**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the South Dakota Department of Health (SD DOH) complaint intake report review, interview, security video review, record review, and policy review, the provider failed to ensure one of one certified nursing assistant (D) safely transported one of one sampled resident (1) in her wheelchair who fell out of her wheelchair and fractured her hip.Findings include:1. Review of the 9/10/25 SD DOH complaint intake report revealed the provider and Adult Protective Services (APS) reported resident 1 fell from her wheelchair to the SD DOH.The SD DOH facility-reported incident (FRI), received on 8/30/25, indicated that on 8/29/25 at around 8:00 p.m., while certified nursing assistant (CNA) D was transporting two residents in their wheelchairs, resident 1's wheelchair brake caught on the activity room window frame. She fell out of her wheelchair and complained of pain in her right hip and right foot. Resident 1 was transported to the emergency department where it was confirmed that she fractured her right hip. The provider re-educated staff in regards to proper movement with wheelchairs.The APS report, received on 9/8/25, revealed that on 8/29/25, CNA D was transporting resident 1 and another resident in their wheelchairs to the designated smoking area. Resident 1 was ran into the wall which resulted in resident 1's right hip fracture. Four people lifted resident 1 up from the floor and threw her onto the gurney to be transported to the emergency department. Resident 1 had emergency surgery on 8/30/25 to correct the hip fracture. 2. Interview on 9/30/25 at 9:12 a.m. with resident 1 revealed that on 8/28/25, CNA D was pushing her and another resident at the same time out to the smoking area. Resident 1 felt that CNA D was not paying attention to where he was pushing her. Her wheelchair got too close to the wall of windows, and something caught on the window frame. She fell out of her wheelchair and as soon as I [resident 1] hit that wall, I felt my hip pop.Resident 1 said that CNA D attempted to pick her up from the floor, but she told him that she was in too much pain. She said that she was hollering. Once other staff arrived, they tried to pick her up off the floor to sit her in her wheelchair, but she was in too much pain to move. The ambulance was called. Two ambulance staff and two CNAs helped lift her onto the ambulance gurney.While at the hospital, it was confirmed that she had fractured her right hip. She had corrective surgery and was readmitted back to the nursing home. She explained that she had rheumatoid arthritis, a disease that affected her joints and caused contractures (permanent tightening of muscles or joints) in her hands and knees. The fall and hip fracture were painful, and she continued to experience pain in her hip after she returned to the nursing home.Since returning to the nursing home, she felt increased anxiety and wanted to talk with someone about her side of the story. She became tearful as she felt that no one wanted to talk to her about the accident. She confirmed she continued to go out to smoke every day. She had to close her eyes and tensed up as she was transported past the area where she fell, as she was fearful of falling again.She confirmed that CNA D still worked at the facility. She did not fear him. She did not feel like he did it on purpose and that it was an accident. She indicated that she was okay with CNA D continuing to help care for her. 3. Interviews with a random sample of residents throughout the facility confirmed no other concerns with staff providing their care. 4. Interview on 9/30/25 at 11:00 a.m. with licensed practical nurse (LPN) E revealed that she was a contracted travel nurse and had not heard about the above accident. She could not recall receiving any recent education about safe resident transporting expectations. She did not know where to find the provider's policy on what to do in the event of a resident fall, but she was able to verbalize understanding of the proper nursing procedures following a resident fall. When she started her contract at that facility, she received a week of mentored training to learn the normal facility routines and procedures. 5. Interview on 9/30/25 at 11:16 a.m. with CNA F and CNA K revealed that neither of them had been at the facility when the above accident happened, but they heard about it when they came back to work. They both confirmed that they did not receive any follow-up education about the fall policy or safe resident transporting expectations. CNA F indicated the report she received about the accident was more of an FYI [for your information]. Continued interview on 9/30/25 at 11:20 a.m. with CNA F individually revealed she heard that CNA D was pushing two residents in their wheelchairs at the same time. She indicated that was not the proper procedure and it was safer to push one resident at a time in a wheelchair. CNA F confirmed she knew where to find the facility policies and procedures regarding falls, accidents, and other topics. She was able to point out where the policies were located. 6. Interview on 9/30/25 at 11:39 a.m. with certified medication aide (CMA) G and CNA H revealed that neither of them was at the facility when the above accident occurred. They did not receive a briefing or report about the accident when they returned to work. They were not provided education recently about safe resident transportation. They learned about that accident from resident 1 when she returned from the hospital. 