**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (1) observed self-administering a nebulizer (device that converts liquid medication into an inhaled mist) treatment in her room, was assessed for the ability to safely self-administer medications, and had a physician's order to self-administer medications according to the provider's policy. Findings include: 1. Observation and interview on 5/19/25 at 8:38 a.m. with resident 1 in her room revealed: *A nebulizer machine with a disassembled nebulizer mask was on her bedside table. *She stated she administered nebulizer medication treatments multiple times per day. *Nursing staff would bring her the medication, set up the nebulizer administration of the medication, leave her room, and then she would administer the nebulizer treatment to herself. *She stated staff would return to her room after she finished administering the nebulizer treatment. They would rinse out the nebulizer mask and then place it on her bedside table to dry. Observation on 5/19/25 at 11:27 a.m. of resident 1 in her room revealed: *She was sitting alone in her room. *She had her nebulizer mask on her face, the nebulizer machine was running, and medication was being inhaled by resident 1 through the nebulizer mask. *No staff were present in resident 1's room or within an area that enabled staff to visualize her. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 3/14/25 Brief Interview of Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *She had a diagnosis of chronic obstructive pulmonary disease (a group of lung diseases that block airflow and can make it difficult to breathe). *A 10/8/24 physician's order for Ipratropium-Albuterol Inhalation Solution(medication to open airways in the lungs) 0.5-2.5 (3) MG [milligrams]/3ML [milliliters] (Ipratropium-Albuterol) 1 vial inhale orally via neb [nebulizer] four times daily and every 4 hours as needed for Cough. *There was no physician's order for her to self-administer the nebulizer medication. *There was no self-administration of medication assessment completed. *Self-administration of medications was not included in resident 1's 5/19/25 care plan. 2. Interview on 5/20/25 at 4:19 p.m. with Minimum Data Set (MDS) coordinator/infection preventionist C revealed: *She completed the resident assessments quarterly with her MDS submissions, which would include an assessment for self-administration of medications. *She was not aware of any resident at the facility who self-administered medications or had a self-administration of medication assessment completed. *She expected a certified medication aide (CMA) or nurse to remain with a resident who was receiving a nebulizer treatment for the entire time the treatment was being administered if there was no self-administration of medications assessment completed and no physician's order for the resident to self-administer medications. 3. Interview on 5/21/25 at 8:57 a.m. with director of nursing (DON) B revealed: *It was her expectation for the nurse or CMA to remain with a resident while the resident was being administered a nebulizer treatment unless the resident had a self-administration of medications assessment completed and a physician's order to self-administer medications. *Leaving a resident alone while a nebulizer treatment was being administered would mean the resident was self-administering the medication. *Resident 1 did not have a self-administration of medications assessment completed and did not have a physician's order to self-administer medications. 4. Review of the provider's June 2020 Administering Medications procedure revealed the staff member who was administering a medication was to, Remain with the resident until he/she has taken all of his/her medicines. Review of the provider's 2/7/24 Assessment Process for Self-Administration of Medications policy revealed: *An assessment for self-administration of medications will be completed upon admission to the facility if ordered from physician and assessed by an RN [registered nurse]. *The physician will assess and update [the] order for self-administration every three months or earlier if needed. *The assessment will always be reviewed by the interdisciplinary team at every care conference thereafter when the care team reviews the president's [resident's] plan of care. *A Self Administration documentation process will be utilized for residents who do have an order for self-administration of medications in [EMR] as extra documentation that the resident is able to administer medications safely.

Based on personnel file review, interview, and policy review, the provider failed to ensure resident safety by employing one of one certified nursing assistant (CNA) M with a known documented history of abuse as prohibited in a provider's policy. Findings included: 1. Personnel file review on 5/20/25 at 3:37 p.m. of CNA M revealed: *She was hired on 10/28/24. *The facility had completed a background check prior to her hire. -That indicated CNA M was charged in 2018 for emotional/psychological abuse of a disabled adult. -CNA M had pleaded guilty to those charges. 2. Interview on 5/20/25 at 3:49 p.m. with executive director A and social service designee D revealed they: *Were aware of the charges listed on CNA M's background check. *Stated they had discussed those charges with CNA M directly. *Acknowledged that they had not contacted the Board of Nursing regarding the charges in relation to the staff's certification. *Acknowledged that no formal or informal check-ins had been conducted with CNA M since her start date related to her history of abuse. *Both agreed that, in the interest of resident safety, regular check-ins with CNA M should have been implemented from the beginning of her employment. 3. Review of the provider's undated Abuse, Neglect, and Misappropriation of Property Prevention Policy revealed: *Screening: 3. [Provider's name] will not employ or continue to employ, anyone, who has any history of documented patient abuse, neglect, or misappropriation of property.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure the proper Medicare notices were filled out completely and were in the required format for three of three sampled residents (1, 6, and 75) prior to their discharge from Medicare Part A skilled services. Findings include: 1. Review of the Entrance Conference Worksheet completed by the provider on 5/19/25 revealed three residents were identified as having been discharged from Medicare Part A skilled services: *Two of those residents (1 and 6) remained in the facility following their discharge from Medicare Part A skilled services. *One of those residents (75) was discharged home following her discharge from Medicare Part A skilled services. 2. Review of the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123, with a revision date of 12/31/11, for resident 1 completed by executive director (ED) A revealed: *The provider's name, address, and phone number were not listed as required above the title of the form. *The Patient Number filled in by ED A was resident 1's Medicare Beneficiary Identifier (MBI), which was required not to be used. *Resident 1's Medicare Part A Skilled Services Episode start date was 9/22/24. *Her last covered day on Medicare Part A Skilled Service was 11/8/24. *The Effective Date Coverage of Your Current {insert type} Services Will End was completed with the date 9-22-24, which was her admission date. *The first bullet point that explained Your Medicare provider . have determined that Medicare probably will not pay for your current {insert type} services . was not completed with the type of services ending. -The type of services ending should have been identified as skilled nursing. *The How to Ask For an Immediate Appeal section was to provide contact information in the fourth bullet point that indicated to Call your QIO [Quality Improvement Organization] at: {insert QIO name and toll-free number of QIO} to appeal, . was not completed with the name and telephone numbers, including TTY (teletypewriter for people with hearing or speech difficulties) of South Dakota (SD)'s QIO. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE] with Medicare Part A covering her stay. *Her 9/22/24 admission and Medicare five-day Minimum Data Set (MDS) assessment's Medicare number entered at line A0600.B. was the same number listed on her NOMNC form above. *On 11/9/24, after her Medicare Part A stay ended, she remained in the facility as indicated on the Entrance Conference Worksheet. Interview on 5/20/25 at 10:08 a.m. with ED A regarding resident 1's NOMNC form CMS-10123 revealed she: *Had completed and delivered the notice to resident 1 on 11/5/24. *Agreed that the provider's name, address, and phone number had not been provided as required. *Agreed the resident's MBI number had been used on the form, as specifically required not to. *Agreed that the type of services ending was not clearly identified. *Agreed that the QIO's name and toll-free phone number had not been provided as required. 3. Review of resident 6's Medicare notices completed by ED A revealed: *His Medicare Part A Skilled Services Episode start date was 10/25/24. *His last covered day on Medicare Part A Service was 11/21/24. Review of the NOMNC form CMS-10123, with a revision date of 12/31/11, for resident 6 completed by his representative on 11/22/24 revealed: *The provider's name was typed above the form's title. *The provider's address and phone number were not listed as required. *The Patient Number filled in by ED A was resident 6's MBI number, which was required not to be used. *The Effective Date Coverage of Your Current {insert type} Services Will End was completed with the date 10-25-24, which was his admission date. *The type of services ending section was not completed. -The type of services ending should have been identified as skilled nursing. *The How to Ask For an Immediate Appeal section was not completed with the name and telephone numbers of SD's QIO. *The form was signed the day after his Medicare Part A skilled services had ended, which had not met the required two-day notice. Review of resident 6's 2024 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 signed by resident 6's representative on 11/15/24 revealed: *The Reason Medicare May Not Pay section, which required a brief explanation to help understand why Medicare may deny payment, was blank. Review of resident 6's EMR revealed: *He was admitted on [DATE] with Medicare Part A covering his stay. *His 11/1/24 admission and Medicare five-day MDS assessment's Medicare number entered at line A0600.B. was the same number listed on his NOMNC form above. *On 11/22/24, after his Medicare Part A stay ended, he remained in the facility as indicated on the Entrance Conference Worksheet. Interview on 5/20/25 at 10:08 a.m. with ED A regarding resident 6's Medicare notices revealed she: *Had completed and delivered resident 6's SNF ABN notice to his representative on 11/15/24. *Agreed that the SNF ABN form had no reason provided for the Reason Medicare May Not Pay Section. *Had failed to provide resident 6's representative the NOMNC form on 11/15/24 when she delivered the SNF ABN form. As a result, she provided the NOMNC to resident 6 on 11/22/24. She acknowledged that the NOMNC form was delivered late. -She confirmed the NOMNC form was given after his Medicare Part A stay had ended and had not met the required two-day advanced notice. *Agreed that the provider's address and phone number had not been provided as required. *Agreed the resident's MBI number had been used on the form, as specifically required not to. *Agreed that the type of services ending was not clearly identified. *Agreed that the QIO's name and toll-free phone number had not been provided as required. 4. Review of the NOMNC form CMS-10123, with a revision date of 12/31/11, for resident 75 completed by ED A revealed: *Her Medicare Part A Skilled Services Episode start date was 10/3/24. *Her last covered day on Medicare Part A Skilled Service was 12/30/24. *The provider's name was typed above the form's title. *The provider's address and phone number were not listed as required. *The Patient Number filled in by ED A was resident 75's MBI number, which was required not to be used. *The Effective Date Coverage of Your Current {insert type} Services Will End was completed with the date 10-3-24, which was her admission date. *The type of services ending section was not completed. -The type of services ending should have been identified as skilled nursing. *The How to Ask For an Immediate Appeal section was not completed with the name and telephone numbers of SD's QIO. Review of resident 75's EMR revealed: *She was admitted on [DATE] with Medicare Part A covering her stay. *Her 10/10/24 admission and Medicare five-day MDS assessment's Medicare number entered at line A0600.B. was the same number listed on her NOMNC form above. *On 12/31/24, after her Medicare Part A stay ended, she was discharged to her home as indicated on the Entrance Conference Worksheet. Interview on 5/20/25 at 10:08 a.m. with ED A regarding resident 75's NOMNC form CMS-10123 revealed she: *Had completed and delivered the notice to resident 75 on 12/27/24. *Agreed that the provider's address and phone number had not been provided as required. *Agreed the resident's MBI number had been used on the form, as specifically required not to. *Agreed that the type of services ending was not clearly identified. *Agreed that the QIO's name and toll-free phone number had not been provided as required. 