. Had not been observed before lunch when she had been assisted to the toilet. Has a cast on her left wrist due to a fracture. Frequently toilets self but does have some difficulty due to cast. Is severely cognitively impaired and not aware of safety limitations. Will continue to use different approaches to encourage her to allow staff to assist her." *8/6/11 7:45 p.m. "Hit another resident with her right hand on the back five times before she could be moved and redirected." *8/17/11 7:30 p.m. "Resident's pants were down around her ankles. The CNA asked her to pull her pants up. When CNA was done giving medications, she turned to help the resident. The resident started to turn to go back into her room, and pants made her trip. The resident fell on buttocks and hit her head and back on the door frame." * 8/31/11 12:15 a.m. "Found by certified nursing assistant (CNA) when he heard a beeper going off down wing two and went to investigate. CNA found resident lying next to the stand lift which was in the hallway outside her room. The stand lift belt was lying next to her. She sustained a 1/4 centimeter (cm) skin tear to the left posterior elbow, a 2 cm reddened area on the right buttock, a 7 cm long by 1 cm wide area on the left mid-back, and a 10 cm reddened area to the right posterior elbow. Steri strips applied to the skin tear. Resident moved to special care unit where she could be monitored more closely. On 8/29/11 psychiatrist made several medication changes and resident was spending from the time she got up in the morning till she was ready for bed in the special care unit (dementia unit)." *9/5/11 6:30 p.m. "Was noted to have a 2 cm by 1 cm skin tear on outer aspect of right forearm. Has been observed picking at her own skin. Fingernails trimmed routinely on bath day and as needed. Will have resident wear long sleeve shirts/sweaters to prevent resident from picking at own skin." *9/7/11 8:55 p.m. "Resident bumped into another resident's wheelchair while walking and landed in a sitting position on her bottom on the floor." *9/19/11 9:15 a.m. "Found on floor sitting by bed in another resident's room. Was found to have bowel movement on the floor and was sitting in it. Redness 4 cm by 1 cm noted right shoulder. Was observed she was sitting against the bed at the time of her fall. Fall occurred due to bowel movement on the floor and she slipped in the bowel movement." *9/21/11 no time "Resident had bruises on bilateral anterior shins. CNA observed resident bumping front of legs when she walks up to the bed to crawl in. Resident has been observed when she is sitting in the recliner with her feet up she puts feet off foot rest and brings them back up numerous times when sitting in the recliner. She also crosses legs back and forth numerous times and her heel crosses her shin in the exact spots where bruises are located." *9/21/11 no time "Observed that bruises were noted to left lateral foot and right posterior upper arm. Observed when she sets on toilet per self she plops back. CNA stated that she has observed resident spinning around to sit on the toilet per self and sits half on toilet and half on toilet rail. Bruise to right posterior arm occurred during self transfer when resident plops and hits arm on toilet rail. Bruise on left lateral foot caused by resident moving feet on/off foot rest of the recliner." *9/22/11 5:45 p.m. "CNA noted a deep purple 4 cm by 3 cm bruise on the left inner buttock cheek next to the rectum." *9/23/11 5:10 p.m. "Has been hitting the table and hitting her head. Redirected by CNAs and med aides when she does these behaviors." *9/23/11 8:30 p.m. "While getting resident ready for bed a 4 cm by 2.5 cm red/purple bruise was noted to the left forearm. Right forearm was observed to have a 2 cm by 3 cm bruise. Injury was not witnessed and the resident could not describe how injury occurred." *9/26/11 3:05 p.m. "Today has been hitting head with her hands and hitting the table with her hands. Tylenol was given with no change." Review of resident 2's psychiatrist physician's notes revealed: *8/29/11 "She is not doing well. Is more agitated, but when I went to the room to see her, she was lying in bed and she did not even look up at me. It seems that she had taken some fall. They were bandaging her arm. Apparently she had twisted or broken it. She impresses me as being over-sedated. [MEDICATION NAME] level was good but she is so sedated and is unable to ambulate steadily. [MEDICATION NAME] will be decreased to 350 milligrams (mg) twice a day. She is also on [MEDICATION NAME] and although she has been taking this for years, I would like to decrease it to 0.5 mg. She is also on [MEDICATION NAME] (dementia medication)." *9/27/11 "Continues to deteriorate very badly. She is confused. Seems to be declining in her function very rapidly. She is going to be moved to another facility to be close to family so I will not make any changes right now. She is not as agitated but she has no awareness of what is going on around her. Sometimes she goes to the bathroom and leaves the bathroom with her pants down. I do not think we can change that, it requires more supervision." Review of resident 2's primary physician's notes dated 8/1/11 revealed "Is very deteriorated. Started to take her clothes off prior to coming to nursing home. Was started on [MEDICATION NAME]. Continue adjusting [MEDICATION NAME] but [MEDICATION NAME] might need to be decreased." Review of the 7/14/11 social service admission note revealed: *"Was admitted from an assisted living facility as no longer appropriate for placement. *Behaviors of wandering and undressing in public. *Was very agitated upon entering long term care facility, trying to get away from the facility. *Wanderguard bracelet applied. *Special care unit (dementia unit) may be appropriate during times of wandering and increased agitation. *No opening in special care unit at this time. *Behaviors improved at assisted living, but may see increase with transition to long term care. *[MEDICAL CONDITION] present." Interview on 10/5/11 at 8:05 a.m. with the ADON revealed: *Resident 2 had been admitted on [DATE] into the long-term care area despite her significant dementia and wandering. They did not have any open beds on the special care unit. They thought resident 2's dementia and behaviors could be managed in the long term care area. *The provider had placed resident 2 in their special care unit for varied hours during the day and that had seemed to calm resident 2. She usually spent about 12 hours in the unit and would on occasion spend the night there. Resident 2 was placed in a room with another female resident. *She did not think it was more disruptive to resident 2 to keep moving her from her long term care bed to the special care unit bed. *Her behaviors and dementia had started to decline upon admission. *Resident 2's frequent bruises were likely related to her being uncooperative with her care. *They never really identified any specific intervention that had worked to keep resident 2 from injuring herself.