**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 (9, 37, and 294) prior to their discharge from Medicare Part A skilled services. Findings include: 1. Review of the Entrance Conference Worksheet completed by the provider on 6/25/25 revealed the list of residents identified as having been discharged from Medicare Part A skilled services included the following: *Two residents (9 and 37) remained in the facility following their discharge from Medicare Part A skilled services. *One resident (294) was discharged to home following his discharge from Medicare Part A skilled services. 2. Review of resident 9's SNF (Skilled Nursing Facility) Beneficiary Notification Review form completed by social services designee (SSD) E revealed: *The resident's Medicare Part A Skilled Services Episode start date was 12/16/24. *Her last covered day on Medicare Part A Service was 1/24/25. Review of resident 9's electronic medical record (EMR) revealed: *She was re-admitted to the facility on [DATE] after a three-day hospital stay with Medicare Part A covering her stay. *On 1/25/25, after her Medicare Part A stay ended, she remained in the facility as indicated on the Entrance Conference Worksheet. *Her 3/9/25 Brief Interview for Mental Status (BIMS) evaluation was scored at seven which indicated she had severe cognitive impairment (a decline in mental abilities including thinking, learning, remembering, and making decisions). 3. Review of resident 294's SNF Beneficiary Notification Review form completed by SSD E revealed: *The resident's Medicare Part A Skilled Services Episode start date was 3/4/25. *His last covered day on Medicare Part A Service was 4/4/25. Review of resident 294's EMR revealed: *He was admitted on [DATE] with Medicare Part A covering his stay. *His 3/6/25 BIMS evaluation was scored at twelve which indicated he was moderately cognitively impaired. *On 4/5/25, after his Medicare Part A stay ended, he was discharged to his home as indicated on the Entrance Conference Worksheet. 4. Review of resident 37's SNF Beneficiary Notification Review form completed by SSD E revealed: *The resident's Medicare Part A Skilled Services Episode start date was 3/26/25. *Her last covered day on Medicare Part A Service was 4/10/25. Review of resident 37's EMR revealed: *She was re-admitted to the facility on [DATE] after a four-day hospital stay with Medicare Part A covering her stay. *On 4/11/25, after her Medicare Part A stay ended, she remained in the facility as indicated on the Entrance Conference Worksheet. *Her 4/11/25 BIMS evaluation was scored at five which indicated she had severe cognitive impairment. 5. Review of the Notice of Medicare Non-Coverage (NOMNC) form CMS-10123, with a revision date of 12/31/11, for residents 9, 37, and 294, completed by SSD E revealed: *The 12/31/11 NOMNC form was outdated and was not the updated form that was required to be used as of 1/1/25, with an expiration date of 11/30/27. *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's (SD) QIO. *The Additional Information (Optional) section indicated SSD E had spoken by phone with the residents' representatives regarding therapy services ending on the actual date Medicare Part A services would end, the reason why Medicare Part A services were ending, and SSD E's signature. *The form indicated on the Signature of Patient or Representative signature line that the residents' representatives had been contacted verbally by a phone call and the date line indicated the date that phone conversation had taken place. -The information provided had not included all of the information required in the 10/31/24 Medicare Claims Processing Manual's Section 260.3.8 - NOMNC Delivery to Representatives Exceptions to in person notice delivery. Review of the 2018 Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (SNF ABN) Form CMS-10055 for resident 9 and 37, completed by SSD E revealed: *The 2018 SNF ABN form was outdated and not the updated 2024 form that was required to be used as of 10/31/24. *The forms indicated the notices had been provided verbally during a phone call to the residents' representatives. 6. Interview on 6/26/25 at 5:08 p.m. with SSD E regarding the above NOMNC forms and SNF ABN forms she had completed revealed she: *Was not aware the forms she had used were outdated and that new, updated forms were required to be used. *Agreed that the type of services ending on the NOMNC forms was not clearly identified. *Agreed that the QIO's name and toll-free phone number had not been provided on the NOMNC forms as required. *Was not aware of the information that was required to be documented on the NOMNC form when a resident's representative was contacted by telephone. *Confirmed she had not filled out the forms completely, according to their instructions. 7. Review of the cms.gov website revealed: *On 8/28/2024: With the help of our contractors, we revised the SNF ABN, Form CMS-10055, and the form instructions. -The SNF ABN form and instructions are located in the download section and are available for immediate use, but will be mandatory for use on 10/31/2024. *On 11/18/2024: New NOMNC and DENC for Original Medicare and Medicare Advantage: -The Office of Management and Budget (OMB) has approved a revised Notice of Medicare Non-Coverage (NOMNC / CMS-10123) . -Please note the updated NOMNC .are to be used for both Original Medicare and Medicare advantage . -Providers must use the revised NOMNC beginning January 1, 2025 . Review of the Form Instructions for the Notice of Medicare Non-Coverage (NOMNC) CMS-10123 revealed: *{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. Review of the 10/31/24 Medicare Claims Processing Manual's Section 260.3.8 - NOMNC Delivery to Representatives Exceptions to in person notice delivery revealed: *The provider must complete the NOMNC as required and telephone the representative at least two days prior to the end of covered services. *The NOMNC must be annotated with the following information on the day that the provider makes telephone contact: -The beneficiary's last day of covered services, and the date when the beneficiary's liability is expected to begin. -The beneficiary's right to appeal a coverage termination decision. -A description of how to request an appeal by a QIO. -The deadline to request a review as well as what to do if the deadline is missed. -The telephone number of the QIO to request the appeal. *Reflect that all of the information indicated above was communicated to the representative. *Note the name of the staff person initiating the contact, the name of the representative contacted by phone, the date and time of the telephone contact, and the telephone number called. *A copy of the annotated NOMNC should be mailed to the representative the day telephone contact is made and a dated copy should be placed in the beneficiary's medical file.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of two certified nursing assistants (CNA) (K) wore appropriate personal protective equipment (PPE) while caring for two sampled residents (22 and 32) who were on enhanced barrier precautions (EBP), which is a type of infection control strategy used in nursing homes to reduce the spread of multidrug-resistant organisms. *One of one CNA (N) practiced appropriate infection control techniques during catheter cares for one of one observed resident (22). *Four of four CNAs (L, M, N, and O) were knowledgeable of the provider's revised catheter care policy and had the skills to implement that policy. *Medical supplies, such as plastic syringes and containers of normal saline found in one of one resident rooms (22) and two of three supply rooms (Rising Sun whirlpool room and the medical supply room), were labeled, stored, and disposed of in an appropriate manner. Findings include: 1. Observation on 6/24/25 at 8:28 a.m. in room [ROOM NUMBER] revealed: *There was a magnet that read EBP at the top of the doorway. *There was PPE hanging on the back of the door. *A poster from the Centers for Disease Control and Prevention (CDC) explaining what EBP was and what direct care staff were required to perform was posted next to the PPE. The poster read: -ENHANCED BARRIER PRECAUTIONS -EVERYONE MUST: --Clean their hands, including before entering and when leaving the room. -PROVIDERS AND STAFF MUST ALSO: --Wear gloves and a gown for the following High-Contact Resident Care Activities. --Dressing --Bathing/Showering --Transferring --Changing Linens --Providing Hygiene --Changing briefs or assisting with toileting --Device care or use: central line, urinary catheter, feeding tube, tracheostomy --Wound Care: any skin opening requiring a dressing. 2. Observation on 6/24/25 at 8:31 a.m. in residents 15 and 22's room revealed: *There was a magnet that read EBP at the top of the doorway. *There was PPE hanging on the back of the door. *There was no EBP poster with instructions for staff as described above. *To the left of the handwashing sink, there was a black plastic trash bag tied to the towel rod. -Approximately three feet of clear plastic tubing was hanging out the trash bag. -There was moisture on the inside of the tubing. -There was a urinary catheter collection bag inside of the trash bag. *To the right of the handwashing sink, there were two black metal storage shelves with personal care products that included: -Two opened containers of normal saline were on each shelf. Neither container was labeled with the date opened or with the resident's initials to identify which resident it belonged to. -One opened plastic package that contained a plastic syringe was on the bottom shelf. Observation on 6/25/25 at 10:23 a.m. in residents 15 and 22's room revealed: *The black plastic trash bag was still tied to the towel rack to the left of the sink. *The catheter tubing was no longer hanging out of the trash bag. *There was moisture buildup on the inside of the catheter collection bag and tubing. Interview on 6/25/25 at 2:50 p.m. with registered nurse (RN) I about resident catheter bags revealed: *He indicated he was a travel nurse and had been working at that facility for four weeks. *Surveyors went with RN I to residents 15 and 22's room to discuss the catheter bag stored there. -It was his understanding that the catheter collection bags should not have been reused. -He indicated that the black plastic trash bag that was tied to the towel rack to the left of the resident's sink contained a urinary catheter collection bag, and it still had traces of urine. -He confirmed that the catheter collection bag was not labeled or dated, and the end of the tube was not capped to protect it from potential contamination. -He confirmed that was not the proper way to store the catheter collection bag. Interview on 6/25/25 at 3:24 p.m. with CNA M about the catheter in residents 15 and 22's room revealed: *CNA M recently passed her CNA certification exam and had been working as a CNA for a couple of weeks. *She confirmed that resident 22 had a suprapubic (SP) catheter and wore a urinary catheter collection bag on her leg (leg bag). *She indicated that she was instructed to keep the leg bag on her leg during the night, rather than switching to a larger bed bag at night. *She confirmed that she also noticed resident 22's urinary catheter collection bag that was in a plastic trash bag and was tied to the towel rack in the resident's room. -She did not know how long that had been stored there like that. Interview on 6/25/25 at 3:35 p.m. with CNA N about catheter care procedures revealed: *Resident 22's leg bag was secured to her right leg during the day. *A bed bag was used to collect urine at night for the resident. *Their normal practice was to rinse and reuse urinary catheter collection bags. -The urinary catheter collection bags were stored in the black plastic garbage bag that was tied to the towel rack in the resident's room. *She explained that a blue solution was used to sanitize the catheter tubing and collection bag. -She did not know what the blue solution was called. -The cleaning solution was supposed to have been stored in the black metal storage shelves located opposite of the towel rack in the resident's room. -She confirmed there was no cleaning solution in resident 22's room. *The blue solution was squeezed through the catheter tubing and into the collection bag. The bag would be filled with about one inch of cleaning solution. -She explained that they allowed the cleaning solution to sit in the collection bag during the day while it was stored in the plastic garbage bag. -The bag was emptied and rinsed with water before switching from one collection bag type to the other. Interview on 6/25/25 at 4:35 p.m. with CNA L about catheter care procedures revealed: *She confirmed that when she helped resident 22 get ready for bed, she would disconnect the resident's leg bag and connect the resident's bed bag for the night. *They stored the bed bag in the black plastic garbage bag that was tied to the towel rack during the day when she was using the leg bag. *The catheter bags they were reusing were cleaned with a liquid in the hopper room (a room where soiled laundry was processed). -She could not find the liquid in the hopper room or in resident 22's room. -She did not know what the liquid was called. -The liquid was bluish-purple in color. Interview on 6/25/25 at 4:48 p.m. with CNA O about catheter care procedures revealed: *She confirmed that residents' urinary catheter leg bags and bed bags were reused. *She would rinse the bags and tubing with water when she changed from one bag to another. -She indicated that she would request other CNAs to clean the catheter tubing and bags because she did not know the procedure for cleaning them. -She had only been a CNA for a few months at the time of the survey. *She did not know what solution was used to clean the catheter tubing and bags. Observation and interview on 6/26/25 at 9:06 a.m. with CNA N while she assisted resident 22 get out of bed revealed: *CNA N confirmed that she and another CNA had assisted the resident to transfer from her bed to her wheelchair. *Resident 22's bed bag was sitting directly on the floor. *CNA N put on a gown, gloves, and a face mask. *CNA N removed a new leg bag from its sterile packaging, uncapped the end of the tubing, and wiped it with an alcohol wipe. -She accidentally touched the resident's leg, the SP catheter tubing, and the bed bag tubing with the end of the new catheter tubing as she struggled to disconnect the bed bag tubing from the SP catheter tubing, potentially contaminating the end of the new catheter tubing. *Once she successfully disconnected the bed bag and connected the leg bag, she brought the bed bag to the bathroom and poured the urine contents into a graduated cylinder (a type of measuring cup) on the floor. She left the graduated cylinder containing urine on the floor in the bathroom, indicating that she would come back after resident 22's shower to clean the cylinder. *She brought the empty bed bag to the sink and said, Where's your garbage bag? -She then grabbed a new black plastic garbage bag and placed the soiled bed bag and tubing inside and tied the garbage bag to the towel rack. *She indicated that she would clean the bed bag after she helped resident 22 take a shower. *She removed her PPE and did not perform hand hygiene before helping resident 22 put her glasses on and brushed her hair out of her face. *She did not perform hand hygiene upon exiting the resident's room. Continued observation and interview on 6/26/25 at 9:46 a.m. with CNA N revealed: *She wanted to correct her comments from the previous day about the catheter cleaning solution. -She learned that the process recently changed to using three parts vinegar to one part water as a cleaning solution. *She went to the medical storage room, grabbed a covered specimen cup and a new plastic syringe, and filled the cup about three-fourths of the way with vinegar. *She brought those supplies to resident 22's room. *Upon entering the room, it was discovered that the graduated cylinder containing urine was no longer there. She stated that someone else must have emptied the cylinder. *She filled the specimen cup of vinegar with water until it was full. *After squeezing the vinegar-water solution through