5. Interview on 5/20/25 at 10:08 a.m. with ED A revealed she: *Did not have a policy regarding the NOMNC and SNF ABN notices. *Was responsible for completing and providing the beneficiary notifications to residents and/or their representatives. *Had the instruction forms for the NOMNC and SNF ABN forms. *Expected the requirements, guidelines, and instructions for the forms to be followed. *Agreed the form instructions for both the NOMNC and SNF ABN forms stated, The beneficiary's/enrollee's MBI number must not be used. *Confirmed that she had used the residents' MBI numbers when completing the NOMNC forms for the past six years. *Agreed that the NOMNC forms had not clearly identified the type of services that were ending. *Confirmed that SD's QIO name and telephone numbers had not been provided as required on the NOMNC form. *She agreed that after the representative's signature, that rep or representative had not been written next to the signature as the form had instructed. 6. Review of the Form Instructions Skilled Nursing Facility Advanced Beneficiary Notice of Non-coverage (SNFABN) Form CMS-10055 and Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed: *The SNF ABN Form Instructions included: -Completing the SNF ABN indicated in the Reason Medicare May Not Pay section, the SNF must give . a brief explanation of why the beneficiary's medical needs or condition do not meet Medicare coverage guidelines. The reason must be sufficient and specific enough to enable the beneficiary to understand why Medicare may deny payment. -Signature and Date indicated If an authorized representative signs for the patient, write (rep) or (representative) next to the signature. *The NOMNC Form's Instructions included: -When to Deliver the NOMNC .The NOMNC must be delivered at least two calendar days before Medicare-covered services end . -For the Heading Contact information: The name, address and telephone number of the provider that delivers the notice must appear above the title of the form. -For the Patient number: . The beneficiary's/enrollee's MBI number must not be used. -{Insert type}: Insert the kind of service being terminated, i.e., skilled nursing, home health, comprehensive outpatient rehabilitation service, or hospice. -In the section How to Ask For an Immediate Appeal Insert the name and telephone numbers (including TTY) of the applicable QIO in no less than 12-point type.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to ensure four of fourteen sampled residents (3, 6, 11, and 20) with bed rails determined to not be restraints were accurately coded on the Minimum Data Set (MDS) assessments. Findings include: 1. Observation and interview on 5/19/25 at 10:16 a.m. with resident 3 revealed: *She was in her room, sitting in her wheelchair. *An electric list chair was in her room, and half bed rails were on both sides of her bed. *She stated she felt her electric lift chair and bed rails had not restrained her but were a help to her. Review of resident 3's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 4/21/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *She had signed a Side Rails Informed Consent and Release on 9/10/24. *A 10/15/24 physician order stated, May use specialized pull up bar at HOB [head of bed] for bed mobility, repositioning, and getting in/out of bed per resident request. *Her 11/28/24 initial Assistive Device Assessment, and her 1/28/25 and 4/17/25 Assistive Device Assessments all had documentation that indicated: -The bed rails had not been used as a restraint. -Use of . bed rails does not restrict her freedom of movement or normal access to her body. -Bed rails will improve her ability to repo [reposition] self in bed & transfer in/out of bed & provide her with comfort & autonomy . -[Resident 3] is cognitively intact and is able to understand/demonstrate proper use of bedrails . *MDS assessments documented her bed rails in section P Restraints and Alarms as a restraint that was used daily on her: -11/4/24 quarterly review assessment. -1/27/25 annual assessment. -4/21/25 quarterly review assessment. *Her current 5/19/25 care plan indicated the use of her side rails as a support to her care had been initiated on 11/7/24 which included: -Half rails up as per Dr.s [doctor's] order to assist with bed mobility. -Observe for injury or entrapment related to side rail use. -Assess quarterly and with significant changes. 2. Observation on 5/19/25 at 10:30 a.m. of resident 6 in his room revealed: *He was lying on his bed with a blanket over him and his eyes closed. *He did not respond to the knock on his door or verbal greeting. *He had side rails on his bed. Review of resident 6's EMR revealed: *He was admitted on [DATE]. *His 4/13/25 BIMS assessment score was 15, which indicated he was cognitively intact. *He had signed a Side Rails Informed Consent and Release on 9/10/24. *A 10/15/24 physician order stated, May use upper side rail for bed mobility, repositioning, and getting in/out of bed per resident request. *His 11/28/24 initial Assistive Device Assessment, and his 1/15/25 and 4/10/25 Assistive Device Assessments had documentation that indicated: -The bed rails had not been used as a restraint. -Use of . bed rails does not restrict his freedom of movement or normal access to his body. -Bed rails will improve [his] ability to repo [reposition] self in bed & transfer in/out of bed & provide him with comfort & autonomy . -[Resident 6] is cognitively intact and is able to understand/demonstrate proper use of bedrails . *MDS assessments documented his bed rails in section P Restraints and Alarms as a restraint that was used daily on his: -11/1/24 admission assessment following his 10/22/24 to 10/25/24 hospitalization. -1/20/25 quarterly review assessment. -4/14/25 quarterly review assessment. *His current 5/20/25 care plan indicated that the use of his side rails as a support to his care had been initiated on 11/7/24 which included: -I use a side rail to maximize independence with turning and repositioning in bed. -[H]half rails up as per Dr.s order to assist with bed mobility. -Observe for injury or entrapment related to side rail use. 3. Observation on 5/18/25 at 3:37 p.m. of resident 11's room revealed: *She had a lift chair. *Her side rail was not up but was able to be raised and lowered on her bed. Interview on 5/19/25 at 4:00 p.m. with CNA U revealed: *Resident 11 had a side rail affixed to her bed that could be raised and lowered. *Resident 11 used the side rail to help with transfers in and out of bed. Review of resident 11's EMR revealed: *She was admitted on [DATE]. *Her 3/4/25 BIMS assessment score of 15, which indicated she was cognitively intact. *Her care plan indicated she used a side rail to maximize independence with turning and repositioning in bed. *The 2/27/25 Assistive Device Assessment had documentation that indicated: - Bed rails will improve her ability to reposition self in bed and transfer in/out of bed and provider her with comfort & autonomy. A lift chair or recliner w/ [with] foot rest elevated would provide comfort, safety, & prevent skin breakdown by providing pressure relief. -Is able to understand/demonstrate proper use of bedrails, recliner, & [and] lift chair. -Use of a recliner w/ elevated foot rest/lift chair/bed rails does not restrict her freedom of movement or normal access to her body. -No was selected to the question Is the device being used as a restraint? *MDS assessments documented her bed rails in section P Restraint and Alarms as a restraint that was used daily on her: -12/9/24 quarterly review assessment. -3/3/25 quarterly review assessment. 4. Observation and interview on 5/19/25 at 4:12 p.m. with resident 20 in his room revealed: *There was a black P-shaped side rail on the left side of his bed and a lift chair. *He used the side rail to help him move while in bed. *He stated his son had brought the side rail to the facility and installed it on his bed so he could move over in bed without assistance from staff. *He denied the side rail prevented him from getting out of bed and he was able to operate the lift chair without staff assistance. Review of resident 20's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/26/25 Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated he was moderately cognitively impaired. *His power of attorney (POA) had signed Side Rail Informed Consent and Release form on 3/17/25. *His care plan indicated, I use a physician prescribed half bed rail to maximize independence with turning and repositioning in bed. *His 3/14/25 Assistive Device Assessment was signed by MDS coordinator/infection preventionist (IP) C which documented: -Bed rails will improve his ability to repo [reposition] self in bed & transfer in/out of bed & provide him with comfort & autonomy. -Is able to understand/demonstrate proper use of bedrails, recliner w/ elevated foot rest & [and] lift chair. -Use of a recliner w/ elevated foot rest/lift chair/bed rails does not restrict his freedom of movement or normal access to his body. -No was selected to the question Is the device being used as a restraint? *His 3/21/25 admission MDS assessment documented his bed rails in section P Restraint and Alarms as a restraint that was used daily. 5. Interview on 5/20/25 at 4:18 p.m. with MDS Coordinator/IP C regarding coding of physical restraints on the resident's MDS for Physical Restraints revealed: *The Resident Matrix provided to the survey team on 5/18/25 had identified four (3,6, 11, and 20) of the current twenty-two residents who had a physical restraint in use. *Director of nursing (DON) B completed the residents' initial Assistive Device assessments. *MDS Coordinator/IP C completed those assessments quarterly. *She agreed the Assistive Device assessments documented the side rails had not met the regulatory definition of a physical restraint and were not used as restraints. *She agreed she had made mistakes completing the MDS assessments for residents who were using bed rails. *She stated that in her training as a nurse, she had been told that a side rail on a bed was a restraint. That is why she had coded side rails as a restraint on the residents' MDS assessments. Interview on 5/20/25 at 5:15 p.m. with DON B regarding bed rails revealed she: *Had worked at the facility for several years and became DON in September 2024. *Had completed the residents' initial Assistive Device assessments and MDS Coordinator/IP C completed the following quarterly assessments. *Agreed the residents' bed rails above were assessed and determined not to be physical restraints and the coding of them as physical restraints in the MDS assessment had been inaccurate. 6. Review of the provider's November 2024 Assistive Device and Restraints policy revealed: *Purpose: To ensure the appropriate assessment, provisions, and use of assistive devices and physical restraints for residents, promoting their independence, safety, and quality of life, in compliance with CMS [Center for Medicare and Medicaid Services] regulations, South Dakota state laws, and evidence-based practices. *Physical Restraints: Any manual method or physical method of mechanical device, material, or equipment attached to or adjacent to the resident's body that the individual cannot remove easily and which restricts freedom of movement or normal access to one's own body. *Assistive Device: Items used to increase, maintain, or improve functional capabilities, including but not limited to, Geri-chairs, Rock-King Chairs, Bed Rails, Lift Chairs, Reclining Chairs, and Concave Mattresses.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, observation, and policy review, the provider failed to ensure baseline care plans had been completed and a written summary of the baseline care plans had been provided to the resident or their representative for four of four recently admitted sampled residents (3, 19, 20, and 175) within 48 hours of their admission to the facility. Findings include: 1. Interview on 5/19/25 at 10:00 a.m. with resident 3 revealed: *She had admitted to the facility from the provider's assisted living facility last year. *She could not recall if her care needs and services were discussed with her after her admission. *She had not received a summary or paper copy of her baseline care plan or a list of her medications. Review of resident 3's electronic medical record (EMR) revealed: *Her 4/21/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *She was admitted on [DATE]. *There were no progress notes from 2/19/24 to 2/21/24 that addressed her baseline care plan or indicated a baseline care plan had been provided to the resident or her representative. *The first progress note pertaining to care planning was titled Care Conference and dated 2/26/24 admission care conference set for 3/6/2024 at 9:30am with son, [resident 3's son] invited to attend with [resident 3]. *Her Baseline Care Plan assessment, initiated on 2/19/24, was still In Progress in the EMR and included: -Minimum Data Set (MDS) coordinator/infection preventionist (IP) C had signed the assessment on 2/20/24. -Resident 3's representative had signed the assessment on 2/28/24. --That was nine days after resident 3's admission to the facility. Interview on 5/20/25 at 4:55 p.m. with MDS coordinator/IP C regarding resident 3's baseline care plan revealed: *She had signed the resident's Baseline Care Plan assessment. *She agreed the assessment's status was In Progress and had not been locked/completed. -She agreed that resident 3's son had signed the assessment on 2/28/24, nine days after the resident's admission, and that had not met the required time frame. 2. Observation on 5/19/25 at 9:49 a.m. with resident 19 revealed: *He was in bed and his speech was limited. *A hospice registered nurse (RN) was in the room with the resident. -She stated on good days he would give a thumb up or thumb down to communicate. -He had not used his thumbs to communicate that day. Review of resident 19's EMR revealed: *He admitted to the facility on [DATE] on hospice care with the hospice service which provided that care at this home. *His 5/1/25 MDS admission assessment indicated the resident was rarely/never understood and that his cognitive skills for daily decision making was modified independence. *His Baseline Care Plan assessment, initiated on 4/23/25, was still In Progress and had not been finalized in the EMR. -Signatures of Staff Completing the Baseline Care Plan included: --Director of nursing (DON) B had signed the assessment on 4/24/25. --Social service designee D had signed the assessment on 4/28/25, which was four days after his admission and did not meet the 48-hour required timeframe. Surveyor requested to review resident 19's Baseline Care Plan. The provider gave a nine-page paper copy that included resident 19's representative's signature. There was no date that indicated when his representative had received it. 3. Interview on 5/20/25 at 4:55 p.m. with MDS coordinator/IP C revealed: *She or DON B completed the Baseline Care Plan assessments for the residents. *She expected that the residents' Baseline Care Plans be completed within 48 hours of their admission. *She stated that DON B had signed resident 19's Baseline Care Plan. *She acknowledged that completing the baseline care plan and its requirements was an area for improvement. *She agreed that some resident baseline care plans had not been completed within 48 hours of their admission, and the baseline care plans had not been given to the resident or representative as required. Interview 5/20/25 at 5:15 p.m. with DON B regarding resident baseline care plans revealed: *Either she or MDS coordinator/IP C had been completing the Baseline Care Plan assessments. *She had signed resident 19's Baseline Care Plan assessment. *She agreed the assessment's status was In Progress and had not been locked/completed. *She recalled providing the baseline care plan to resident 19's wife but could not remember the date. *She agreed that some of the baseline care plans had not been provided to the family or representative within the required 48-hour timeline. *She agreed they were not consistently meeting the requirements for the baseline care plan. 4. Review of resident 20's EMR revealed: *He was admitted on [DATE]. *His 3/14/25 baseline care plan did not include documentation for, Active diagnoses contributing to admission and resident 20's wishes related to advanced directives and code status. *On 3/14/25 Minimum Data Set (MDS) coordinator/infection preventionist C signed that she had completed the baseline care plan. *Resident 20's power of attorney (POA) signed the baseline care plan, but a date was not documented as to when the baseline care plan was signed. 5. Review of resident 175's EMR revealed: *She was admitted on [DATE]. *Social service designee D signed that she had completed the baseline care plan but did not date when she signed it. *Director of nursing (DON) B signed and dated resident 175's baseline care plan as having been completed on 5/18/25. *Resident 175 signed her baseline care plan on 5/19/25 which did not meet the 48-hour timeframe. 6. Interview on 5/20/25 at 4:19 p.m. with MDS coordinator/infection preventionist C revealed: *She or DON B attempted to complete all residents' admission assessments, but any nurse could have completed them. *Baseline care plans were to be completed on the day of the resident's admission by the nurse who was admitting the resident. *Baseline care plans were to be completed, printed, reviewed with the resident or the resident's representative, and signed after the by the resident or resident representative within 48 hours of admission. *She was aware the baseline care plans had not been completed, reviewed, and signed within the required 48-hour time frame. 7. Review of the provider's October 2021 Care Plan Policy and Procedure revealed: *Care plan will be developed by an interdisciplinary team with participation of the resident, family, and/or representative (when available). *Upon admission,[the] resident will be assessed by the Charge Nurse and a baseline care plan will be developed with information gathered from the resident and [the] resident's family.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to ensure: *A bed rail was properly installed for one of one sampled resident (20). *Entrapment risk was assessed for two of two sampled residents (11 and 20) with bed rails. *There was documented resident-specific risk versus benefits education provided for the informed consent for use of bed rails for two of two sampled residents (11 and 20). *Alternatives were attempted and documented prior to the installation of bed rails for two of two sampled residents (11 and 20). *There was routine maintenance of the bed rails for two of two sampled residents (11 and 20). Findings include: 1. Observation on 5/19/25 at 8:37 a.m. of resident 20's room revealed there was a black P-shaped bed rail on the left side of his bed. Observation and interview on 5/19/25 at 4:12 p.m. with resident 20 in his room revealed: *He used the bed rail to help him move while in bed. *He stated his son had brought the bed rail to the facility and installed it on his bed. *The semi-circular opening to the P-shaped black bed rail (zone 1) measured eleven inches by five inches. -The opening in the bed rail was large enough for a body part to become entrapped and had potential for injury. *The bed rail lifted the mattress and bed springs when it was pulled away from the bed. *When the bed rail was pulled toward the foot of the bed it tilted approximately four inches from its resting position. *The bed rail was affixed to a wooden board which was secured to the bed frame and springs with a black strap. *The black strap was crossed over the board and around the bed springs. Review of resident 20's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/26/25 Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated he was moderately cognitively impaired. *He had a diagnosis of Parkinson's disease (a disorder of the central nervous system that affects movement). *His care plan indicated, I use a physician prescribed half bed rail to maximize independence with turning and repositioning in bed. -It did not include which side of the bed the bed rail was on or what type of bed rail it was. *His 3/14/25 Assistive Device Assessment indicated the bed rails were used to improve his ability to repo [reposition] self in bed & [and] transfer in/out of bed & provide him with comfort & autonomy. -A physical therapy or occupational therapy consult was not obtained. -There was no documentation that indicated entrapment risk was assessed, or alternatives were attempted prior to the installation of the bed rails. *The risk versus benefits documented on the Side Rail Informed Consent and Release were not specific to resident 20's needs and risk factors such as his cognition and his Parkinson's diagnosis. 2. Observation and interview on 5/19/25 at 5:01 p.m. with director of nursing (DON) B in resident 20's room revealed: *The P shaped bed rail was brought in by resident 20's family. *She thought the facility's maintenance department staff had installed the side rail. *She agreed the opening within the side rail was large enough for a head or body part to become entrapped, the side rail was not secure, and it was a safety risk for the resident. 3. Interview on 5/20/25 at 9:15 a.m. with maintenance supervisor G revealed: *Resident 20's family had brought in the bed rail and installed it on the resident's bed. *He did not complete assessments for potential risk of entrapment related to bed rails. *There was no scheduled routine maintenance on the residents' beds or side rails. *It was his expectation that housekeeping staff would notify him if they identified an issue with a bed or side rail. 4. Interview on 5/20/25 at 10:25 a.m. with housekeeping laundry supervisor F revealed: *He expected the housekeepers to notify maintenance if an issue with a bed or bed rail was identified. *Housekeeping was not responsible for ensuring correct installation and maintenance of the side rails. 5. Interview on 5/20/25 at 10:54 a.m. with certified nursing assistant (CNA) N revealed: *Resident 20 used his side rail to sit up and scoot forward while he was in bed. *She did not feel the opening in resident 20's side rail was a safety risk for him, but did state there were other residents who had poor cognition that wandered into other resident rooms, and she felt the size of the opening on the bed rail may be a safety risk for those residents. *She verified resident 20's bed was an adjustable bed. *She stated she would notify the charge nurse and maintenance if she identified a loose bed rail or a bed rail in need of repair. 6. Review of resident 11's EMR revealed: *She was admitted on [DATE]. *She had a 3/4/25 BIMS assessment score of 15, which indicated she was cognitively intact. *Her diagnoses were lack of coordination, muscle weakness, and dementia. *Her care plan indicated she used a bed rail to maximize independence with turning and repositioning in bed. -It did not include which side of the bed the bed rail was on. *The 2/27/25 Assistive Device Assessment indicated, Bed rails will improve her ability to reposition self in bed and transfer in/out of bed and provide her with comfort & autonomy. -It did not include documentation of education provided, alternative attempted, or an assessment for risk of entrapment. *The risk versus benefits documented on her 9/10/24 Side Rail Informed Consent and Release were not specific to resident 11's needs and risk factors such as her lack of coordination and muscle weakness. 7. Interview on 5/19/25 at 4:00 p.m. with CNA U revealed: *Resident 11 had a bed rail affixed to her bed that could be raised and lowered. *Resident 11 used the bed rail to help with transfers in and out of bed. 8. Interview on 5/20/25 at 4:19 p.m. with Minimum Data Set (MDS) coordinator/infection preventionist (IP) C revealed: *DON B completed the Assistive Device Assessments on admission, and MDS coordinator/IP C completed them quarterly, annually, and with a significant change with the resident's MDS assessment. *If a bed rail was requested for a resident MDS coordinator/IP C would notify DON B of the request. DON B would complete the Assistive Device Assessment, obtain consent from the resident or resident representative, and get an order from the resident's physician for the use of bed rails. *There was no process in place to assess for a resident's entrapment risk. *There was a place on the Assistive Device Assessment to document education provided related to the assistive device, but she did not provide that education quarterly to the residents or representatives. *Alternatives attempted prior to the installation of a bed rail were not documented. *She was not aware of any alternatives that were attempted prior to the installation of the bed rails for residents. *All the bed rails in the facility, besides resident 20's, were affixed to the beds. *There was no process in place to determine if a bed rail was installed and functioning properly. 9. Interview on 5/21/25 at 8:57 a.m. with DON B revealed: *There were no documented alternative attempted prior to the installation of a bed rail documented in the residents' records. *The facility attempted to consult the therapy department prior to the installation of bed rails related to services the therapy department may be able to provide for the resident, and the resident's ability to properly use a bed rail, but that was not documented in the resident's EMR. *The risks versus benefits included on the Side Rails informed Consent and Release was not individualized to each resident's unique needs and risk factors. *The facility did not assess the resident's risk for entrapment related to the use of bed rails. *The facility did not complete and document scheduled maintenance to the resident beds or bed rails as was indicated in the provider's policy. *Manufacturers' recommendations and specifications were not followed with the application of resident 20's bed rail. *She verified resident 20's bed rail was not installed properly, was not secure, and it was a safety risk related to potential entrapment. 10. Review of the provider's undated manufacturer's instructions for the Stander bed rail revealed: *There is a risk of entrapment associated with all bed rails and other similar bedside mobility aides. *Entrapment can result in serious injury and death. *BEFORE INSTALLING THIS PRODUCT, YOU MUST ENSURE THAT IT IS SAFE TO USE ON YOUR BED AND MATTRESS. *Failure to properly install and use these components [clamps, safety straps, and other means] significantly increases the risk of entrapment. *DO NOT use on adjustable beds. *If this product is used in a nursing home, assisted living center, or a similar facility, follow these instructions and all of the institution's Bed Rail/Handle installation policies. If this product does not comply with those installation policies, do not install this product. *ENTRAPMENT ZONES - Zone 1: Within the Rail- Any open space between the perimeters of the rail can present a risk of head entrapment. The FDA [Food and Drug Administration] recommended space is less than 4.75 in [inches]. *If the safety strap provided is not properly secured, the product may move into an unsafe position which increases the danger of entrapment. See enclosed ASSEMBLY INSTRUCTIONS for proper use of the straps. *ASSEMBLY INSTRUCTIONS -Extend both straps (C) below mattress to the opposite side of bed. Unbuckle strap and wrap one end between mattress and BED FRAME (or board) and re-buckle strap. 