the catheter tubing and into the collection bag, she explained that the new policy was to swish the solution around in the bag and empty it. They were no longer supposed to leave the cleaning solution in the bag throughout the day or overnight. *After pouring the contents of the catheter bag into the toilet, she wiped the end of the catheter tubing with an alcohol wipe and placed it back into the same potentially soiled garbage bag that it had been stored in before she cleaned it. *She stated she sometimes changed the resident's catheter bag to a new one on the resident's bath days, and it was changed at least monthly. Interview on 6/26/25 at 10:39 a.m. with Minimum Data Set (MDS) coordinator/infection preventionist C and director of nursing (DON) B revealed: *It was their expectation that residents' catheter bags should not have been directly on the floor to protect them from potential damage and contamination. *If the insertion tube on a catheter was potentially contaminated by touching other objects, it was their expectation that it should have been sanitized with an alcohol wipe before inserting it into the resident's SP catheter tube. *It was their expectation that staff should have cleaned the SP catheter tube after disconnecting the old collection tube. *They had not used the blue cleaning solution for cleaning catheter bags in a long time. -DON B indicated that she had been working at the facility for one and a half years and they had always used the vinegar solution to clean the catheter bags. *The management team had recently been updating policies and they implemented a new catheter care policy the previous week. -They placed the new policies in the policy binder at the nurse's station on Monday 6/23/25. -They informed staff to review the new policies both verbally and via a sign by the staff's clock-in station. -Once staff reviewed the new policies, they should have signed a piece of paper in the policy binder indicating that they reviewed the policies. *They recently started completing nursing staff competencies in April 2025 by recommendation of their nurse consultant. -Their first nursing staff competency was focused on peri cares (the hygiene and cleaning of the perineal area, which includes the genitals and anal area) due to the high rate of urinary tract infections amongst residents. *They expected staff to drape the catheter bag and tubing over the towel rack to drain and dry and place a bin beneath to catch any liquids draining from the bag. -They indicated that placing the catheter bag into the black plastic garbage bags for storage when not in use was acceptable for dignity purposes, if that still allowed for adequate draining and drying of the catheter bag. *They expected staff to perform hand hygiene before putting on PPE, and after taking off PPE. *Staff should have been dating and labeling the resident's products like the containers of normal saline, and staff should not be reusing plastic syringes. -DON B confirmed that staff used the containers of normal saline to flush the resident's SP catheter. -DON B discarded the opened and unlabeled containers of normal saline and the open syringe package from resident 22's room at that time. *When they were informed that CNA N had made a three-parts vinegar to one-part water solution rather than the three-parts water to one-part vinegar solution as their new policy stated, they did not have any comments. Interview on 6/26/25 at 4:33 p.m. with MDS coordinator/infection preventionist C revealed: *When asked how they ensured staff were aware of and educated on new policies and procedures, she repeated that they placed the policies in the policy binder, staff were to review it and sign it, and if they had questions, they were to find one of the nurse managers. *They review policies at all-staff meetings. Review of resident 22's electronic medical record revealed: *There were no physician's orders describing when the resident's urinary catheter collection bag should have been changed, such as changing the leg bag to a bed bag at night. *She had the following physician's orders: -Flush catheter every night at bedtime and as needed with 60mL [milliliters] saline or sterile water. as needed for catheter [maintenance]. Ordered and started on 3/27/25. -Flush catheter every night at bedtime and as needed with 60mL saline or sterile water. at bedtime for catheter maintenance. Ordered on 3/27/25. Started on 3/28/25. *Her suprapubic catheter was last changed on 6/10/25. *Her care plan did not include directions for when the urinary catheter collection bags should have been changed, such as changing the bed bag to a leg bag during the day. *Her care plan included the following interventions: -EBP are used for high contact cares such as transfers, catheter cares, showers. Initiated on 6/10/25. -Perform catheter cares per facility policy. Initiated on 6/10/25. -Please use enhanced barrier precautions when caring for me. Initiated on 6/1/25. -PPE for enhanced barrier precautions is only necessary for performing high-contact care activities such as transfers, peri cares, dressing, and bathing. Initiated on 6/1/25. Review of the provider's 6/19/25 Changing the Urinary Collection System revealed: *Policy: The urinary collection system shall be changed at the time of a new catheter insertion per provider order or as needed based on clinical assessment (e.g., visible damage, leakage, or malfunction). Aseptic technique must be maintained throughout the procedure to preserve the integrity of the closed urinary drainage system and minimize infection risk. *Required Supplies -Clean non-sterile gloves -Alcohol swabs -Barrier (e.g., disposable pad or paper towel) -Graduated cylinder (for measuring urine) -New sterile urinary drainage bag/system *Procedure -1. Preparation -- .b. Perform hand hygiene. --c. Gather all required supplies and place a barrier on the working surface. -2. Apply Gloves and Empty Current System --a. [NAME] [Put on] clean gloves. --b. Place the graduated cylinder below the drainage spout and empty the contents of the current urinary drainage bag. --c. Record the amount and appearance of the urine per facility protocol. -3. Setup of New System --a. Open packaging of the new sterile urinary drainage bag/system, maintaining sterility of the connection port. -4. Disconnection and Cleaning --a. Clamp the catheter (if applicable per manufacturer guidance) to prevent leakage. --b. Disconnect the old urinary drainage bag from the catheter tubing. --c. Discard the old system appropriately. --d. Using an alcohol swab, cleanse the catheter tubing connection site thoroughly. -5. Connecting New Drainage System --a. Remove the protective cap from the new drainage tubing, being careful not to contaminate it. --b. Immediately connect the sterile tubing to the catheter. --c. Unclamp the catheter to allow drainage to resume. --d. Secure the drainage bag to the bed frame or mobility device, keeping it below the level of the bladder to maintain gravity drainage. Ensure there are no kinks in the tubing. -6. Completion --a. Dispose of gloves and used materials in accordance with facility policy. --b. Perform hand hygiene. -7. Documentation: Document the following in the resident's medical record: --Date and time of the urinary drainage system change --Reason for the change (e.g., routine with catheter replacement, damaged bag) Review of the provider's 6/19/25 Urinary Bag Cleaning & Storage policy revealed: *Policy: Urinary bags to be properly cleaned and stored between use. *Purpose: -1. Maintain asepsis of urinary catheter bags. -2. To prevent introduction of micro-organisms into the urinary drainage system. -3. To prevent urinary tract infections. *Equipment needed: -1. Alcohol Swabs -2. Vinegar solution (3:1 ratio of water to vinegar) - stored in oxygen room -3. Specimen Cup- Stored in the resident room, changed every 3 months with supplies. -4. Graduated cylinder -5. Clean Gloves -6. Paper Towels -for barrier -7. Clean plastic bag- if transport is necessary *Procedure: -1. Preparation -- .Prepare a cleaning solution using three parts water to one part vinegar in a clean specimen cup. - .5. Attach New Bag --Attach a clean urinary drainage bag to the catheter tubing. Label bag with resident initials and room number. -6. Clean Used Bag --Take the used bag to the designated sink. --With the draining port open, flush the bag and tubing thoroughly with the vinegar solution. --Allow excess liquid to drain fully. -7. Hand Hygiene --Remove gloves and perform hand hygiene. *Storage Instructions for Cleaned Urinary Bags -Hang the clean urinary bag on the towel rack near the sink. -Place a basin (labeled with resident initials/room number & urinary drainage basin) below the urinary bag lined with clean paper towels beneath to absorb residual moisture. -Replace paper towels after each cleaning. Review of the provider's Education Signature Sheet that was located at the front of the policy binder at the nurse's station revealed: *Education: Updated Policies/Procedures 6/23/25 *Only two people had signed that they had reviewed the updated policies by the end of the survey on 6/26/25. *CNAs L, M, N, and O had not signed the sheet, indicating they had reviewed the policies. 3. Observation on 6/24/25 at 8:49 a.m. in the whirlpool room on the Rising Sun hallway revealed: *The room appeared to have been used as a storage room. *There was a package of wet wipes that was open to air sitting on the edge of the handwashing sink. It was not labeled with which resident it belonged to. *An opened bottle of barrier cream was sitting on the sink that was not labeled for a specific resident. *There was an unidentified dried brown substance on the faucet handles. *On the shelving unit, there was a bin labeled [hospice provider's name] Hospice Extra Supplies that contained: -One bottle of hand sanitizer that had an expiration date of 08/22. There was an unknown dried brown substance smeared on the bottom of the bottle. -One opened bottle of baby powder that was not labeled for a specific resident. Observation on 6/25/25 at 4:00 p.m. in the medical supply room on the Rising Sun hallway revealed the following expired supply items: *Two Dover brand silicone two-way hemostatic catheters with expiration dates of 1/9/25. *Approximately 25 Cure brand male catheters with expiration dates of 3/28/25. *One package of Tri-Flo Suction Cath-N-Glove catheter kit with an expiration date of 2/8/25. 4. Observation on 6/25/25 at 11:44 a.m. of CNA K assisting resident 32 to transfer from her recliner to her wheelchair revealed CNA K: *Confirmed that resident 32 was on EBP for the opened wounds on her bottom. *Explained that the resident would often remove the bandages from her wounds. *Did not put on a protective gown before helping resident 32 stand up from the recliner and pivot to her wheelchair. *Put on a protective gown before taking the resident to the bathroom. -While in the bathroom, CNA K confirmed the resident had taken her bandage off of the wounds. *Did not offer hand hygiene for resident 32 after she brought her out of the bathroom. Interview on 6/25/25 at 12:00 p.m. with CNA K about the above observation revealed: *She confirmed she was aware of what EBP was and the need for using PPE when assisting those residents with care. *She confirmed she had not put on PPE for transferring resident 32 from her recliner to her wheelchair. -She thought if resident 32 was dry and had not been incontinent, she was not required to put on the protective gown before transferring her. *She indicated that the EBP poster was supposed to be on the back of the resident's door that explained what staff were supposed to do. -She could not find the EBP poster in resident 32's room. -She showed the surveyors the EBP poster in resident room [ROOM NUMBER]. *When she read on the poster that staff were supposed to wear a gown during transfers, she said, My bad. Review of resident 32's care plan revealed she had the following interventions: * .Please use enhanced barrier precautions when caring for me. EBP are used for high contact cares such as transfers, catheter cares, showers. Initiated on 6/8/25. Revised on 6/25/25. *PPE for enhanced barrier precautions is only necessary for performing high-contact care activities such as transfers, peri cares, dressing, and bathing. Initiated on 6/10/25. B. Based on policy review and interview, the provider failed to ensure the infection prevention and control program (IPCP) had policies and procedures that described as required the following areas: -A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility -When and to whom possible incidents of communicable disease or infections should be reported. -The duration of isolation precautions. -A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. -The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. -A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. Findings include: 1. At the start of the survey on 6/23/25, the survey team was provided with a DOH Survey Binder that contained items requested from the entrance conference that was conducted at 8:18 a.m. with administrator A and DON B. *The survey team requested to review the provider's infection prevention and control program policies and procedures. *Three different policies were provided titled Infection Prevention Precautions Policy, Infection Control, and Antibiotic Stewardship Program. 2. Review of the provided policies did not address, describe, or explain the following: *A system of infection surveillance. *A system for recording incidents and the corrective actions taken. *When and whom to report communicable diseases to. *Under what circumstances the facility must prohibit employees with communicable diseases from direct contact with residents or their food. *The duration of isolation precautions. *An explanation that isolation precautions should be the least restrictive possible for residents. 3. Interview on 6/26/25 at 2:36 p.m. with administrator A and DON B revealed: *They confirmed they did not have a policy on reportable diseases. -She explained that they used the South Dakota Department of Health's Reportable Diseases list for that. 4. Interview on 6/26/25 at 4:08 p.m. with MDS coordinator/infection preventionist C revealed: *She confirmed they did not have a policy on reportable diseases. *She indicated that their chosen clinical laboratory was required to report diseases on the Reportable Disease list, so they did not report the required reportable diseases, such as syphilis. *When asked about the missing policies above, she was able to describe actions that addressed the requirements, but confirmed they did not have written policies or procedures for those areas. -For example, when asked about how they identified staff with communicable diseases and prohibited them from direct contact with residents and their food, she indicated that staff would contact their direct supervisor if they did not feel well, and sometimes requested them to come in to be assessed by a nurse or required a doctor's note. 5. Review of the provider's 6/19/25 Infection Prevention Precautions Policy revealed: *The policy described standard precautions, airborne precautions, contact precautions, and droplet precautions. *The policy did not describe the duration of the isolation, depending upon the infectious agent or organism involved, and a requirement that the isolation should be the least restrictive possible for the resident under the circumstances. 6. Review of the provider's 6/19/25 Infection Control policy revealed: *The policy described the following topics: -Standard precautions. -Staff training requirements. -Hand hygiene. -Glove use. -Different types of PPE and when to use each type. -Handling of resident care equipment. -Cleaning of environmental surfaces. -Handling and transporting linens. -Needle safety. -Aseptic techniques when handling injection equipment. 7. Review of the provider's January 2025 Antibiotic Stewardship Program revealed: *There was a section for Reporting and Surveillance that included -a. Report all infections to the Infection Preventionist or designee. -b. Monitor infection rates and trends by surveillance. -c. Investigate outbreaks and take the necessary corrective actions.

Based on interview, record review, policy review, and review of the South Dakota Department of Health (SD DOH) facility reported incident (FRI), the provider failed to ensure a controlled medication (medication with potential for abuse and addiction) for one of one sampled resident (41) had remained secured and was accounted for. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Interview on 1/16/25 at 8:40 a.m. with registered nurse (RN) D regarding resident narcotic medication counting at the end of her shift revealed: *She had counted the resident narcotics when she had arrived to begin her shift on 11/23/24 6:00 a.m. with no discrepancy identified. *RN D did not count the resident narcotics with licensed practical nurse (LPN) R at the end of her shift on 11/23/24 at 6:30 p.m. *RN D had not left her shift and not counted resident narcotics before 11/23/24 at 6:30 p.m. *LPN R refused to do the narc count until RN D insisted on it. *She had been notified on 11/24/24 at 6:25 a.m. by administrator A to return to work and help locate the morphine sulfate (a controlled pain medication) liquid that had been missing. *RN D had called LPN R on 11/24/24 at 7:00 a.m. and LPN R had already left the facility without locating the missing medication. 2. Interview on 1/16/25 at 10:30 a.m. with nurse manager C regarding the missing morphine sulfate revealed: *She had been notified on 11/24/24 that six milliliters (ml) of morphine sulfate liquid had not been accounted for. *Nurse manager C had been working with the pharmacy to complete the investigation of the missing medication and staff education that had been completed on 12/19/24. *LPN R had been instructed to stay at the facility until RN D arrived to help locate the missing medication. *She had not thought that the missing medication would have been considered theft until the pharmacy had informed her that the missing medication was theft. 3. Interview on 1/16/25 at 11:50 a.m. with pharmacist T regarding the missing medication revealed: *He had been informed on 11/24/24 of the missing six ml of morphine sulfate. *Pharmacist T had been involved with the investigation of the missing medication. *He had helped with providing education to staff regarding medication safety, procedures and regulations. 4. Review of the controlled drug receipt/record/disposition form for resident 41's liquid morphine sulfate revealed the last dose of morphine sulfate had been administered on 11/16/24 at 5:00 a.m. with six ml remaining in the bottle. 5. Review of the provider's undated Narcotic Count Policy revealed: *Narcotics will be counted by licensed nursing personnel to assure they are properly accounted for at the beginning and ending of each shift. *The ongoing and off going nurse at shift change will perform a physical count of the narcotic drawer. 6. The provider implemented changes to ensure the deficient practice does not recur was confirmed on 1/16/25 after record review revealed the facility had followed their quality assurance process, education was provided to all staff who were approved to administer medication regarding the regulations for controlled substances, that a system to account for controlled medication is in place and followed, receipt and disposition of medication, a shift-to-shift controlled medication count is completed by the appropriate staff to ensure accurate reconciliation of medications on hand, interviews revealed staff understood the education provided regarding those topics, and observation of controlled medication count compared to the medication supply on hand was accurate. Based on the above information, non-compliance at F602 occurred on 11/24/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 1/16/25, the non-compliance is considered past non-compliance. Review of education provided on 12/19/24 to all staff that administer medication revealed: *Regulations for controlled substances require facilities have a system to account for controlled medication, receipt and disposition in sufficient detail to ensure accurate reconciliation. *A shift-to-shift count is required to pass responsibility and accountability of controlled medication. Education was provided on 12/19/24 to all staff that administer medication regarding controlled medication regulations and accountability of those medications, including liquid medications. 7. Education was provided on 12/19/24 to all staff that administer medication regarding controlled medication regulations and accountability of those medications, including liquid medications.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review the provider failed to report the missing controlled medication (medications with potential for abuse and addiction) had been reported timely to SD DOH. Findings include: 1. Review of the provider's 12/4/24 SD DOH FRI revealed on 11/24/24 six milliliters (ml) of morphine sulfate (a controlled pain medication) had been unaccounted for. 2. Interview on 1/16/25 at 11:28 a.m. with nurse manager C regarding the reporting the missing controlled medication revealed: *She had not known the timeline requirement for reporting the missing controlled medication to SD DOH. *She had not known that the missing medication could be considered theft of personal belongings. *She had known that she had not followed the facility's policy for reporting the potential diversion of a controlled substance. *On 11/25/24 she had begun the paperwork the pharmacy had provided her for drug diversion. *The pharmacy had informed her that it was a misappropriation of a personal item on 12/4/24. 3. Interview on 1/16/25 at 12:16 p.m. with administrator A regarding the reporting of the missing controlled medication revealed: *She had not been aware of the timeline for reporting missing medication to the SD DOH. *Administrator A agreed that she had not followed their policy for reporting the potential diversion of a controlled substance. Review of the provider's undated Reporting and Investigating Diversion of Controlled Substances Policy revealed: *The investigation will be conducted with the assistance of human resources and will be completed within 48 hours of the incident's discovery. *Severity of the theft or loss must be evaluated when considering reporting. *Agencies to whom narcotic thefts may be reported include local office of [NAME] licensing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the provider failed to ensure one of one sampled resident (24) had been monitored for consistent weight loss. Findings include: 1. Observation on 1/15/24 from 12:00 p.m. through 12:35 p.m. of the lunch meal service revealed: *Resident 24 was seated in her wheelchair at a table. *An empty chair was between her and another resident. *Certified Nursing Assistant (CNA) G sat in the chair and assisted to resident to her left. *At 12:02 p.m. CNA Q brought her meal, and cut her burger in half, told the resident she had a cheeseburger and fries. *Resident 24 did not respond to the CNA. *At 12:06 p.m. CNA G reminded the resident that she had a burger and fries. *She made several attempts to pick up her burger and was able to take a small bite. *CNA G assisted her in eating several bites of fruit fluff. *At 12:25 p.m. CNA G left the table and began helping other residents leave the dining room. *At 12:33 p.m. CNA H walked up to the table and said [resident's name], are you awake? -CNA H did not encourage her to eat or assist her with eating. *At 12:35 p.m. the resident pushed herself away from the table. -She consumed approximately one-quarter of the cheeseburger, no fries, approximately 3 oz. of fruit fluff, and 2 oz. of the red liquid which was identified by CNA G as Boost. [supplement] -No documentation of her consumption was made in the EMR. 2. Interview on 1/16/25 at 10:30 a.m. with CNA G revealed that resident 24 had refused breakfast. *Interview on 1/16/25 at 10:50 a.m. with Nurse Manager C revealed: *She agreed that nutrition was addressed in multiple places in the resident's care plan. -She would expect all meal consumption for resident 24 to be documented. -She was unaware that there was no documentation for many meals. _She was unaware that there was no documentation for any evening meals this month. -The residents' meal percentage consumed should be recorded by dietary staff if the resident eats in the dining room and by CNA if the resident eats in their room. -The resident had been sleeping a lot in the last few months and missing a lot of meals in the dining room. *She was unaware that meal consumption was not being regularly recorded for resident 24. *The management team would meet every morning at 10:00 a.m. and discusses resident information including weight. -Weights were to be obtained weekly on bath day. -Weight loss should have been brought to the attention of the charge nurse. -She was unaware that resident 24 had flagged for weight loss on her past seven of the past weekly weights. -She stated that they had a hard time with CNAs obtaining accurate weights. 3. Review of resident 24's electronic medical record (EMR) revealed: *She was admitted to the facility on [DATE]. -She has an indwelling catheter that was present on her admission. *She had a Brief Interview for Mental Status (BIMS) assessment score of 7 on 11/13/24, indicating severe cognitive impairment. *Was to receive a regular diet. *Her current care plan included: -She needed supervision or touching assistance by 1 staff member when eating. -A 5/8/24 initiated and 1/14/25 revised focus area that indicated she had a functional abilities performance deficit. -EATING: I need supervision or touching assistance by 1 staff member for eating. *An initiated 5/8/24 focus area of congestive heart failure, Encourage adequate nutrition. Offer small frequent feedings. -Monitor/document for s/sx [signs/symptoms] of malnutrition. Do not force me to eat. Offer small frequent feedings. Monitor/document food preferences. -An initiated 5/8/24, revised 5/17/24, focus area of I have peripheral vascular disease, Encourage good nutrition and hydration. -An initiated 5/10/24, revised 8/7/24, focus area of I have a potential nutritional problem r/t hx (related to history] of dementia and CHF [congestive heart failure]. -Initiated 5/8/24, revised 5/17/24, focus area of I have potential to have impairment of skin integrity, Encourage good nutrition and hydration in order to promote healthier skin. *On 1/6/25, Registered Dietician Licensed Nutritionist (RDLN) S entered a nutrition note in the EMR that indicated: -Weight down 5# x 1 mo. (4%). -down 13# x 3 mo. (10.8%). -down 10# x 6 mo. (8.3:%). -Indicates a significant weight loss over past 3 months. -Resident is assisted with meals. -Consider need for appetite stimulant. -Encourage meal intake. *Resident 24's meal documentation was incomplete in the EMR (electronic medical record): -From 1/3/25 to 1/15/25, there were 39 meals served. -A total of 25 meals showed documentation. -There was no documentation of any evening meal consumed. -7 of 25 meals were marked as 0-25% of meal eaten. -Her meal consumption recorded on 1/15/2025 at 10:05 a.m. was 51-75%. -According to the task list report in the EMR, the schedule for nutrition recording was every day at 09:00 a.m., 13:00 p.m., and 18:00 p.m. -The CNAs and Dietary Aides were responsible for the nutrition recording. *No hydration documentation was recorded in the EMR. -A task to record supplemental fluids was added to the EMR on 1/15/24, to be completed three times a day by a dietary aide or a CNA. *No update to the care plan had been made addressing resident's weight loss of greater that 10%.