11. Review of the provider's undated Resident LTC [long term care] Bed Service Manual revealed: *Use only accessories specifically identified for use with the Resident LTC bed. The use of accessories not identified for this bed could compromise the safety of the bed. *Use only Hill-Rom parts and accessories. Do not modify the bed without authorization from Hill-Rom. *Perform preventative maintenance annually to ensure all bed features are functioning as originally designed. Pay particular attention to safety features regarding the Resident LTC bed including but not limited to: -Siderail latching mechanism. 12. Review of the provider's November 2024 Assistive Device and Restraints policy revealed: *Purpose: To ensure the appropriate assessment, provisions, and use of assistive devices and physical restraints for residents, promoting their independence, safety, and quality of life, in compliance with CMS [Center for Medicare and Medicaid Services] regulations, South Dakota state laws, and evidence-based practices. *Assistive Device: Items used to increase, maintain, or improve functional capabilities, including but not limited to, Geri-chairs, Rock-King Chairs, Bed Rails, Lift Chairs, Reclining Chairs, and Concave Mattresses. *Our facility is committed to providing residents with access to assistive devices as part of their individualized care plans. These devices must be safe, functional, and appropriate for the resident's clinical and functional needs. *Assistive Devices -1. The Assistive Device Assessment in [EMR] will be completed upon admission, quarterly with MDS, with a significant change in condition, or upon request to determine the appropriateness and continued appropriateness of devices based on the resident's physical and cognitive abilities. -2. The assessment will be reviewed by the Interdisciplinary Team, Resident/Representative, and Physician. -3. Resident/Representative will be informed of appropriate devices and receive education and training on proper use of device if utilized. -4. Resident/Representative consent, education, and justification/functional need for device will be documented within the Assistive Device Assessment in [the EMR]. -5. Any assistive device utilized will be added to the resident's care plan. *Bed Rails: Resident/Representative will review and sign the Bed Rail Informed Consent and Release form to provide education regarding safety, risks, benefits, and use.

2. Interview and observation on 5/19/25 at 9:22 a.m. in resident 5's room revealed: *She had a refrigerator in her room. *There was no temperature log with the refrigerator temperatures posted on or near the refrigerator for May 2025. *There was a thermometer on the inside of the refrigerator door that read 33° Fahrenheit (F). *She stated the refrigerator temperatures were not checked daily by staff. *Her daughter would check the refrigerator every few days when she visited. *The resident would keep her drinks and snacks in the refrigerator, so they were available to her when she wanted them. 3. Observation on 5/20/25 at 10:42 a.m. in resident 5's room of her refrigerator revealed: *The temperature read 32°F. *The top shelf contained the following items: -A 64-ounce plastic bottle of opened prune juice with no open date. -Four 4-ounce opened vanilla pudding cups with no open dates. -One metal Christmas canister with a lid that contained candy. -One small Styrofoam cup with a lid that contained an unidentified liquid that was unlabeled and had not been dated. *The bottom shelf contained the following items: -Three unlabeled plastic bottles that contained a dark liquid and one was wrapped in a plastic bag. 4 Interview and observation on 5/19/25 at 11:19 a.m. in resident 16's room revealed: *She had a refrigerator in her room. *There was no temperature log with the refrigerator temperatures posted on or near the refrigerator for May 2025. *There was a thermometer on the inside of the door that read 48°F. *She stated the refrigerator temperatures were not checked daily by staff. *She stated that she took care of her refrigerator and would clean it as needed. *She stated that she would mainly keep her soda in it. 5. Observation on 5/20/25 at 10:35 a.m. in resident 16's room of her refrigerator revealed: *The temperature read 40°F. *The top shelf contained the following items: -One partially eaten unidentified meat and cheese sandwich stored in a Ziploc bag that was not labeled or dated. *The bottom shelf contained the following items: -One navy blue insulated cup with a lid that contained an unidentified liquid. *The refrigerator door contained a soiled navy-blue washcloth. 4. Observation and interview on 5/18/25 at 3:44 p.m. with resident 12 in her room revealed: *There was a personal refrigerator in her room. *There was no documentation of refrigerator temperatures seen on or near the refrigerator. *She did not think the staff were checking the temperature of her refrigerator. *There had been a piece of paper that the temperatures were documented on when she was admitted to the facility, but that paper was no longer being hung on her refrigerator. *Her refrigerator contained canned unopened beverages and open empty pop bottles in her freezer *She stated when her freezer needed to be defrosted, she would notify a staff member, and the staff would defrost it. 5. Observation and interview on 5/19/25 at 9:19 a.m. with resident 8 in her room revealed: *There was a personal refrigerator in her room. *There was no documentation of refrigerator temperatures seen on or near the refrigerator. *Her daughter had brought in the refrigerator for her to use. *She did not know if staff monitored and documented the temperature of her refrigerator. *The temperature in the refrigerator was 33 degrees Fahrenheit. *She had canned beverages in her refrigerator. *There was a brown dried substance on the lower shelf of the refrigerator. 6. Observation and interview on 5/19/25 at 9:23 a.m. with resident 2 in her room revealed: *There was a personal refrigerator in her room. *There was no documentation of refrigerator temperatures seen on or near the refrigerator. *She did not know if the staff monitored and documented the temperature of her refrigerator. *The temperature of the refrigerator was 35 degrees Fahrenheit. *She stated she used her refrigerator for prepackaged beverages and if her family brought in food for her. 7. Interview and observation on 5/19/25 at 3:44 p.m. with registered nurse (RN) H revealed: *The nurse on the night shift was responsible for checking the temperatures of the personal refrigerators in the resident rooms. *She stated the temperatures were to be documented on a piece of paper on the resident's refrigerator. *She verified there were no forms for documentation on the residents' refrigerators. Interview on 5/19/25 at 3:47 p.m. with director of nursing (DON) B regarding the residents' refrigerators revealed: *Temperatures in residents' personal refrigerators were not being monitored or documented. *Staff previously monitored the temperatures of the personal refrigerators and documented them on paper but had stopped quite a while ago. Interview on 5/20/25 at 2:20 p.m. with food service supervisor E revealed the dietary staff was not responsible for the food or refrigerators in the residents' rooms. An additional interview on 5/21/25 at 8:44 a.m. with FSS E revealed: *She was responsible for the dietary department. *She was not a certified dietary manager (CDM), but stated social service designee (SSD) D was the provider's CDM. *She stated that the two-page 2018 Food Brought in from an Outside Source policy was their current policy and that she had received the policy from their consultant dietitian. *She was aware of the provider's June 2020 Refrigerator Policy. *She stated that the dietary department was not responsible for the residents' personal refrigerators. Interview and policy review on 5/21/25 at 8:55 a.m. with SSD D revealed she: *Was the assistant administrator, responsible for the social services department, and had a 3/17/25 certificate as a CDM. *Stated that during the residents admissions process, residents and family members would ask about personal refrigerators. *Was a resource to FSS E, who was responsible for the provider's dietary department. *Stated the dietary department was responsible for monitoring and recording the temperatures for the refrigerators in the kitchen. *Agreed that the two-page 2018 Food Brought in from an Outside Source policy was their current policy and that she had reviewed it. -She agreed that the staff were not checking food or beverages brought into the facility for resident consumption before being accepted for storage as the policy stated. -She agreed that the staff were not labeling Food or beverages brought in from the outside . with the resident's name, room number and . the current date the item(s) are brought into the facility for storage. -She agreed that staff were not monitoring All cooked or prepared food brought in for a resident and stored in the . personal room refrigerator will be . discarded after 72 hours/3 days. -She agreed that the staff were not following the policy regarding No home-prepared food items that are canned or preserved will be permitted. *Was not aware of the provider's June 2020 Refrigerator Policy and stated it was the first time she had seen that policy. *Had listed the personal refrigerators on each residents' Inventory of Personal Effects form *Thought there were six or seven residents with personal refrigerators in their rooms, but she had not compiled a list of that. *Stated that DON B and the nursing department assisted with monitoring the temperatures of the residents' personal refrigerators. *She had received thermometers last week, which the maintenance staff had placed in the residents' personal refrigerators. Interview on 5/21/25 at 9:37 a.m. with maintenance supervisor G revealed the maintenance staff had checked those personal refrigerators and other electrical appliances (lamps, electric lift chairs, etc.) when family members brought them into the facility. 8. Review of the provider's 2018 Food Brought in from an Outside Source policy revealed: *All food or beverages brought into the Community for resident consumption will be checked by a staff member before being accepted for storage. Any suspicious or obviously contaminated food or beverage will be discarded immediately. *Food or beverages brought in from the outside will be labeled with the resident's name, room number and dated by staff with the current date the item(s) are brought into the facility for storage. *All cooked or prepared food brought in for a resident and stored in the facilities [facility's] refrigerator or personal room refrigerator will be dated with accepted for storage and discarded after 72 hours/3 days. No home-prepared food items that are canned or preserved will be permitted. Review of the provider's June 2020 Refrigerator policy revealed: *The refrigerator must be approved by maintenance to meet state code requirements. *The refrigerator must maintain a safe temperature range of 36-41 degrees Fahrenheit. *The night nurse will monitor and record the temperature reading every night. *All food in the refrigerator will be covered. Once the container is opened, it will be dated and removed in an acceptable time frame. Based on observation, interview, and policy review, the provider failed to ensure: *Safe food storage temperatures were monitored and documented. *Soiled containers were removed, cleaned, or discarded. *Items stored in the refrigerators were approved, dated, and monitored for discarding according to the provider's policy for six of six sampled residents' (2, 3, 5, 8, 12, and 16) with personal refrigerators. Findings include: 1. Observation and interview on 5/19/25 at 10:08 a.m. with resident 3 in her room revealed: *There was a personal refrigerator in her room. *The thermometer in her refrigerator read 34° Fahrenheit (F). *She stated a maintenance staff person had brought in the thermometer a couple days ago. *There was no documentation of the refrigerator temperatures seen on or near the refrigerator. *She stated the staff had not monitored the temperature of her refrigerator. *The inside of her refrigerator contained: -A 16-ounce (oz) container of heavy whipping cream with a best by (BB) date of 7/13/25. -A bowl of strawberries that was not dated. -A glass pint jar of home-canned beets that was not labeled or dated. -A glass jar of Maple Bacon Onion Jam that had been opened but was not dated. -An unopened small glass container of Hot Pepper Jam. -An unopened small glass container of Maine Maple Champagne Mustard. *She stated the strawberries were from the Mother's Day event on Sunday, 5/11/25, which was eight days ago, and she was worried that some of them were turning soft. Review of resident 3's electronic medical record (EMR) on 5/21/25 of her May 2025 Treatment Administration Record (TAR), which included a schedule for Record Temperature of personal refrigerator in resident's room every night shift with a Start Date of 5/19/25 at 1800 (6:00 p.m.) revealed the following recorded temperatures: *42° F on 5/19/25. *37° F on 5/20/25.