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review the provider failed to adequately implement and monitor an effective antibiotic stewardship program. Findings include: 1. Observation and interview on 1/14/25 at 8:26 a.m. of resident 10 in room [ROOM NUMBER] revealed: *She was sitting in her recliner working with an occupational therapist. *Her goal was to get stronger and go to assisted living. *She had been in the hospital recently for an infection. Review of resident 10's EMR revealed: *She was admitted on [DATE]. *Her diagnoses were: -Chronic kidney disease, stage four. -Type two diabetes mellitus without complications. -Retention of urine, unspecified. -History of urinary tract infection. *Her 1/14/25 revised care plan had an intervention to monitor for signs and symptoms of infection, UTI (urinary tract infection) initiated on 3/27/24. *She had orders for antibiotics to treat a UTI on 8/20/24, 8/21/24, 9/9/24, 10/21/24, 11/19/24, 12/6/24, and 12/16/24. Interview on 1/15/25 at 3:29 p.m. with minimum data set (MDS)/director of nursing (DON) B revealed: *She is the infection preventionist. *She presented a spreadsheet of the infections in the facility as her antibiotic stewardship tracking. *She stated that the infections each month are discussed at QAPI (quality assurance and performance improvement). *A PIP (performance improvement plan) has been developed related to urinary tract infections in the facility. *Management was auditing resident fluid intake, staff rounding on residents every two hours, and wiping from front to back when staff was performing genital hygiene. *Management had done hand hygiene audits in the past. *Staff was not obtaining an order each time a urine dip was completed. *It was her expectation that staff document the reason for completing a urine dip or getting a UA. *She expected a nurse's note to be entered into the resident's EMR that indicated what the staff was doing and why. *She did not believe that staff were using a form, such as a SBAR (situation, background, assessment, recommendation) to determine if a urine dip or UA is indicated. *She believed that there was an SBAR form available on the computer. -The SBAR form she located was for Skin/Soft Tissue. *She indicated she believed a form such as an SBAR form would be helpful in the decision-making process for the nurses. *She is responsible for follow-up of UA and urine culture (UC) results. *After the urine culture is resulted, she waits for the provider to either write an order to continue the antibiotic or stop the antibiotic. *Lab sends the results of the UA and UC to the facility and the results are scanned into the resident EMR. *She was unable to locate a UC result in resident 11's EMR for a UTI diagnosis and treatment on 1/16/24. *The provider does not get results of chest x-rays when residents go to the clinic and are diagnosed with pneumonia. Interview on 1/16/25 at 10:05 a.m. with CNA G regarding resident 10's chronic UTIs revealed: *She had been instructed to watch for changes in her behavior that would indicate a UTI. *She would report any changes to the charge nurse. *If a UTI was suspected they would put a hat in her toilet to collect a urine sample. Interview on 1/16/25 at 10:21 a.m. with registered nurse (RN) D revealed: *If the nurse suspected a resident had a urinary tract infection (UTI) the nurse would complete a urine dip test. *If the urine dip was positive the primary care provider would be faxed with the resident's signs and symptoms and a request to collect a urine sample for a urinalysis. *The urine would then be sent to lab for evaluation. *The lab would send the results of the urinalysis to the facility and the primary care provider would decide if treatment was necessary. *An order for the urine dip was not obtained prior to completing the urine dip test. *She was under the understanding since she was hired that there was an understanding with medical director U that a urine dip test could be performed with any signs and symptoms of a UTI. *Symptoms she would consider to be signs of a UTI included: urine with a strong odor, frequency of urination, pain, burning with urination, and with certain residents behavior changes. *She did not enter a progress note in a resident's chart if she completed a urine dip test or the reasoning the urine dip test was completed. *She would enter a progress note in the resident's chart when she faxed for the UA, the results are returned, and when the family was notified of the treatment. *When asked about documentation of the urinalysis completed on resident 11 in January 2025. RN D stated she was asked by resident 11's family to contact hospice to obtain a UA order. She agreed there was no documentation in the resident's chart that indicated the family requested the UA and any communication with hospice or the reason the UA was requested by family. Review of resident 11's hospice note revealed a UA was being obtained by SNF (skilled nursing facility) for symptoms if a UTI. Review of the Infection Prevention spread sheets revealed: *There were five UTIs (four residents) and two cellulitis (skin infection) (one resident) treated in August 2024. *There were seven UTIs (five residents) treated in September 2024. *There were six UTIs (four residents) and two cellulitis treated in October 2024. *There were two UTIs, two cellulitis, and two respiratory infections treated in November 2024. *There were three UTIs, and four pneumonias (three residents) treated in December 2024. *From August through December there were six residents that were prescribed antibiotics more than one time. Review of the provider's 2024 Infection Control and Prevention policy revealed: *The infection preventionist is responsible for Systemic data collection to identify, trend and track infection in residents. *The facility will work to optimize the treatment of infections while reducing the adverse events associated with antibiotic use. *Antibiotic use will be tracked and reported monthly. -Number of resident prescribed antibiotics. -Number and type of infections---trends and outbreak control if applicable. -Number of lab proof of infections versus those without. -Number of residents with C. [Clostridium] Difficile, antibiotic resistant organisms or adverse drug events.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for: *Three of three sampled residents (4, 9 and 34) who had fallen. *One of one sampled resident (7) who had a facility acquired pressure ulcer. *One of one sampled resident (10) who had a history of urinary tract infections. *One of one sampled resident (11) who developed a facility acquired pressure sore. *One of one sampled resident (29) who had attempted to leave the facility without staff knowledge. Findings include: 1. Review of resident 34's electronic medical record (EMR) revealed: *She had fallen on 8/25/24, 10/12/24, and 12/28/24. *On 12/28/24 resident 34 had an injury after her she fell and required a laceration repair above her left eye in the emergency room. *On 8/14/24 the care plan had identified her as at risk for falls. Interventions on the 8/14/24 initiated care plan included a physical therapy evaluation to treat as needed and to follow the facility's fall protocol. Interview on 1/15/25 at 2:00 p.m. with Minimum Data Set (MDS)/director of nursing (DON) B regarding interventions for resident 34 due to her falls revealed: *She had an intervention for physical therapy (PT) to evaluate and treat as ordered initiated on 8/14/24. *MDS/DON B stated that the facility's fall protocol was the same as their fall policy. 2. Observation and interview on 1/14/25 at 8:26 a.m. of resident 10 while in her room revealed: *She was sitting in her recliner working with an occupational therapist. *Her goal was to get stronger and go to assisted living. *She had been in the hospital recently for an infection. Review of resident 10's EMR revealed: *She was admitted on [DATE]. *Her diagnoses included: -Chronic kidney disease, stage four. -Type two diabetes mellitus without complications. -Retention of urine, unspecified. -History of urinary tract infection. *Her 1/14/25 revised care plan had an intervention to monitor for signs and symptoms of infection, UTI (urinary tract infection) initiated on 3/27/24. *She had orders for antibiotics to treat a UTI on 8/20/24, 8/21/24, 9/9/24, 10/21/24, 11/19/24, 12/6/24, and 12/16/24. *No updates to the care plan were implemented regarding resident 10's UTIs since 3/27/24. Interview on 1/16/25 at 10:05 a.m. with CNA G regarding resident 10's UTIs revealed: *She had been instructed to watch for changes in her behavior that would indicate a UTI. *She would report any changes to the charge nurse. *If a UTI was suspected they would put a hat in her toilet to collect a urine sample. *She did not have access to the residents' care plans. Interview on 1/16/25 at 1:05 p.m. with MDS/DON B regarding resident 10's care plan revealed: *The interdisciplinary team would review resident care plans and make changes as needed. *If changes were made that information was communicated to staff in the pocket care plans (a print out of residents' basic needs for staff to follow). *It was her expectation the care plans would be updated with any significant health issues that would arise. *She agreed resident 10's care plan should have been updated to reflect her care needs related to UTIs. 3. Review of resident 29's electronic medical record (EMR) revealed: *She had opened the front door and started to exit the facility on 12/14/24 at 3:35 p.m. -Alarms sounded and alerted the staff. -She was observed by registered nurse (RN) D standing in the doorway with her walker. -She had been assisted back into the building by RN D. -Her vital signs were taken, were within normal limit, and were documented. *The incident was documented in her chart. -Her family, provider, nurse manager C, and administrator A were notified. *The Elopement Risk Tool completed by RN D on 12/14/24 at 3:50 p.m. -Identified resident 29 was at risk for elopement *Her diagnoses included: -Vascular dementia (brain damage caused by multiple strokes) with psychotic disturbance. -Adjustment disorder. -Weakness. -Hypertension. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12 which indicated she had moderate cognitive impairment. -There was an order dated 12/31/24 to switch out monitors twice daily to recharge for safety monitoring. *Her care plan did not indicate she was at risk for elopement. -No interventions were indicated on her care plan following the above attempted elopement incident on 12/14/24. Interview on 1/15/25 at 2:17 p.m. with registered nurse D revealed: *She had started 30-minute visual checks on resident 29 following the above attempted elopement. -They continued those checks for 24 hours. -Then hourly visual checks were completed during the day. -From 8:00 p.m. to 8:00 a.m. she would have been on 30-minute visual checks. *She completed the Elopement Risk Tool on 12/14/24. -That identified resident 29 as at risk for elopement. *Care plans were to be updated by MDS/DON B. *She was unsure if a tile alarm device was used on resident 29 following the incident. Interview on 1/15/25 at 3:00 p.m. with MDS/DON B revealed: *Regarding resident 29's elopement risk they would have considered her behaviors not the score on the assessment. *On 10/18/24 her elopement risk score was 10, and she was not considered an elopement risk at that time. *The elopement risk assessment score of 25 completed on 12/14/24, identified her as at risk for elopement. *She agreed resident 29's care plan should have been updated after interventions were initiated. *Nurse manager C and administrator A would decide on the use of tile device alarms. As an elopement prevention intervention. *She agreed resident 29's care plan had not been updated to following the above attempted elopement or any interventions put in place. Interview on 1/15/25 at 3:00 p.m. with administrator A and nurse manager C revealed: *Resident 29 had used a tile device following the above incident on 12/14/24. -Her family had approved and consented to the use of the device. *They would have expected the care plan to have been updated following the elopement. *Elopement education was provided to staff following resident 29's elopement on 12/14/24. *Behavioral health had recommended memory care placement for resident 29. 4. Observation on 1/14/24 at 9:09 a.m. with resident 4 in the dining room revealed: *She was seated in her wheelchair. *She had an electronic monitoring device on her wrist. Review of resident 4's electronic medical record (EMR) revealed: *She was admitted on [DATE] *She had a Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated she was moderately cognitively impaired. *Her diagnoses included cellulitis, dementia, and bulbous pemphigoid (an autoimmune disease that causes skin blisters). *She had fallen on 8/9/24, 8/13/24, 8/14/24, 8/15/24, 8/28/24, 9/9/24, 10/10/24, 10/11/24, 10/13/24, and 12/18/24. *She had an electronic monitoring device on her wrist that would alarm to alert staff of position changes as a fall prevention. *There was no documentation of interventions in her care plan that addressed fall prevention since her admit date on 5/23/24. 5. Observation and interview on 1/14/24 at 10:35 a.m. with resident 9 in her room revealed: *She was seated in her wheelchair listening to an audiobook. *She had a full body mechanical lift sling underneath her. *She had recently fallen. *She used her walker for transfer assistance before she had fractured her ankle. *She was transferred with the use of a full body mechanical lift and the assistance of two staff. Review of resident 9's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 11, which indicated she was moderately cognitively impaired. *Her diagnoses included chronic obstructive pulmonary disease, Parkinson's disease, and hypertension. *She had fallen on 10/27/24, 10/28/24, 11/3/24, 12/9/24, 12/19/24, 12/20/24, and 12/22/24. *There was no documentation of interventions in her care plan that addressed fall prevention since her admit date on 2/14/24. Interview on 1/15/25 at 1:01 p.m. with registered nurse (RN) D revealed: *MDS/DON B updated the residents' care plans and the pocket care plans. *Hired agency workers and staff referred to the pocket care plans to help care for residents' needs. Interview on 1/15/25 at 3:28 p.m. with MDS/DON B regarding resident care plans revealed: *She updated the resident's care plans and pocket care plans. *She stated the care plans should be updated when a new intervention was added for a resident. *She confirmed that residents 4 and 9 did not have new interventions documented on their care plans after their fall incidents. *She confirmed the care plans should be updated to provide appropriate care for the residents' needs. Interview on 1/16/25 at 8:32 a.m. with nurse manager C regarding resident care plans revealed: *DON B was responsible for updating residents care plans. *The interdisciplinary team (IDT) would meet daily at 10 a.m. to review resident falls that occurred during the night and discuss interventions to implement. *Her expectation was that DON B would update and document the interventions in the residents' care plans after the IDT meetings. *She was not aware that fall interventions were not documented for residents 4 and 9 in their care plans. *She had the capability to update the pocket care plans if it was needed. 6. Observation and interview on 1/14/24 at 9:02 a.m. with resident 7 revealed: *There were two cushions in her wheelchair. *The top cushion was a waffle cushion that covered the bottom and back of the wheelchair. *The cushion under the waffle cushion was a Roho cushion (air cushion that helps distribute weight evenly to prevent pressure ulcers). *The Roho cushion was not inflated. *Resident 7 transferred herself to her recliner. *There was no cushion in the recliner. *Resident 7 stated that her daughter brought her the waffle cushion for her comfort. *She did not remember if she had any sores or skin problems. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 12/7/24 brief interview for mental status (BIMS) assessment was 12, which indicated moderate cognitive impairment. *Her diagnoses included dementia, repeated falls, and weakness. *She had a stage II pressure ulcer (a shallow open ulcer that resulted due to pressure) identified on 11/16/24. *The stage II pressure was documented as healed on 12/6/24. *She was prescribed mirtazapine with an Indication for Use: antidepressant. *She did not have a diagnosis of depression. Review of resident 7's 1/14/25 care plan revealed: *She had a focus area of I have the potential to have impairment to skin integrity which was initiated on 5/30/24 and updated on 6/3/24. *The use of the ROHO cushion or the waffle cushion was not included in the care plan. *A focus area of I have a potential nutritional problem r/t [related to] hx [history] of CHF [congestive heart failure]; COPD [chronic obstructive pulmonary disease] and recent hip fracture with repair initiated on 7/8/24 included an intervention of Resident with stage II wound to left hip. Dislikes supplements. Will offer extra 1 oz [ounce] of protein with meals to aid in wound healing that was initiated on 12/6/24. *A focus area of, I use antidepressant medication (mirtazapine) and interventions to: -Administer ANTIDEPRESSANT medication as ordered by physician. Monitor/document side effects and effectiveness Q-SHIFT. -Monitor/document/report PRN [as needed] adverse reactions to ANTIDEPRESSANT therapy: change in behavior/mood/cognition; hallucinations/delusions; social isolation, suicidal thoughts, withdrawal; decline in ADL [activities of daily living] ability, continence, no voiding; constipation, fecal impaction, diarrhea; gait changes, rigid muscles, balance probs [problems], movement problems, tremors, muscle cramps, falls; dizziness/vertigo; fatigue, insomnia; appetite loss, wt [weight] loss, n/v [nausea/vomiting], dry mouth, dry eyes 7. Observation and interview on 1/14/25 at 9:20 a.m. with resident 11 revealed: *She was admitted to the facility after she fell and broke her hip. *She stated she was mixed up. *During the conversation resident 11 spoke with her eyes closed. Review of resident 11's EMR revealed: *She was admitted on [DATE]. *Her 10/7/24 BIMS assessment was 10, which indicated moderate cognitive impairment. *Her diagnoses included: weakness, hallucinations, generalized anxiety, and dementia with psychotic disturbance. *She was prescribed: -lorazepam 0.5 mg (milligrams) every four hours as needed for anxiety or restlessness. -olanzapine 5 mg two times per day related to dementia with psychotic disturbance. Review of resident 11's care plan revealed: *A focus area of, I use psychotropic medications (olanzapine) with interventions to: -Administer PSYCHOTROPIC medications as ordered by physician. Monitor for side effects and effectiveness Q-SHIFT. -Monitor/document/report PRN adverse reactions to PSYCHOTROPIC medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person. *Lorazepam or interventions to monitor for adverse effects was not referenced in resident 11's care plan. *Non-phamalogical interventions relating to her hallucinations, anxiety, or psychotic disturbance, was not addressed in resident 11's care plan. Interview on 1/15/25 at 3:28 p.m. with MDS/DON B revealed: *She expected staff to follow the interventions on the residents' care plans. *She was responsible for updating resident care plans. *Care plan were to be updated when there were changes in resident care. *She agreed that resident 7's care plan was not updated to include her facility-acquired pressure ulcer. Interview on 1/16/25 at 8:34 a.m. with nurse manager C revealed: *She expected resident care plans to be updated to include pressure-reduction devices. *She believed that the staff knew how to access resident care plans. Interview on 1/16/25 at 10:21 a.m. with registered nurse (RN) D revealed: *She had access to view resident care plans. *She was not able to edit the care plans. *Therapy [physical and occupational] was to be initiated for residents with pressure ulcers. *If therapy placed ROHO cushions in residents' chairs they were to inform MDS/DON B to update the care plans. *Nurse manager C worked with the pharmacist on the psychotropic medications. *The charge nurse did not chart the side effects and effectiveness of the psychotropic and antidepressant medications. Review of provider's 3/2024 Care Planning Process Policy revealed: *Using an intradisciplinary approach, each resident will have an individualized plan of care which addresses the resident's needs and severity of condition, impairment, disability, or disease and based on the universal care standards identified by the DNRC staff as the minimum standards for all residents. *It is the responsibility of the IDT members to access the resident, individualize the plan of care, evaluate the effectiveness and the plan of care, revise the plan of care as the resident's needs change and attend care conferences. Review of the provider's undated Fall Policy revealed: *A licensed nurse will update the care plan to reflect interventions instituted to prevent further falls. *The resident's fall will be discussed with interdisciplinary team as soon as possible after the falls to determine new interventions to try.

Based on observation, interview, and policy review the provider failed to ensure chemicals had not been stored under sinks in four of four rooms and were secured per their written instructions. Findings include: 1. Observation on 1/14/25 at 8:36 a.m. of the Garden Terrace hopper room revealed: *The Garden Terrace hopper room was not locked. *Under the sink was a brown wood cabinet with a lock present on the door. *The door was not locked. *This cabinet contained: -A spray bottle with a broken top labeled 75% Ethyl Alcohol. -A spray bottle labeled C-Diff Solution Tablets. -A bottle of Betco Kling toilet bowl cleaner. *On the wall above the sink was a sign that said, Keep all chemicals in LOCKED Cupboard and securely locked when not in use. 2. Observation on 1/14/25 at 9:29 a.m. of the Happy Trails hopper room revealed: *The Happy Trails hopper room was not locked. *The cupboard and under the sink was: -An aerosol spray can of Spectracide wasp and hornet killer. -An empty spray bottle with a handwritten label PH7Q Dual disinfectant Do not throw away. -An empty bottle labeled Isopropyl Rubbing Alcohol 70% that was outdated on 6/17. *In a cupboard between the sink and the hopper was: -A partially full bottle of Dermal Wound Cleanser that did not have a resident name or date of opening on the bottle. -An aerosol bottle of Lustre-Mist furniture polish. 3. Observation on 1/14/25 at 1:36 p.m. of the beauty shop revealed: *The beauty shop door was open. *There was a wooden cabinet beside the stationary hair dryer with a lock on it. *The cabinet was not locked. *In the cabinet was: -A spray bottle with a white label that did not have a chemical name on it. --The label was identified as a Drug Facts Label with the main ingredient on the label identified as Ethyl Alcohol 75%. --The label also included Uses: Hand sanitizer to help reduce bacteria that potentially can cause disease. --The label was dated 4/17/20. -A bottle of Brush Delite. --The label indicated Use rubber or plastic gloves. NEVER bare hands. -Nail polish remover that was outdated on 4/19. -A partial bottle of BETCO odor eliminator. *On the counter was a blue-green bottle with a clear liquid in the bottle that was one-third full. This bottle did not contain an identifier of what was in the bottle. 4. Observation on 1/15/25 at 8:43 a.m. of the shower room revealed: *The door to the shower room was not locked. *There was no staff present in the shower room. *On an over-the-bed table near the window was a spray bottle with a clear liquid that was almost empty. -Handwritten on the spray bottle was, For reusable items combs tweezers razor parts. Use new label for each bottle of alcohol label w/ [with] exp [expiration]. The adhesive label attached to the bottle reads Alcohol Spray 05/25. *A tall white cabinet had a padlock with a key hanging from the padlock and the door was open. *On the bottom shelf of the white cabinet was a spray bottle that contained a blue liquid. -Virex II 256 Disinfectant cleaner was handwritten on the spray bottle. *Between the toilet and the wall was a white basin that held a toilet plunger, two toilet brushes, and a white bottle of blue liquid. -The bottle was labeled Kling Toilet Cleaner on a manufacturer's label. 5. Interview on 1/15/25 at 9:35 a.m. with certified nursing assistant (CNA) I revealed: *The shower room door was not locked. *The white cabinet was supposed to be locked when staff were not present. *The key for the cabinet was stored on the top of the cabinet. 6. Interview on 1/15/25 at 11:08 a.m. with housekeeping L revealed: *Chemicals were to be stored in a closet or storage room. *All chemicals were to be in a locked area. *Chemicals were to be stored away from residents. 7. Interview on 1/15/25 at 4:30 p.m. with minimum data set (MDS)/director of nursing (DON) B revealed: *She was unaware that the cabinet in the beauty shop was unlocked. *It was her expectation that the beauty shop cabinet was locked. *She had been told that items could not be stored under the sinks. *She confirmed there were items stored under the sinks in the hopper rooms and some were chemicals. *She was unaware that chemicals needed to be labeled with manufacturer's labels. *She expected the toilet bowl cleaner to be in a locked cabinet and not accessible to the residents. 8. Interview on 1/16/25 at 8:34 a.m. with nurse manager C about chemical storage revealed: *It was her expectation that chemicals were not stored under the sink. *The provider was previously told that products could not be stored under the sink. *She believed that the cupboards under the sink had been cleaned out. *Chemicals were to be kept out of access from the residents. *Chemicals were to be stored in locked cabinets and not left unattended. *Indicated that the toilet bowl cleaner stored in the shower room beside the toilet was accessible to residents due to the door not being locked. 9. Interview on 1/16/25 at 10:50 a.m. with CNA G revealed: *She did not handle chemicals. *She stated it was the responsibility of housekeeping and maintenance. 10. Review of the provider's 2/24 Chemical Safety policy revealed: *Promote safe use and storage of chemicals. *Toxic items such as detergents and polishes will be properly stored, labeled, and used in a way that will not contaminate food. *This policy, presented by the provider as the chemical storage policy, referred to dietary staff and chemical use and storage related to food contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the provider failed to ensure four sampled residents (11, 29, 33, and 34) had received the wrong medication administered by four of four of staff, registered nurse (RN) (D and F) and certified medication aide (CMA) (O and P). Findings include: 1. Record review of resident 33's electronic medical record (EMR) revealed: *On 12/8/2024 at 1:09 a.m. a nursing progress note had been entered that resident 33 had been given another resident's medications by CMA O. *Resident 33 was given the following medications: -Tylenol 1000 milligrams (mg) (pain reliever), -Olanzapine 5mg (antipsychotic), -Celecoxib 100mg (pain reliever). -Tamsulosin 4mg (to treat an enlarged prostate). 2. Record review of resident 34's EMR revealed: *On 9/14/24 at 5:00 p.m. resident 34 had been administered: -Carbidopa/Levodopa 25/100 mg (treat symptoms for Parkinson's disease) by CMA P. -This medication had not been ordered based on review of the physician orders. *Poison control had been notified and guided to monitor for adverse reactions including agitation and stomach pain. 3. Review of resident 11's EMR revealed: *She was not a diabetic. *On 12/13/24 at 2:30 p.m. a progress note that stated, Resident 11 was mistaken for a different resident. At 1200 [12:00 p.m.], her blood sugar was taken and found to be 172. 7 units NovoLog insulin (a fast acting insulin) given by mistake at that time, and resident ate a good lunch. Primary MD [medical doctor] and resident's daughter were both notified. Will continue to monitor for hypoglycemia. Re-check BS [blood sugar] 1400 [2:00 p.m.] =145. *There were no further blood glucose checks documented in resident 11's EMR. *On the 12/13/24 at 1:54 p.m. fax that was sent to the provider that notified him of the medication error, the provider replied, OK: Noted- Continue to monitor for signs of hypoglycemia [low blood sugar] for 8-12 hrs [hours] from injection. Review of the provider's 12/13/24 Medication Error Incident Audit Report for resident 11 revealed: *The Medication Error Incident Audit Report was completed by registered nurse (RN) F on 12/13/24 at 5:20 p.m. *Resident 11 was mistaken for a different resident. Her blood sugar was taken and found to be 172. 