Based on observation, interview, and policy review, the provider failed to follow appropriate infection control practices to ensure: *Shared sit-to-stand mechanical lift slings used for three of three residents who required the sit-to-stand mechanical lift for transfers was properly disinfected between resident use. *Personal protective equipment (PPE) was available in one of one soiled utility rooms to prevent infections and cross-contamination when using the hopper to rinse soiled linens. 1. Observation on 5/19/25 at 8:50 a.m. of the soiled utility room revealed: *There was a hopper (a flushing device used to rinse items and linens soiled with bodily fluids) without a barrier to prevent splash contamination to staff who cleaned contaminated linen. *No gown or eye protection was available in the soiled utility room to be worn by staff to prevent contamination of staff clothing while they used the hopper to rinse out soiled linens. 2. Interview on 5/20/25 at 10:54 a.m. with CNA N revealed: *Staff used the hopper in the soiled utility room to rinse out soiled linens prior to sending them to laundry. *She stated she had worn a gown previously to rinse out soiled linens in the hopper. *She verified there were no gowns available inside the soiled utility room and she was unable to identify where the closet gowns were available for staff to use when using the hopper. 3. Observation on 5/19/25 at 8:57 a.m. of CNA N as she exited resident 4's room revealed: *Resident 4 had a sign at her room entrance which indicated she was on enhanced barrier precautions (EBP) (required the use of gown and gloves while providing direct personal cares which included transfers). *CNA N wiped down a cloth-covered sling for the sit-to stand lift with a disinfectant wipe. *The sling was not wet immediately after being wiped down with the disinfectant wipe. -Without the sling remaining wet for the indicated contact time of one minute, per manufacturer's instructions, the sling would not be able to be considered disinfected. *CNA N stated the sit-to-stand lift was used for three people, including resident 4, in the facility. 4. Interview on 5/20/25 at 5:14 p.m. with MDS coordinator/infection preventionist (IP) C revealed: *She was aware the sit-to-stand lifts slings were being shared for use for multiple residents and it was her expectation the slings were being wiped with a disinfectant between uses. *She agreed disinfectant cloth wipes would not be effective in disinfecting the sit-to-stand sling due to it being a cloth material. *She was aware there were no goggles or gowns available in the soiled utility room for staff to wear while rinsing soiled linen which posed a risk for splash contamination. *She knew about the splash and water droplet contamination risk that hoppers could cause but had not thought about having PPE or a splash guard for the hopper to protect staff and items in the soiled utility room from contamination. 5. Interview on 5/21/25 at 8:57 a.m. with director of nursing (DON) B revealed: *It was her expectation that staff would wear personal protective equipment (PPE) if there was a risk of splash contamination. *She agreed the hopper would be an area of risk for splash causing contamination while staff used it to rinse soiled items. *She had not thought about a splash guard or PPE availability inside the soiled utility room for staff use to prevent cross contamination. *It was her expectation that items shared between residents be cleaned and disinfected between use to prevent the spread of infection. *She was aware the slings for the sit to stand were being used between residents and it was her expectation the staff was wiping down the slings between each resident. *She agreed the material of the slings would not make it possible for the contact time to be reached with the disinfectant cloths due to the material absorbing the liquid. -Without the required disinfectant contact time the sling, shared between residents, would not be considered disinfected for the next resident's use. 6. Review of the provider's January 2025 Cleaning and Disinfecting Reusable Medical Equipment policy revealed: *The goal is to minimize the risk of infection and cross-contamination by maintaining high standards of hygiene and following best practice in accordance with current infection control guidelines. *Reusable Medical Equipment: Any equipment or device used on multiple residents that can be cleaned, disinfected, and reused. *Cleaning: The physical removal of dirt, debris, and bodily fluids from surfaces. *Disinfection: The process of using chemicals to kill harmful microorganisms on surfaces of reusable medical equipment. *All reusable medical equipment must be cleaned and disinfected after each use. *Cleaning and Disinfection Procedure: -Wear appropriate personal protective equipment (PPE). Including gloves, mask, and gowns, as required by infection control protocols.

Based on record review, interview, and policy review, the provider failed to follow their policy and facility assessment to ensure an effective training program for one of two contracted (agency) staff (O). Finding included: 1. Review of the provider's 10/18/2024 Employee Orientation & Ongoing Education policy revealed: *Purpose: To assure all new employees, current employees, & volunteers receive the education and information required by federal, state, & facility regulations. *Policy Statements: Orientation Program for All New Employees includes the following: -Watching the Mandatory Extravaganza DVDs: *Disc 1: Mandatory. -Safety First. -Infection Prevention. -Workplace Environment. --Resident Rights and Compliance. *Disc 2: Caregiver. -Resident Care. -Caregiver Well-Being. -Health Conditions. *Handwashing Demonstration *Completing additional information as outlined in the New Employee Orientation Checklist. *Reading and understanding the following documents & policies: -Resident's Rights. -Abuse Prevention and Protection of Resident Rights. -Ethics and Compliance. -Notice of Privacy Acts. *Mandatory annual training for All Personnel includes the following: -Abuse, Neglect, & Misappropriation. -Accident Prevention & Safety Procedures. -Corporate Compliance & Ethics. -Fire, Disaster, & Medical Emergency Preparedness. -HIPAA & Confidentiality. -Nutrition, Hydration, & Dining Experience. -Quality Assurance & Performance Improvement. -Trauma Informed Care. -Advanced Directives. -Care of Residents with Unique Needs. -Dementia Care. -Hospice & End of Life Care. -Infection Control & Disease Prevention. -Resident Rights. -Use of Restraints. *Certified Nursing Assistants will receive an additional 12 hours of education/training determined by our residents' population, unique needs, facility assessment & environment, & staff turnover. 2. Review of certified nursing assistant (CNA) O's education records revealed: *She was hired on 12/14/2024 as a contracted CNA. *Her first scheduled shift to work was on 12/14/2024. *There was no documentation to support that employee O had been trained on all the topics according to the provider's orientation and education policy. 3. Interview on 5/21/25 at 8:16 a.m. with executive director A revealed: *She stated the facility does not have agency staff complete the training topics listed in their policy. *She stated that the contracts received by the agencies were reviewed but the education piece of the contracts was not looked at closely. *Her expectation was for the agency staff's employing company to have had the staff complete the training before the agency staff provided care and services at the facility. *She agreed for the safety of the residents, the agency staff should have had the required training completed according to their policy. 4. Review of the provider's New Employee Orientation Checklist revealed: *Human Resources Representative and/or Specified Department Manager: -Initial each item when completed. --Schedule Date/Time to Watch Orientation Videos. *Business/Administrative Manager. -Ensure Collection and Confirm Completion of All Forms: --Employee Orientation and Education Policy. 5. Review of the provider's January 2025 Facility Assessment revealed: *Individual staff assignment: -We staff according to census and acuity. All staff are oriented to both stations and trained to provide continuity of care for all residents. *Staff training/education and competencies. -All registered nurses (RNs), licensed practical nurses (LPNs), certified medication aides (CMAs), and certified nursing assistants (CNAs) staff are required to complete new hire orientation. -Staff with no experience in long-term care will have longer orientation periods. -Ongoing training/education opportunities are completed initially upon hire and annually. -Staff are assigned to a team leader to train and assist them with resident activities of daily living (ADLs). *Training Topics: (this is not an inclusive list): -Communication, -Resident's rights and facility responsibilities, -Abuse, neglect, and exploitation, -Infection Control, -Culture change, -Identification of resident changes in condition, -Cultural competency, -Person-centered care planning, education of staff and family, -Activities of daily living, -Disaster planning and procedures, -Medication administration, -Measurements, -Resident assessment and examinations, -Caring for persons with Alzheimer's or other dementia, -Specialized care, -Caring for residents with mental and psychosocial disorders, trauma or post-traumatic stress disorder, *Policies and procedures for provision of care. -Our policies and procedures then would be updated to reflect the new requirements to ensure we are meeting the current professional standards of practice.