7 units of NovoLog insulin given by mistake. Resident ate a good lunch. *Resident 11's description was documented as Oh, okay. *The Description of Action Taken was, Primary MD and resident's daughter were notified. Will Continue to monitor for hypoglycemia over the next 6-8 hours. Will recheck BS at 1400. Interview on 1/15/25 at 2:16 p.m. with nurse manager C regarding resident 11's medication error revealed: *She was not sure if education was provided or if a review of the medication error had been completed. *She stated she would have to look if there was anything completed because she was not available at the facility at the time of the medication error. Interview on 1/16/25 at 8:34 a.m. with nurse manager C about medication errors revealed: *An agency staff member made resident 11's medication error. *The company that the agency staff work for is responsible for the education and competencies of all agency staff. *Agency staff was not provided training by the provider. *When she reached out to the travel agency to request agency staff receive education on something she expected the travel agency to complete the education. *She did not follow up with the travel agency to be sure the education was completed. *She expected agency staff to work on the floor on the first day of hire after being given a facility tour. 4. Review of resident 29's EMR revealed: *She was admitted on [DATE]. *Her 7/26/24 BIMS was 12, which indicated moderate cognitive impairment. *On 12/29/24 at 2:36 p.m. an incident/fall progress note indicated, This writer had just counted controlled medications with med aide today and counted Lorazepam [Ativan] for resident. Reviewed paper order in the Narcotic book and gave 1 tablet of 5mg [milligram] Lorazepam. When this nurse went to chart in the EMR, realized medication had been discontinued but not removed from the narcotic drawer of the medication cart. Contacted Nurse Manager C. Contacted resident 29's next of kin regarding medication given with no [current] order. Review of the provider's 12/30/24 Medication Error Report Sheet for resident 29 revealed: *On 12/29/24 at 1:31 p.m. RN D administered Ativan (an anti-anxiety medication) 5mg by mouth to resident 29. *The order for Ativan for resident 29 was discontinued on 11/11/24. *Steps taken to correct the error were, Medication was removed from cart. Education provided on 5 rights of med administration. PCP [primary care provider] faxed, vitals taken. *The cause of the error was identified as Medication was not verified in the EMAR [electronic medication administration record] prior to administration. *The action taken to prevent the error from reoccurring was, Always use 5 rights of med administration, when medications are discontinued pull medications @that time. Review of the provider's Medication Error policy revealed: *The policy was Guidelines designed to prevent, identify, report and address errors related to administration of medications. *The policy outlines responsibilities, steps of reporting errors, and corrective actions to be taken. *To ensure patient safety by minimizing the risks associated with medication administration. *The procedure included: Obtain Vital Signs, Fax Provider. If after clinic hours or during weekend call the on-call provider., Create Incident in Risk Management., and Notify Nurse Manager/DON to initiate Medication Error Report Sheet. *The Medication Error Report Sheet included details about the medication error as well as, Type of Medication Error, Steps taken to correct error, Was Physician notified, Describe exactly what caused error to occur, and Actions taken to prevent error from reoccurring.

Based on Payroll Based Journal (PBJ) record review, employee timecard review, staffing schedules, and electronic medical record (EMR) review, the provider failed to submit PBJ data accurately for one of one federal fiscal quarter (Quarter 4, 2024). Findings include: 1. Review of PBJ records submitted to the Center for Medicaid and Medicare Service (CMS) revealed the provider submitted no licensed nursing coverage 24 hours per day for quarter 4, 2024: 9/15/24, 9/17/24, 9/19/24, and 9/21/24. Review of the provider's employee timecards, staffing schedules, and residents' EMR records documentation revealed the provider had licensed nursing coverage 24 hours per day for the period referenced above. Interview on 1/15/25 at 3:03 p.m. with administrator A and nurse manager C revealed: *Nurse manager C made the nursing schedule. *She did not participate in PBJ submission. *Administrator A submitted the records to PBJ. *The information was automatically obtained from the individual staff timecards by their electronic payroll system. *She entered the agency staff manually. *She was not aware the PBJ reports indicated the provider did not have licensed nursing coverage 24 hours per day in quarter 4, 2024. *She did not know where to find the PBJ reports. *She thought the missed information could have been due to her manually entering agency staff hours. *She reviewed the September 2024 nurse schedule and indicated that some of the days of missing coverage in the report were not staffed by agency staff. *She did not know how the hours were incorrectly reported to PBJ.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 16. Interview on 1/14/25 at 3:50 p.m. with certified nursing assistant (CNA) H regarding enhanced barrier precautions revealed he had been unsure what that had been and asked other nurses to help him. Interview on 1/14/25 at 3:25 p.m. with Minimum Data Set (MDS)/ director of nursing (DON)/ infection preventionist (IP) B regarding enhanced barrier precaution revealed: *It had been used for wounds, catheters, and anything that could transmit bacteria. *PPE had been stored in the medication storage room. *It would have been the facility's discretion if PPE was required with enhanced barrier precautions. Interview on 1/15/25 at 2:00 p.m. with medical director U regarding residents placed on enhanced barrier precautions and urinalysis collection revealed: *He had not been aware of enhanced barrier precautions and the criteria for residents to place on precautions. *He would not want residents to be isolated if there were on precautions. *If a resident has had multiple urinary tract infection, he would prefer a catheter urinalysis to be collected. *He would prefer more infection symptoms to be exhibited by the resident before a u/a is collected. *He does participate in the antibiotic stewardship and other providers have access to the facilities program.15. Observation and interview on 1/15/25 at 9:41 a.m. with CNA G regarding resident 20 and enhanced barrier precautions (EBP) revealed: *There was a small magnetic sign on the top of the door frame titled EBP. *CNA G entered resident 20's room and sanitized her hands. -Put gloves on. -Put paper towels on the floor as a barrier. -Put a plastic cylinder on the paper towels. -Emptied the urine from the catheter bag into the cylinder. -Emptied the container of urine into the toilet. -Rinsed the cylinder in the sink and emptied it into the toilet. -Put the cylinder back on a shelf. -Removed her gloves and sanitized her hands. *She confirmed this was how she normally emptied catheter bags. *She was not sure what the EBP sign at the top of the door frame meant. Review of resident 20's electronic medical record (EMR) regarding her catheter revealed: *She had an order for a suprapubic catheter due to urine retention. *Her revised 7/1/24 care plan directed staff to: -Check tubing for kinks each shift. -Encourage fluid intake. -Monitor and document output as per facility policy. -Monitor/document for pain/discomfort due to catheter. *She was dependent on one staff for toileting. *The care plan had no guidance for enhanced barrier precautions. 17. Observation on 1/14/25 at 1:40 p.m. revealed a 1.5 x 3 inch magnet with EBP written on it stuck to the top of the door frame to resident 24's room. -No personal protective equipment (PPE) was present in the hall or in resident 24's room. Interview on 1/14/25 at 1:57 p.m. with certified nursing aide (CNA) Q revealed: -She wasn't sure what the EBP tag meant. -She thought it had something to do with the floor mat. -She stated I should know since I get her up. -She went to the nurse's station and returned, saying that the EBP had to do with blood sugars. -She did not know what enhanced barrier precautions meant. -She did not wear any PPE when working with resident 24. Record review on 1/14/25 revealed resident 24 had an indwelling catheter since prior to admission on [DATE]. -The care plan had no guidance for enhanced barrier precautions. Review of the provider's 6/23/23 Cleaning of Durable Medical and Therapy Equipment policy revealed: *To provide residents with clean, sanitary equipment and prevent the spread of infection. *The policy did not address items such as thermometers or blood pressure cuffs. Review of the provider's Hand Hygiene policy revealed: *Cleaning hands promptly and thoroughly between resident contact and after contact with blood, body fluids, secretions, excretions, equipment and potentially contaminated surfaces is an important strategy for preventing healthcare associated infections. Hand hygiene should be performed: After removing gloves, After handling equipment supplies, or linen contaminated with body substances, and When moving from contaminated to clean body sites. Review of the provider's Infection Control and Prevention policy revealed: *Using Standard and Transmission based Precautions appropriately and correctly, you will keep yourself and your residents safe from acquiring infection while in the healthcare setting. *Standard Precautions include Hand washing single most effective way to prevent the transmission of disease. Review of the provider's April 2024 Enhanced Barrier Precautions policy revealed: *It is a policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug resistant organisms (MDRO). *Enhanced barrier precautions (EBP) are an infection control intervention designed to reduce transmission of multidrug resistant organisms (MDROs) in nursing homes. Enhanced barrier precautions involve gown and glove use during high contact resident care activities for residents known to be colonized or infected with a MDRO as well as those at increased risk of MDRO acquisitions (e,g ,residents with wounds or indwelling medical devices ). Based on observation, interview, record review, and policy review the provider failed to: *Accurately identify and implement enhanced barrier precautions (EBP) for three of three sampled residents (4, 20, and 24) who had care concerns requiring personal protective equipment (PPE). *Utilize appropriate hand hygiene and gloves during cares by one of one staff (certified nursing assistant (CNA) I with one of one resident (33). *Appropriately maintain and dispose of resident care items in two of two hopper rooms, one of one shower room, and one of one beauty shop. Findings include: 1. Observation on 1/14/25 at 8:15 a.m. of the Garden Terrace hallway revealed there was no PPE in the hallway or residents' rooms. Observation on 1/14/25 at 9:09 a.m. of resident 4 in the dining room revealed: *She was seated in her wheelchair. *She had her right lower extremity (RLE) wrapped in a dressing. *She was touching what appeared to be a wound on her RLE that was not covered and was open and red. 2. Observation on 1/14/25 at 9:36 a.m. of resident 4's room revealed: *There was no sign indicating a need for EBP. *There was no personal protective equipment (PPE) outside or inside her room. *She shared a room with resident 9. *The room and an adjoining bathroom with the room next door. Review of resident 4's electronic medical record (EMR) revealed: *She was admitted on [DATE] *She had a Brief Interview of Mental Status (BIMS) assessment score of 8, which indicated she was moderately cognitively impaired. *Her diagnoses included cellulitis, dementia, and bulbous pemphigoid (autoimmune disease that causes skin blisters) *She had an order for wound care to her RLE. *She was not on enhanced barrier precautions. Interview on 1/15/25 at 9:22 a.m. with registered nurse (RN) D regarding how she performed resident 4's RLE dressing change revealed: *She performed hand hygiene before putting on gloves. *She removed the dirty wound dressing and threw it away in the garbage can. *She performed hand hygiene before putting on a clean pair of gloves. *She applied clean dressings to the wound. *She confirmed she would only wear gloves for PPE for resident 4's dressing change of her wound. Interview on 1/15/25 at 12:09 p.m. with minimum data set (MDS)/ director of nursing (DON) regarding their enhanced barrier precautions (EBP) protocol revealed: *She believed the statement in the policy that read, CMS [Center for Medicare and Medicaid Services] notes facilities have some discretion when implementing EBP and balancing the need to maintain a homelike environment for residents came from the CDC (Center for Disease Control) website. *She did not produce where that portion of the policy was referenced from as requested. Interview on 1/16/25 at 10:21 a.m. with RN D about EBP revealed: *Anyone with a urinary catheter was on EBP. -She listed three residents who had a urinary catheter. *She indicated that residents who had MRSA (methicillin-resistant Staphylococcus aureus) or VRE (Vancomycin resistant enterococcus) would also be on EBP. -There were no residents in the facility that currently had either of these. 3. Observation on 1/14/25 at 8:15 a.m. of Garden Terrace hallway revealed: *There was one wall hanging alcohol-based hand sanitizer (ABHS) in the hallway. -It was in the middle of the hallway. *Each resident room had a wall hanging ABHS near the bathroom door. 4. Observation on 1/14/25 at 8:36 a.m. of the Garden Terrace hopper room revealed: *The cabinet under the sink contained: -A spray bottle labeled 75% Ethyl Alcohol with a broken spray top. -A spray bottle labeled C-Diff [clostridium difficile] solution tablets. -Multiple glass containers. -A plastic basin. -Empty plastic ice cream buckets. -A short white extension cord. -A bottle of toilet bowl clearer with a brush in a plastic white bucket. The bottom of the bucket had multiple black flecks of an unknown substance and a yellow crusty unknown substance. *There was no ABHS available in or outside the door of the hopper room. *Soap and water were available at the sink. *Two unidentified staff opened the door, threw trash in the garbage and exited the room without washing their hands. 5. Observation on 1/14/25 at 8:56 a.m. in Garden Terrace hallway revealed: *A covered cart was parked in the hallway. *On top of the cart were two fabric soaker pads and a bed sheet. *The linen was not covered. *There were two full body mechanical lifts parked in the hallway. *Neither lift had a container of disinfectant wipes. 6. Observation on 1/14/25 at 9:29 a.m. of the Happy Trails hopper room revealed: *There was no ABHS available in or outside the door of the hopper room. *Soap and water were available at the sink. *The cabinet under the sink contained: -One teal plastic bedpan and two gray plastic bed pans. -A can of Spectracide wasp and hornet killer. -A white basin. -Two plastic buckets. -A clear Sterlite four-quart plastic container with brown paper towels. On top of the paper towels was a rectangular silver metal cover with green corrosion on it. Inside the clear container along the paper towels was cobwebs and brown flakes of an unknown substance. -An empty spray bottle labeled PH7Q Dual disinfectant. -A partial bottle of tearless Shampoo & Body Wash. -An open container of Super Sani-Cloths. - Two round pink basins. -Two bundles of brown paper towels and two rolls of toilet paper. -An empty bottle labeled Isopropyl Rubbing Alcohol 70% that had outdated on 6/17. *The cabinet between the hopper and the sink contained: -A partial bottle of Dermal Wound Cleanser that was outdated on 4/22. -A partial bottle of hand sanitizer that was outdated on 8/22. -A cardboard box that contained red bags with moisture damage present to the box. *Two unidentified individuals opened the door, threw garbage into the hamper and did not wash their hands. 7. Observation on 1/14/25 at 1:36 p.m. of the beauty shop revealed: *A wooden cabinet around the stationary hair dryer. *The wooden cabinet contained: -A partial bottle of hand sanitizer that was expired on 7/22. -Nail polish remover that was expired on 4/19. -A bottle of Tresemme conditioner that had a name on it that was not a current resident. -A partial container of disinfectant wipes that was expired on 2/21. *The counter beside the hair washing sink contained: -A dry container of disinfectant wipes. -A bottle of ABHS that was outdated on 9/23. -A bottle of Biolage Antidandruff shampoo that was outdated on 10/24. -A white bucket that contained hair curlers with no resident identifier on the bucket. -The curlers contained strands of gray and white hair. -A clear container of pins to secure the curlers with no resident identifier. *The filter on the back of the stationary hair dryer had a thick coating of dust and gray and tan particles. Interview on 1/14/25 at 1:56 p.m. with RN D revealed: *Staff use the beauty shop for the residents. *Bath aides use the curlers to set residents' hair. *Local beauticians use the beauty shop to cut residents' hair. 8. Observation on 1/15/25 at 8:43 a.m. of the shower room revealed: *There were tiles missing on the shower floor. *In a plastic three-drawer cabinet were: -Two electric razors that were filled with white and gray hair. -Two different sized curling irons with an unknown crusted white substance and long white hairs on the barrels. *On the floor near the sink were two blue squares of non-stick rubber-like material that had hairs and other unknown white particles on them. *On the wooden shelves between the cabinet and the sink there were: -Multiple bags of open incontinent products without any resident identifiers. -An open container of disposable skin wipes with an unknown brown substance on the container. --There was no resident identifier on the container. -Twelve uncovered towels. -A gray basin with black garbage bags and two unrolled gait belts with a brown substance on one of the gait belts. *On the outside of the white cabinet was a piece of paper titled Bath Aide. -A list of the bath aide duties was on the piece of paper. -Under the duties there was a portion labeled Infection Control. --Use 1/3 cup or less Virex Cleaner in spray bottle fill with water. Spray down shower chair/bath in between resident use. --Use alcohol spray for all other reusable items between uses. Combs Nail clippers Tweezers Shave Parts. *A towel was covering an over-the-bed table by the window. *On the towel was a plastic gray basin that contained two black electric razors filled with gray hair, a temporal thermometer (thermometer that takes temperature on the forehead), a wrist blood pressure cuff, and a white coffee cup. *The coffee cup contained: -Eight pens, two black combs, one purple pick, one silver scissors, one black handles scissors, two nail clippers, a spray bottle with a handwritten label For reusable items combs tweezers, razor parts. Alcohol Spray 05/25, and a bottle of alcohol-based hand sanitizer (ABHS). *A towel was covering an over-the-bed table near the shower. *On the towel was five wash cloths and two pump bottles labeled conditioner and shampoo and body wash. 9. Observation and interview on 1/15/25 at 9:09 a.m. of CNA I as she removed hair rollers from a resident in the beauty shop revealed: *She removed the rollers from the resident's hair and placed them in a white bucket with other rollers. *She did not clean the rollers, or the pins used to hold the rollers in place. *She stated that this was the only resident she set hair for. *She had not been trained on the use of rollers or how to clean them. *She reused the rollers and pins without them being cleaned. 10. Observation and interview on 1/15/25 at 9:35 a.m. of CNA I during a resident shower revealed: *Applied gloves without prior hand hygiene. *She undressed the resident. *Took the resident's blood pressure and temperature and did not cleanse the equipment after use. *Shaved the resident's face with the electric razor from the over-the-bed table. *Sprayed the outside of the razor with the bottle labeled alcohol with three sprays and placed it on a paper towel. *She did not empty the facial hair from the razor. *Pushed the resident on the shower chair into the shower and pumped the shampoo and body wash into a washcloth she removed from the over-the-bed table near the shower. *After the shower she used a towel from the wooden shelves to dry off the resident. *She changed gloves without hand hygiene. *She placed the two blue squares of non-stick rubber-like material under the resident's bare feet for the resident to stand on while she observed and dried his skin. *She used a pump lotion bottle, without a resident identifier on it, multiple times to dispense lotion and apply it on the resident. *Used spray deodorant and dressed the resident. *She changed her gloves without performing hand hygiene. *She assisted the resident in putting on his clothing. *Cleaned under the resident's fingernails with a wood stick. *Applied after shave, without a resident identifier on it, to the resident. *Changed her gloves without performing hand hygiene. *Applied skin protectant cream to the resident's buttocks from a tube that was dated 7/20/24 with no resident identifier on it. *She removed her gloves without performing hand hygiene. *She placed the aftershave, skin protectant cream, and deodorant into the white cabinet without disinfecting after resident use. *She did not disinfect the lotion after use and left it on the over-the-bed table. *She stated that some residents have their own products, but others used shared products. *The shared products should be wiped with a disinfectant wipe after each resident's use. *The end of the razor was sprayed with the alcohol after each use and the razors were emptied at the end of the day. *Nail clippers and combs were also sprayed with alcohol after each resident use. *She sprayed the shower chair with the bottle labeled Virex. *She did not spray the floor or the walls of the shower. *She indicated she would let the chair sit for a couple minutes. *She washed her hands with soap and water. 11. Interview on 1/15/25 at 4:30 p.m. with MDS/DON B revealed: *She was unaware there was outdated products in the beauty shop and both hopper rooms. *She was unaware there was a filter in the back of the stationary hair dryer that needed to be cleaned. *She did not know how the hair rollers were supposed to be cleaned. *She stated the provider had been told during a previous survey that items could not be stored under the sink, and she thought the items had been removed. *She was unaware how the nail clippers, razors, and combs were being cleaned. *She verified the electric razors in the shower room had not been emptied and were filled with white and gray hair. *She did not know the linen in the shower room needed to be covered. *It was her expectation staff performed hand hygiene after bringing soiled materials into the hopper rooms. *It was her expectation that hand hygiene be performed prior to applying gloves and after removing gloves. 12. Interview on 1/15/25 at 5:00 p.m. with administrator A revealed: *The provider did not have a policy for cleaning of hair rollers, nail clippers, and hair combs. *The provider did not have a policy on expired products. 13. Interview on 1/16/25 at 8:34 a.m. with nurse manager C revealed: *Razors should be cleaned between each resident, per facility policy. *She did not know how the razors were currently being cleaned. *She expected that the facial hair be brushed out, the parts were taken out, and the parts were sprayed with alcohol. *She thought the instructions were on the rubbing alcohol bottle that told staff [NAME] to mix the spray bottle, but the manufacturer's instructions were to be followed when mixing. *She believed that environmental service manager J had told the nursing staff the process of dilution. *Linen should be covered when in the hallway and the towels in the shower room be in a covered cart. *Nothing was to be stored under the sinks. *There was not a person assigned to check outdates. *She felt that there should be someone responsible for this. 14. Interview on 1/16/25 at 9:09 a.m. with environmental service manager J revealed: *She had not provided training to the nursing staff about mixing chemicals. *She was not aware that nursing staff was using alcohol. Interview on 1/16/25 at 10:21 a.m. with RN D regarding expired products revealed: *She was not sure who oversaw checking for expired products. *She checked the expiration dates of products as she used them. *She indicated that nurse manager C completed audits of the medication carts for expired medications and products.