Based on policy review, observation, record review, and interview, the provider failed to ensure one of one low-temperature dishwasher: *Wash and rinse cycle temperatures were monitored and documented at each meal according to their policy. *Chlorine sanitizer concentration level was monitored and documented at least once per shift according to accepted food safety standards of practice. Findings include: 1. Review of the facility's undated Dish Machine Temperature Log revealed: Policy: Dishwashing staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. Procedure: The director of food and nutrition services will post a log near the dish machine for the staff to document temperatures. 2. Staff will record dish machine temperatures for the wash and rinse cycles at each meal. The director of food and nutrition services will spot check this log to assure temperatures are appropriate and staff is correctly monitoring dish machine temperatures. 2. Observation on 5/18/25 at 3:15 p.m. in the kitchen revealed: *The mechanical dishwashing machine had a label on it that read: -Wash Temperature 120 degrees F [Fahrenheit] minimum. -Rinse Temperature 120 degrees F minimum. *The logs for the dishwasher temperatures for May 2025 were on a clipboard on the wall and included: -Columns to record Wash Temp Rinse Temp Rinse PPM [parts per millimeter] Staff Initials for AM [morning] and PM [evening]. -The AM rinse temperature column had recorded temperatures from 5/1/25 through 5/17/25. --Those temperatures ranged from 120 degrees F to 127 degrees F. *There was no temperatures documented in the PM column. *Review of additional dishwasher temperature logs revealed: -For April 2025: --Columns to record Wash Temp Rinse Temp Rinse PPM Staff Initials for AM and PM. -The AM wash temperature column had recorded temperatures from 4/15/25 through 4/25/25. --Those temperatures ranged from 118 degrees F to 121 degrees F. -The AM rinse temperature column had recorded temperatures from 4/15/25 through 4/30/25. --Those temperatures ranged from 122 degrees F to 124 degrees F. *There was no temperatures documented in the PM column. *At the bottom of the monitoring sheet, it reads, Record dish machine temperatures and sanitizer PPM every AM and PM. 3. Observation and record review on 5/18/25 at 3:25 p.m. in the kitchen revealed: *The dishwasher chlorine sanitizer monitoring sheets had been filled out once a day. -The chlorine sanitizer levels documented were within acceptable standards of practice. -No documentation indicated it was monitored and documentated at least once per shift as required according per standing of practice. 4. Interview on 5/18/25 at 3:35 p.m. with food service supervisor E revealed she: *Had been the kitchen supervisor since 5/12/22. *Confirmed they been monitoring and documenting the dishwasher sanitizer chlorine levels only. *Stated she checked the wash temperatures and rinse temperatures, but had not written them down. -until last month, when the dishwasher vendor's service department informed her, they needed to start documenting the temperatures, but only the rinse temperature. *Agreed if proper sanitization was not followed; it could have caused foodborne illness. *Was unaware the facility's policy had stated the staff would record the wash temperature and rinse temperature of the dishwasher at each meal. *Was unaware she needed to check the dishwasher chlorine levels per shift according to food safety standards of practice. 5. Observation on 5/21/25 at 10:39 a.m. in the kitchen revealed: *The logs for the dishwasher temperatures for May 2025 had been updated to include each meal. *From 5/19/25 through 5/21/25 the dishwasher temperatures ranged from 120 degrees F to 139 degrees F. 6. Interview on 5/20/25 at 4:15 p.m. with executive director A revealed she: *Confirmed no gastrointestinal (GI) outbreak had occurred in the facility *Expected the staff to follow the facility policy for the dishwasher to ensure proper sanitization of the dishes.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) submitted complaint report, record review, observation, interview, and policy review the provider failed to ensure: *One of one sampled resident (3) with a suprapubic catheter was place on enhanced barrier precautions (EBP). *Two of two sampled residents (1 and 2) with multi-drug resistant (MDRO) infections were placed on contact precautions. Findings include: 1. Observation on 12/4/24 at 10:50 a.m. of resident 2's room revealed: *There was no sign that indicated precautions on her door. *Gowns were in a plastic basket hanging on the wall in her room. *Housekeeper G was in the room cleaning with gloves on. She was not wearing a gown. 2. Observation on 12/4/24 at 10:30 a.m. of resident 2's skin in the tub room after her bath was completed revealed: *Licensed practical nurse (LPN) D, certified nursing assistant (CNA) E, and Hospice CNA F were assisting her to get dressed. *They did not wear gowns while they assisted her. *Resident 2 had multiple open, draining wounds on her scalp. *One of those wounds exposed her skull. *She had a dark red discoloration near her tailbone. Review of resident 2's EMR revealed: *She was admitted on [DATE]. *She had diagnoses of basal cell carcinoma (skin cancer) and a history of MRSA. *She was on hospice. *She had open and draining wounds on her scalp that were not covered with a dressing. *Her 12/4/24 care plan did not indicate the need for transmission-based precautions (infection control precautions for residents/patients with a suspected or confirmed infection that requires additional precautions) or EBP. Observation on 12/4/24 at 10:55 a.m. of resident 3's room revealed: *There was no precaution sign on the door. *Gowns were present in a plastic basket hanging on the wall in his room. *The plastic around the gowns had not been opened. Interview on 12/4/24 at 10:55 a.m. with resident 3 revealed. *He had a suprapubic catheter (a tube surgically placed in the bladder through the abdomen to drain urine). *He indicated that staff wore gloves when they provided his care, but only some staff wore a gown. *He indicated staff only wore gowns when they provided his catheter care. Review of resident 3's EMR revealed: *He was admitted on [DATE]. *His 11/7/24 brief interview for mental status (BIMS) of 15 which indicated he was cognitively intact. *He had a suprapubic catheter that was present on admission. *His 12/4/24 care plan did not indicate the need for EBP. Interview on 12/4/24 at 11:35 a.m. with LPN D revealed: *Staff were to use EBP when providing care for any resident with big wounds or devices. *She identified that EBP required staff to wear a gown and gloves when they provided direct cares. -Resident 1 was on precautions because he had wounds to his right lower extremity and was being treated for cellulitis (a bacterial infection of the skin). -Resident 2 was on precautions because she had wounds on her scalp. -Resident 3 was on precautions because he had a suprapubic catheter. Observation on 12/4/24 at 11:45 a.m. revealed: *A sign that indicated EBP had been placed on resident 1's door. *There were no signs on the doors of residents 2 and 3 that indicated precautions were to be used. Review of resident 1's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He had four wounds on his right leg that required daily treatments. *He was on an antibiotic for methicillin resistant staphylococcus aureus (MRSA) (a bacteria that is resistant to many antibiotics). -The antibiotic was started on 11/6/24. *His 12/4/24 care plan identified: -I have chronic wounds to my RLE [right lower extremity] so I require staff to use enhanced barrier precautions. -The goal related to his chronic wounds was I will remain free from s/s [signs and symptoms] of MDROs by the review date.] -The need for EBP was initiated on 4/16/24. Interview on 12/4/24 at 12:30 p.m. with director of nursing (DON) B and minimum data set (MDS) coordinator/infection preventionist C revealed: *There were residents who required EBP. *Staff were made aware of which residents were on EBP by a sign on the door of the resident's room. *Some signs were not on the residents' doors due to maintenance painting the walls. *Signs to educate staff and the public on EBP were at the entrances and by the break room. -Some of those signs were not present due to painting. *Housekeeping had a list of residents on EBP on each cart labeled Gowns needed in these rooms. *EBP and transmission-based precautions should be included in the resident's care plan when indicated. *They would expect staff to wear a gown for more than just catheter cares on resident 3. *Resident 2 had open wounds on her head that were draining. -She refused to have her wounds covered with a dressing. -She had a history of MRSA but her current wounds had not been cultured. *Resident 2 should have been placed on contact precautions related to her current wounds, with a history of MRSA without a current culture. *Resident 1 has chronic (present over an extended period of time) wounds to his leg. *He was on an antibiotic for cellulitis and a diagnosis of MRSA. *Resident 1 should have been placed on contact precautions related to his wounds and a diagnosis of MRSA. Review of the provider's 4/2024 Enhanced Barrier Precaution Policy revealed: *EBP refers to an infection control intervention designed to reduce the transmission of multidrug-resistant organisms [MDRO] that uses targeted gown and gloves use during high contact resident care activities. -High-contact resident care activities include dressing, bathing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use such as catheter care, and wound care for any open skin requiring a dressing. * EBP signs will be placed on resident's door if the resident requires EBP. * EBP will be initiated for resident with any of the following: - Wounds [e.g., chronic wounds such as pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and chronic venous stasis ulcers] and/or indwelling medical devices [e.g., central lines, urinary catheters, feeding tubes, tracheostomy/ventilator tubes] even if the resident is not known to be infected or colonized with a MDRO. *Contact precautions would be used unless/until a specific organism is identified if a resident has a wound or indwelling medical device, and secretions or excretions that are unable to be covered or contained and are not known to be infected or colonized with any MDRO. Review of the provider's 10/2024 Infection Prevention Precautions policy revealed: *Transmission-based precautions should be implemented in addition to standard precautions for residents known or suspected to be infected with pathogens that require additional measures. -Contact Precautions: Used for infections spread by direct or indirect contact. Utilize gloves and gown, and limit resident movement outside of their room. *Isolation precautions should be used In addition to standard and transmission-based precautions, implement the following isolation precautions: -Isolation Signage: Clearly label isolation rooms with appropriate signage indicating required precautions.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), SD DOH complaint intake report review, interview, observation, record review, and policy review, the provider failed to ensure: *Six of twelve severely cognitively impaired sampled residents (1, 2, 3, 4, 5, 6) who had lift recliner chairs in their rooms had been assessed for appropriate use and as potential restraints. * One of three severely cognitively impaired sampled residents (1) who used a specialty wheelchair had been assessed for the appropriate use to determine if it was a potential physical restraint. Findings include: 1. Review of the provider's FRI submitted on date/time revealed: *On 10/20/24 at 5:27 p.m. resident 1 was found on the floor in front of her lift recliner chair with the chair at its highest position. *She had a laceration to her left temple that required ambulance transport to the hospital for stitches. *The final report revealed that Minimum Data Set (MDS) coordinator/infection preventionist C educated nursing staff on the need to ensure that residents who were not cognitively intact cannot have access to their lift recliner chair remote. 2. The SD DOH complaint intake report review revealed concerns regarding: *Lack of safety assessment prior to the use of the lift chair. *The residents who are not cognitively intact cannot have access to their chair remotes as they are possibly restraining residents. 