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), observation, interview, and record review the provider failed to ensure the safety of one of one sampled resident (1) identified at risk for elopement, who had eloped (left the facility without staff knowledge) after staff turned a door alarm off. Failure of staff to ensure the door alarm was reactivated resulted in the resident's elopement and put her at risk for physical injury or serious harm. This citation is considered past non-compliance based on the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 11/20/24 SD DOH FRI revealed: *On 11/20/24 at 1:00 p.m. certified nursing assistant (CNA) G reported to licensed practical nurse (LPN) H the fire exit door in the living room was cracked open. *The alarm did not sound. *Resident 1 was standing on the sidewalk by the door. -She was last seen prior to that eating lunch in the dining room. -She stated she was going to get hot chocolate. *Resident 1 was immediately put on one-to-one observation with activities assistant F. *Her vital signs were taken and were within normal limits. *No injuries were noted at the time of the incident. *She was wearing a Tile tracking device and a watch with the capability to track her location. *The charge nurse notified administrator A, director of nursing (DON) B, the physician, and resident 1's son of the incident. *The door alarm system was immediately checked, and the alarm for that door was noted to be turned off. *The door alarm was turned back on and noted to be working. Observation on 11/26/24 at 9:30 a.m. at the nurse's station revealed: *The door alarm system was on. *New education for staff was posted directly under the panel. *Observation and interview on 11//26/24 at 10:30 a.m. with resident 1 in her room revealed she was watching TV in her room with her husband and had no concerns at this time. *Interview on 11/26/24 at 10:47 a.m. in the dining room with activities assistant F regarding the elopement process revealed she: *Would retrieve the resident from outside. *Ensure they were ok, bring them inside, and get them a cup of coffee. *Notify the charge nurse or her supervisor. Interview on 11/26/24 at 10:52 a.m. with housekeeping assistant E regarding elopement revealed: *She would notify her supervisor and help look for the resident. *If she found the resident, she would call 911 so they could do an assessment. *She would notify her supervisor that the resident was found. Interview on 11/26/24 at 11:05 a.m. with CNA D regarding the elopement process revealed she: *Would retrieve the resident if they got outside. *Would make sure they were ok. *Bring them inside and notify the charge nurse so they could do an assessment. Interview on 11/26/24 at 11:39 a.m. with registered nurse (RN) C regarding education provided after the elopement revealed: *Staff were provided education in a binder regarding elopements. *They were required to read and sign before the next shift worked. *The nurses were now documenting door alarm checks completed each shift in the treatment administration record (TAR) and in paper narcotics count book, the alarm checks on each shift. *The nursing staff continued to monitor resident 1 hourly while she had her watch on, and every 30 minutes once it was removed to be charged. The staff had participated in monthly elopement drills. Interview on 11/26/24 at 1:10 p.m. with administrator A regarding resident 1's elopement revealed: *The door resident 1 exited through did have an alarm on it. *That door was the only one that did not have a key pad to code out on. *She was placed on 15-minute checks immediately after the incident. *They had provided education for staff regarding which doors were appropriate to use to exit the building, as well as monitoring residents who wandered. *She was auditing the door alarms daily for one week, then she planned to complete weekly audits for four weeks. *Maintenance staff used the living room door to complete maintenance tasks outside. *The process for resetting the door alarms was to silence the alarm button, push the reset button, turn off the alarm switch and then turn it back on. *She thought someone missed the last step and did not turn the alarm back on. *She could not determine which staff member shut off the alarm, so education had been provided to all staff members. *She had ordered a new keypad for the fire exit door in the living room so staff would have to enter a code to exit the building along with the door being alarmed. *The keypad was scheduled to arrive on 11/27/24 and maintenance would install it the day it arrived. *Resident 1 wore a watch that was used with a provider-owned cell phone to track her location. *Resident 1 also wore a Tile tracking device that would show her location if she left the property. *Staff were also educated to do physical checks on resident 1 hourly during the day and every half hour at night. Interview on 11/26/24 at 1:25 p.m. with DON B regarding the interventions put in place after resident 1's elopement revealed: *She was moved to a different table in the dining room for the exit door to not be in her immediate line of sight. *Immediately after the elopement resident 1 was placed on one-to-one observations with the activity assistant and was taken to Bingo for close monitoring. *She was checked for a urinary tract infection (UTI), as they had discovered that had elevated her exit seeking in the past. *The administrator was in the process of obtaining a door alarm bracelet system for her. *A coded pad has been ordered for the fire door that the resident eloped from. *Alarm checks were added to the TAR and the narcotis countc book for the nurses to check and document. *Resident 1's care plan was reviewed, and the table change intervention was added. Review of resident 1's electronic medical record (EMR) revealed: *Her Brief Interview for Mental Status (BIMS) assessment score was 10 which indicated she had moderate cognitive impairment. *She was monitored one-to-one by activities assistant F immediately after the elopement on 11/20/24. *Staff had documented the 15-minute checks in the TAR. *Her care plan was updated to ensure she was seated in the dining room so the living room exit door was not in her line of sight. The provider implemented changes to ensure the deficient practice does not recur was confirmed after record review revealed the facility had followed their quality assurance process, education was provided to staff regarding the door alarming process and the new interventions that were added to resident 1's care plan, observations and interviews revealed staff understood the education provided and had implemented those interventions, the door alarms were on and monitored, and the process was being audited ongoing to assist in deterring resident elopement. Based on the above information, non-compliance at F689 occurred on 11/20/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 11/26/24, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on record review, interview, and policy review, the provider failed to report one of one sampled resident's 8 blood sugars that were out of parameter to the doctor per the doctor's order. Findings include: 1. Record review on 8/7/24 of resident 8's electronic medical record (EMR) revealed: *There was an order from his doctor on 3/21/24 to check his blood sugar four times daily and to call the provider if his blood sugar is less than 60 or greater than 500. *He had a blood sugar on 5/14/24 at 7:04 p.m. that was 542 and again on 5/25/24 at 7:01 p.m. that was 517 -There was no documentation in his EMR that the doctor was notified on the high blood sugars. 2. Interview on 8/8/24 9:41 a.m. with licensed practical nurse (LPN) G revealed she: *Agreed the high blood sugars were not reported to the doctor. *Would have been expected that the doctor to have been notified. 3. Interview on 8/8/24 at 10:37 a.m. with nurse manager C revealed: *She stated they had a new blood sugar parameter reporting policy as of 8/1/24 with the medical director. *She agreed resident 8's blood sugars had not been reported to his doctor and should have been faxed per the physicians orders. 4. Interview on 8/8/24 at 2:47 p.m. with administrator A regarding resident 8 revealed: *She had been auditing the staff to ensure they had been reporting abnormal blood sugars. *She had not been aware they were not reporting resident 8's abnormal blood sugar tests per physician's orders. 5. The provider's blood sugar parameter policy dated 8/1/24 revealed: *The purpose was to ensure adequate blood sugar parameters are reported and monitored by physicians. B. Based on observation, interview, record review, and policy review, the provider failed to follow their policy regarding storage of resident prescriptions for one of one sampled resident (27) who had prescription ointment on her bedside table. Findings include: 1. Observation on 8/6/24 at 2:25 p.m. in resident 27's room revealed there was a green tin of Bag Balm with a prescription label attached to it on the resident's bedside table. 2. Interview on 8/7/24 at 3:58 p.m. with licensed practical nurse (LPN) G about storing prescription medications in a resident's room revealed: *A resident must have a physician's order for a medication to be kept at their bedside. *The resident must also be assessed for competencies regarding what medication it was, how to use it, how much to use, and when to use it. 3. Continued interview on 8/8/24 at 9:29 a.m. with LPN G about resident 27's prescription ointment revealed: *She confirmed there was no physician's order for resident 27's Bag Balm to have been kept at her bedside. *Resident 27 was not able to open the tin of ointment by herself. *The ointment was probably there for staff to use when they were performing perineal cares. *It should have been stored in the medication room. 4. Interview on 8/8/24 at 10:02 a.m. with director of nursing (DON) B about resident 27's prescription ointment revealed: *She indicated it was acceptable for resident 27 to have the Bag Balm at her bedside for the staff to use. *She confirmed that resident 27 was not able to use the ointment by herself. 5. Review of resident 27's electronic medical record revealed: *There was no physician's order for the Bag Balm to have been stored at resident 27's bedside. *There were no medication self-administration assessments. *Resident 27 was admitted on [DATE] and had a Brief Interview for Mental Status score of 7, which suggested severe cognitive impairment. *There was a physician's order for Bag Balm Ointment APPLY TOPICALLY TO PERI AREA AS DIRECTED that started on 7/19/24. *The resident's care plan did not indicate anything about Bag Balm being stored at her bedside. 6. Review of the provider's 6/15/24 Bedside Medication Storage policy revealed: *Bedside medication storage is permitted for residents who wish to self-administer medications, upon the written order of the prescriber and once self-administration skills have been assessed and deemed appropriate in the judgement of the facility's interdisciplinary resident assessment team. *Procedures: -A. A written order for the bedside storage of medication is present in the resident's medical record. -B. Bedside storage of medications is indicated on the resident medication administration record (MAR) and in the care plan for the appropriate medication. 7. Review of the provider's 6/15/24 Storage of Medications policy revealed: *Medications and biologicals are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. *The medication supply is accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.

Based on menu review, observation, and interview, the provider failed to ensure adequate portions were served according to the menu for one of one observed meal. This had the potential to affect all residents receiving the main menu in the facility. Findings include: 1. Review of the provider's menu for lunch on 8/8/24 revealed the following main menu items: *One cup of taco bake. *The pureed portion size was 2/3 cup. 2. Observation on 8/8/24 from 11:43 a.m. to 12:11 p.m. in the kitchen for lunch service revealed: *Cook H set up the steam tables, placed pans of food into the steam table, and placed the serving scoops next to each pan of food. *She used a 1/2 cup scoop for the taco bake, and another 1/2 cup scoop for the pureed taco bake. -1/2 cup of taco bake was 50% less than what the menu called for. -1/2 cup of pureed taco bake was about 33.33% less than what the menu called for. 3. Interview at that time with cooks H and I about the menu revealed: *Cook H had been working at that facility for about three weeks. *She had not made that recipe before. *Neither [NAME] H nor [NAME] I were aware that the serving size for the regular taco bake was one cup, and the serving size for the pureed taco bake was 2/3 cup. *Cook H indicated that she was trained to use the 1/2 cup scoop for every recipe. *When asked if cook H was aware how to verify the correct serving size, she looked at the posted menu with each diet listed and the serving sizes, but said, No I was not aware of that. *Cook H continued to use the incorrect scoop sizes for the remainder of the meal service. 4. Interview on 8/8/24 at 2:55 p.m. with administrator A about the above observations revealed: *She was not aware that the dietary staff served the wrong portion sizes for lunch that day. *She was the acting dietary manager as the previous one had ended their employment the previous week.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one dishwasher was adequately cleaned and delimed on a regular basis to prevent food scum and limescale buildup. Findings include: 1. Initial kitchen observation on 8/6/4 from 8:24 a.m. to 8:35 a.m. revealed: *The dishwasher was in use to clean dishes from breakfast. *There was a line of limescale buildup on the outside of the door where water was spraying out of a seam. *There was a buildup of food scum on the outside borders and inside seams of the dishwasher doors. *Limescale buildup was present on the wash arms and piping inside the dishwasher. 2. Interview on 8/8/24 at 11:57 a.m. with cook I and dietary aide J about the dishwasher revealed: *They did not know when the dishwasher was cleaned or how often. *Dietary aide J had never cleaned or delimed the dishwasher before. *Cook I had not been tasked with cleaning or deliming the dishwasher in a long time. *The night shift was responsible for cleaning and deliming the dishwasher. 3. Interview on 8/8/24 at 2:55 p.m. with administrator A about the dishwasher revealed: *She thought the dishwasher was supposed to have been delimed once per week. *The instructions and deliming schedule were hanging on the wall across from the dishwasher. *She confirmed the night shift was responsible for cleaning and deliming the dishwasher. *She was not aware of the state of the dishwasher. 4. Review of the dishwasher deliming schedule revealed the last time it was recorded that the dishwasher was delimed was on 6/12/24, about two months ago. 5. Review of the provider's 3/23 Dishwashing policy revealed: *Policy: Dietary staff will ensure that food preparation equipment, dishes, and utensils are [effectively] cleaned and sanitized to destroy potential disease carrying organisms, and ensure equipment is stored in a protective manner. *Procedure: -1. Follow the manufacturer's instructions for operation. .14. The [dietary manager] will monitor completion of tasks and accuracy of records.