3. Interview on 10/29/24 at 9:04 a.m. with administrator A and director of nursing (DON) B revealed that they did not have a facility policy regarding the assessment of assistive devices to determine if their use would be a restraint. 4. Interview on 10/29/24 at 9:44 a.m. with MDS coordinator/infection preventionist C revealed: *In response to resident 1's 10/20/24 fall from a lift recliner chair with injury, she stated that residents who are not cognitively intact should not have lift recliner chair remotes. *She clarified that residents with severe cognitive impairment should not have lift recliner chair remotes. 5. Observation on 10/28/24 at 4:53 p.m. of resident 1 revealed: *She was seated in her lift recliner chair with the leg rest in the up position. *The chair remote was draped over the arm of the chair and was lying on the floor. *She had a bruise on her left upper temple. 6. Review of resident 1's electronic medical record (EMR) revealed: *Her 8/19/24 Brief Interview for Mental Status (BIMS) assessment score was 3 which indicated she had severe cognitive impairment. *No assistive device assessment had been completed to determine if her lift recliner chair would be considered a restraint. 7. Observation on 10/29/24 at 10:50 a.m. of resident 2's room revealed a lift recliner chair was plugged in with the chair remote in the side pocket of the chair. 8. Review of resident 2's EMR revealed: *Her 10/16/24 BIMS assessment score was 7 which indicated she had severe cognitive impairment. *Her 5/14/24 MDS assessment indicated she was able to stand from a sitting position independently and was able to move from chair to chair independently. *No assistive device assessment had been completed to determine if her lift recliner chair would be considered a restraint. 9. Interview on 10/29/24 at 10:54 a.m. with certified nursing assistant (CNA)/certified medication aide (CMA) D about resident 3 revealed: *She had a lift recliner chair in her room. *She was ambulatory and completed tasks independently. *She was able to operate her chair remote appropriately. 10. Review of resident 3's EMR revealed: *Her 9/10/24 BIMS assessment score was 3 which indicated she had severe cognitive impairment. *No assistive device assessment had been completed to determine if her lift recliner chair would be considered a restraint. 11. Observation on 10/29/24 at 10:50 a.m. of resident 4's room revealed a lift recliner chair was plugged in with the chair remote on the right side draped over the arm of the chair. 12. Review of resident 4's EMR revealed: *His 9/3/24 MDS indicated his cognitive skill for daily decision-making was severely impaired. *No assistive device assessment had been completed to determine if his lift recliner chair would be considered a restraint. 13. Observation on 10/29/24 at 10:50 a.m. of resident 5's room revealed a lift recliner chair was plugged in with the chair remote inside the left armrest. 14. Review of resident 5's EMR revealed: *Her 9/6/24 BIMS assessment score was 5 which indicated she had severe cognitive impairment. *No assistive device assessment had been completed to determine if her lift recliner chair would be considered a restraint. 15. Observation on 10/29/24 at 10:50 a.m. of resident 6's room revealed a lift recliner chair was plugged in with chair remote inside the right chair arm. 16. Interview on 10/29/24 at 11:22 a.m. with CNA E revealed resident 6 was not able to use the chair remote due to his dementia. 17. Review of resident 6's EMR revealed: *His 9/23/24 MDS indicated his cognitive skill for daily decision-making was severely impaired. *No assistive device assessment had been completed to determine if his lift recliner chair would be considered a restraint. 18. Observation on 10/29/24 at 8:25 a.m. of resident 1 revealed she was in the dining room seated in a specialty wheelchair. 19. Interview on 10/29/24 at 9:04 a.m. with administrator A and DON B revealed they had no policy regarding assessing specialty wheelchairs as potential restraints. 20. Interview on 10/29/24 at 12:09 p.m. with MDS coordinator/infection preventionist C revealed: *Three residents (1, 6, 7) were currently using Rock-King X3000 specialty wheelchairs. -Resident 6 was assessed by occupational therapy (OT) for appropriate use of the specialty wheelchair on 2/12/24. -Resident 7 was assessed by OT for appropriate use of the specialty wheelchair on 1/3/24. *There was no assessment or evaluation completed for resident 1's use of the specialty wheelchair. 21. Review of the provider's October 2021 abuse and neglect policy revealed: *[Provider's name] shall ensure that the resident's environment remains as free of accident hazards as possible and that each resident received adequate supervision and assistive devices to prevent accidents. *Accident Hazards are defined as physical features in the facility environment which can endanger a resident's safety, including but not limited to: .physical restraints. *[Provider's name] shall take ongoing steps to identify each resident at risk for accidents and/or falls, and adequately plan care, and implement procedures to prevent accidents, and shall assure that all residents receive a preliminary evaluation with physician's orders for immediate care, which shall be [completed] upon admission. In addition, residents shall receive a complete, comprehensive, accurate, and reproducible assessment of their functional capacity and the degree of accident risks to which each resident's condition places them. This assessment shall be standardized within the facility .

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure a code status (individual desire to resuscitated Full Code with cardiopulmonary (CPR) versus not resuscitated if their heart stopped Do no resuscitate (DNR)) was designated by the resident and/or their representative for two of two sampled residents (10 and 20). Findings include: 1. Review of resident 10's electronic and paper medical record revealed: *She had a durable power of attorney (DPOA) assignment document. *A copy of her [DATE] physician's order summary report from the nursing home provider she was transferred from indicated a do not resuscitate (DNR). *That physician's order was changed to cardiac pulmonary resuscitation (CPR) upon admission. *There was no documentation that resident 10 or her representative had changed her wishes for her code status from the previous nursing home. 2. Review of resident 12's electronic and paper medical record revealed: *There was a DPOA who was her son. *There was no documentation regarding resident 12 or her DPOA choice of a DNR designation. Interview on [DATE] at 10:30 a.m. with social services designee G revealed: *A code status treatment option form was to have been completed when a resident was admitted to the facility. *The treatment option form was given to the resident and/or representative. If a DNR was requested a physician's order was required. *All resident's code status' were reviewed during their quarterly care conferences. *She was not aware residents 10 and 12 had no code status option form completed. Review of the provider's revised [DATE] Advance Directives policy revealed: *Advance directives were defined as preferences regarding treatment options and included, but were not limited to: -Do Not Resuscitate - Indicates that, in case of respiratory or cardiac failure, the resident, legal guardian, healthcare proxy, or representative (sponsor) have directive that no cardiopulmonary resuscitation (CPR) or other life-saving methods are to be used. *Changes to or removals of an advance directive should have been submitted to the administrator. *The director of nursing services would then notify the attending physician of the resident's advance directive. The attending physician would be responsible for issuing appropriate orders that would coincide with the resident's advance directive.

Based on interview, record review, and policy review the provider failed to ensure one of one sampled resident (8) who had a fall with a fracture and transported to an acute care facility was thoroughly investigated and reported to the South Dakota Department of Health (SDDOH). Findings include: 1. Review of resident 8's electronic medical record (EMR) revealed: *She had a witnessed fall on 8/30/23 at 7:07 a.m. *She was seen by the physician nine days after the fall on 9/8/23 and an x-ray revealed a left pelvic fracture. *There was no documentation in the EMR that the fall had been investigated or reported to the SDDOH. Interview on 12/21/23 at 12:10 p.m. with administrator A revealed: *He was aware she had fallen but he was not aware of the pelvic fracture. *He agreed it should have been investigated and reported by the previous director of nursing (DON) to the SDDOH. *The DON was responsible to investigate all incidents. *The DON is responsible to report incidents that met the criteria to the SDDOH as applicable. *The DON employed at that time was no longer employed. Review of the providers undated Fall Prevention Program policy revealed the charge nurse would complete the required healthcare facility event reporting form from the SDDOH and to the local ombudsman. *The nurse initiating the investigation is responsible for the following through with the investigation process and completed the final report within 5 days. All documentation and investigation interviews will be documented on the event reporting form. *Any major incident, event, injury, or any injury of an unknown origin will be reported immediately to the administrator and director of nursing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure the activity coordinator had the ability to develop, implement, supervise, and evaluate a one-to-one activities program for four of four sampled residents (10, 12, 13 and 19) at risk for social isolation. Findings include: 1. Random observations of resident 10 on 12/19/23 from 8:00 a.m. through 5:00 p.m., on 12/20/23 from 8:00 a.m. through 5:00 p.m. and on 12/21/23 from 9:00 a.m. through 10:30 a.m. revealed: *Observations on: -12/19/23 from 8:00 a.m. through 11:50 a.m. she had been assisted out of her bed and into her recliner about 9:30 a.m. She was stayed sitting in her recliner the rest of the morning. During the above time the lights were off in her room and she had her eyes closed. She had a television and a talking book player in her room. -12/19/23 at 2:30 p.m. she was still seated in her recliner. The lights were on and her roommate was in the room seated in her recliner. They both had their eyes closed. -12/19/23 at 5:00 p.m. she was in her bed with the lights off. Her eyes were closed. -12/20/23 at 8:30 a.m. she had been assisted into her recliner. She was eating her breakfast. -12/20/23 at 10:30 a.m. she was still seated in her recliner with her eyes closed. The lights were off in her room. -12/20/23 at 4:00 p.m. she was lying in her bed. There were a group of children singing Christmas carols in the hall outside of her room. -12/21/23 at 9:00 a.m. she was lying in her bed with her eyes closed. The lights were off in her room. -12/21/23 at 10:30 a.m. she was seated in her recliner with her eyes closed. The lights were off in her room. Observation and interview on 12/19/23 at 8:14 a.m. with certified nursing assistant K during and after she had provided personal care and assisted resident 10 from her bed to her recliner revealed: *CNA K only provided information with resident 10 during her personal cares and transfer on what she need to help with or with what was next. *CNA K did not engage resident 10 in any other conversation. *Resident 10 did not like to come out of her room at all. She also does not like to get out of her bed many times. *There was a television and and talking book reader in her room. Neither of those items were offered to be turned on. Review of resident 10's electronic medical record (EMR) revealed: *A 2/14/23 activity assessment. That assessment revealed she: -Participated in one to two activities a week. -Did not like to participate in group activities. -Participated in one-to-one activities. -Required assistance to attend activities. -Preferred to stay in her room and be alone. Will visit with family and friends. -Was blind. *A 11/8/23 activity participation progress note indicated she did not come out for group activities and preferred to stay in her room. She enjoyed word games, trivia, conversing, and nail care. One-to-one visits as the were able during the week, usually three to four times a week. Review of resident 10's 8/23/22 activity care plan revealed: *Need: I am dependent on staff for meeting emotional, intellectual, physical, and social needs d/t [due to] my blindness, inability to walk, feeling tired/having little energy, feeling depressed and sleeping too much. *Goals: I will attend/participate in activities of choice by next review date. -I will maintain involvement in cognitive stimulation, social activities as desired through review date. *Supports: All staff please converse with me while providing care and entering my room. -Honor my choice not to attend activities as I so choose. -I will participate in talking books and the Activity Director will assist me with receiving books from the SD [South Dakota] State Library. Staff will assist me in turning the talking book player on/off. -Invite and assist me to scheduled activities per my interests and choices. However, I choose not to participate in group activities and I prefer to stay in my room; generally in bed. -I will receive 1-1 visits for added stimulation and interaction. -Offer and assist me with turning my TV on. I do like to listen to the music channels at times. 2. Review of resident 12's EMR revealed: *A 3/6/23 activity assessment. That assessment revealed he: -Participated in three-to-five activities a week. -Chose not to participate in group activities. -Participated in one-to-one activities. -Required assistance to attend activities. -Was a passive participant in activities. -Rarely initiated conversations. -Preferred to be out of his room. -Preferred to be with people. -Ambulated with an assistive device. -Had a short attention span. *Activity participation notes since his 3/6/23 activity assessment revealed: -On 5/31/23 In the past seven days. [Resident] has not participated in any activities in the activity room. He has been in the sunroom on occasion and hardly participates in the small group reminiscing activity. He will read something when prompted and watches TV. -A activity note on 10/3/23 included: --Due to [Resident} decline in health and difficulty speaking we try to stimulate him with balloon/ball toss, reality orientation pictures, pet visits, picture books, and we converse with him. --He spends the majority of his time in his room or the Sun Room sleeping, interacting and people watching with residents, visitors, and staff. -On 12/16/23 [Resident] attends very limited activities due to his declining health and inability to speak .We are working on a schedule of 1:1 activities for [resident] that could include: ball toss, picture orientation, and fidget sensory activities. Review of resident 12's last updated 12/18/23 care plan revealed no area for activities were identified. 3. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *There was no activity assessment located in the EMR. *A 11/24/23 activity participation note: [Resident] refuses to come out of her room for activities. But we continue to invite her She is content to stay in her room and has an iPad that she uses to communicate with family & friends. She also plays cards on it. Review of resident 13's 9/12/23 care plan revealed no area for activities were identified. 4. Review of resident 19's EMR revealed: *He was admitted on [DATE]. *An activity admission assessment was completed on 4/25/23 revealed: -He had current interests that included spending time outdoors, watching TV, and conversing with others. -For the question of when he preferred to participate in scheduled activities his answer was none. Review of resident 13's revised 10/10/23 care plan revealed: *Need: The resident has little or no activity involvement r/t [related to] onset of Lewy Body disease [a form of dementia]. *Goal: The resident will participate in activities of choice three times per week. *Supports: Explain to the resident the importance of social interaction, leisure activity time. Encourage the resident's participation by (SPECIFY). The rest of this support had not been completed. -Remind the resident that the resident may leave activities at any time, and is not required to stay for the entire activity. -The resident needs assistance/escort to activity functions. Interview on 12/20/23 at 3:52 p.m. with activity coordinator I revealed she: *Had started in May 2023 and was currently working full-time. *Was in the process of completing the activity coordinator classes. *Was in the process of completing her nursing assistant certification. *Had not completed any activity needs assessments for the residents. *Was not sure how to revise or change a resident's care plan. *Had not completed any one-to-one activity assessments. *Did not think section F on the Minimum Data Set (MDS) was helped provide activities for resident interests and preferences. *Had not updated any care plans. *Did not document in the EMR. *Had some documentation in her book. *Had a activity consultant to assist her with the completion of assessments for the residents. *Had not completed any specific training with the previous activity coordinator. *Had not worked with the MDS coordinator to work on care plans. The MDS coordinator had just started in November 2023. *Did not have any assistance to organize the activity program. *Had a activity assistant who worked full-time. *Had a volunteer that assisted with activities Monday through Thursday from 9:30 a.m. to 3:00 p.m. for both the nursing home and the assisted living residents. Review of the provider's revised 1/2/23 1-1 Programming Policy revealed: *The 1-1 programming is designated for the following resident: 1) the bed fast resident; 2) the resident in isolation; 3) the resident with severe communication problems; 4) the resident who appears unable to cooperate in any group activity and 5) the resident who is severely withdrawn and depressed. *Each 1-1 program must work on a goal in each contact. Each contact should be at least 15 minutes. *All approaches should be based on known interests, lifestyles, and habits. *When charting 1-1 programming; the program, resident response and length of time spent with resident must be charted. *Individualized 1-1 programming must be care planned.

Based on interview, staff schedule review, and payroll record review, the provider failed to ensure a registered nurse (RN) was scheduled for eight consecutive hours for multiple shifts from April 2023 through August 2023. Findings include: 1. Interview and staff schedule review on 12/20/23 at 10:42 a.m. with administrator A regarding RN coverage revealed he: *Had been aware they did not have eight hours of RN coverage seven days per week. *Stated they always had a nurse in the building, but not always an RN on weekends. *Thought there was a document for a certain number of days that waived RN coverage for eight hours per day. 2. Interview, staff schedule review, and payroll record review on 12/20/23 at 2:33 p.m. with administrator A and business manager C revealed: *Business manager C was responsible for filing the payroll-based journal (PBJ) reports. *Business manager C was aware they had not provided eight hours of RN coverage seven days per week. *Payroll records and staff schedule comparisons confirmed no RN coverage for the following: -One of five Sundays in April. -Two of four Saturdays in May. -Three of four Sundays in May. -One of five Mondays in May. -One of five weekends in July. -One of four weekends in August. *Administrator A had taken over the nursing schedule a couple of months ago from the former director of nursing. *It was administrator A's expectation to have met the federal requirements for RN coverage.

Based on observation, interview, and policy review, the provider failed to have a secure system for storing medications that were awaiting destruction in one of one medication storage cupboard. Findings include: 1. Observation on 12/20/23 at 3:30 p.m. of the medication carts, medication room and the cupboards adjacent to the long-term care medication room revealed: *There was a locked cupboard outside of the medication room. -When registered nurse (RN) D was asked about the cupboard she stated it was used to store resident medications that were awaiting destruction. Observation of the contents of the cupboard included eight blister pack cards that had the following medications: *Five of those resident blister pack cards contained non-narcotic medications. *Three of the eight cards contained schedule IV controlled medication (considered high risk for drug diversion). *Resident 28 had one card of nineteen tablets of Alprazolam 0.25 milligram. -Eleven tablets had been removed. *Resident 6 had two cards of Tramadol HCL 50 mg: -One card contained eighteen tablets. --Twelve tablets had been removed. -The second card contained nineteen tablets. --Eleven tablets had been removed. Interview with RN D regarding the security of the medication cupboard revealed: *The cupboard was affixed to the wall. *There was only one lock on the cupboard door. *No locks were used inside the cupboard. *All medications stored for destruction were removed from the medication carts and medication rooms and placed in the cupboard, including controlled substances. *The above blister seal cards had no disposition documentation attached to the card to identify how many tablets were in the card when it was placed in the cupboard. *The medications placed in the cupboard, including the controlled drugs were not being counted after they were placed in the cupboard. *RN D stated there were three keys to the cupboard; Each nurse on duty carried a key while working. The director of nursing also had a key. *RN D confirmed: -The cupboard should have been double-locked if controlled medications were being stored in the cupboard. -There should have been complete documentation of the medication count when the medication was placed in the cupboard for destruction. -The controlled medication in the cupboard was not being counted by the nursing staff between shifts. Interview on 12/21/23 at 12:30 p.m. with DON B confirmed the controlled medication had not been stored securely. Review of the provider's 6/20/20 Storage of Medications revealed all controlled drugs were to have been stored under double-lock and key.

Based on interview, and policy review, the provider failed to ensure all licensed nursing staff [registered nurses (RNs) and licensed practical nurses (LPNs)], unlicensed assistive personnel (UAPs), and certified nursing assistants (CNAs) completed competency evaluations prior to working with residents, and annually. Findings include: 1. Interview on 12/19/23 at 1:00 p.m. with registered nurse RN D and RN E regarding competencies for the RNs and LPNs, UAPs, and CNAs revealed: *A new director of nursing (DON) B had started working approximately one month ago. She asked RN D to put together a competency plan for the CNAs to use in learning and maintaining skills necessary to provide care to the residents. *RN D: -Had been working on the skill sets and they would be completed soon. -Stated the CNAs had not completed any competencies since before the pandemic in 2020. -Was not aware that the competencies were supposed to have occurred before working with residents. *When asked about UAPs receiving medication competencies annually RN D stated she: -She had no part in training the UAPs. -Had not seen any UAP competencies completed since before the pandemic. -Was making a plan for developing a UAP competency skills. *When RN D was questioned about any recent nurse competencies she stated the most recent licensed nurse was at the beginning of the pandemic. -That competency was for hand washing. *RN D stated there were no competencies available for use. 2. Interview on 12/21/23 at 1:00 p.m. with DON B regarding the use of competencies revealed she confirmed the nursing staff, including CNAs and UAPs had not been receiving any competency education. 3. Review of the provider's 5/9/22 Training Requirements for Nursing Assistants revealed the DON or delegated experienced person would have a CNA demonstrate at least five skills and the observer would determine if the demonstration was pass or fail. If the CNA did not meet performance standards, additional education would have been provided and the CNA would demonstrate the skill until performance standards were met. There was no documentation in the above training requirements policy for UAPs or licensed nurses.