7. Review of the security camera footage on 9/30/25 at 12:17 p.m. with interim administrator A revealed that the accident occurred on 8/28/25 at around 7:25 p.m. CNA D was pushing two residents in their wheelchairs at the same time. He was pushing resident 1 with his right hand, and resident 2 with his left hand. Resident 1 was close to the wall of windows of the activity room, and it appeared that something on her wheelchair caught on the window as the wheelchair suddenly stopped, and resident 1 fell forward out of her wheelchair and landed on her right hip. CNA D attempted to catch her, but he did not make it to her in time.Several other staff attended to the scene immediately and registered nurse (RN) J began measuring resident 1's vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate). CNA D and another CNA brought the full body lift (a mechanical lift and sling used to lift a person's full body) near resident 1 and attempted to slide the lift sling underneath the resident. They were not able to as resident 1 was showing signs of pain.LPN I sat on the ground with resident 1 and waited with her for the emergency medical service (EMS) to arrive. Two EMS employees, CNA D, and LPN I helped to lift resident 1 from the ground onto the gurney. Resident 1 left the facility with the two EMS employees via ambulance. 8. Review of the provider's incident investigation documentation revealed that they interviewed all staff and all interviewable residents. Staff questions included Has anyone reported to you that they do not feel safe in the facility? Yes or No, Has anyone reported to you that they do not feel safe with their care team? Yes or No, Has any resident reported abuse, neglect, theft, mistreatment to you? Yes or No, and Who do you report abuse, neglect, theft, or mistreatment to?Resident interview questions included Do you feel safe in the facility? Yes or No. [If] no, why? Do you feel safe with your care team? Yes or No. [If] no, why? In the past week has anyone physically abused you? Yes or No, and In the past week has anyone mistreated you? Yes or No.Resident 1 was interviewed on 9/4/25 and answered Yes to the first and second resident questions regarding feeling safe, and No to the third and fourth resident questions regarding physical abuse and mistreatment.The investigation documentation included the SD DOH FRI, a letter to the SD DOH from administrator A that explained the provider's investigation process and included RN J and CNA D's witness statements, and CNA D's background check and training records from his contract staffing agency.The letter from administrator A to the SD DOH included the statement, In good faith effort the facility will provide education on how to push a wheelchair. There was no documentation provided to support who was educated, what the education topics included, or when the education occurred. 9. Review of resident 1's electronic medical record revealed that she was admitted on [DATE]. Her 6/23/25 Brief Interview for Mental Status score from her admission Minimum Data Set (MDS) assessment was 14, which indicated her cognition was intact. She had a diagnosis of rheumatoid arthritis, which is a disease where the body's immune system mistakenly attacks the joints, causing pain, swelling, and stiffness in the joints. She had contractures in her knees and hands, and she could not bend or move her joints normally.Her current care plan indicated Locomotion: Her primary mode of transportation is via manual wheelchair. She is dependent on staff [assistance] of 1. D/T [Due to] her contracture she does refuse to utilize her foot pedals. Continually remind her to utilize the foot pedals. Foot pedals need to be on [when] going to appointments. That was initiated on 7/7/25 and revised on 9/26/25.A progress note from 8/29/25 read, Resident had a witnessed fall at 1925 [7:25 p.m.], after contacting Avel E-care for transport due to resident complaint of 10/10 right hip and right foot pain. Resident transported out of facility via [NAME] County ambulance to [provider name] ED [emergency department] per resident request at approximately 2005 [8:05 p.m.] this evening. This RN contacted [provider name] ED for [a] nurse-to-nurse report. Resident 1's primary care physician was contacted with the update.A progress note from 8/30/25 read, This RN received an update from [provider name] ED from Nurse [name redacted], resident is being admitted and results from the x-ray to the right hip show a fracture, currently waiting for results of the x-ray to right leg. Faxed MAR [medication administration record] to [provider name] Pharmacy. Resident gave this RN a verbal okay to sign bed hold and verbalized understanding of bed hold policy.Resident 1 returned to the facility on 9/3/25 after surgical repair of her hip. She returned with the following pain relief medication prescriptions:*Lidocaine patch (a pain relief patch applied to the skin). To be applied to the affected area and remain on for 12 hours, then taken off for 12 hours. That was to repeat for three days. Started on 9/13/25 and discontinued after 9/15/25.*Diclofenac (a pain relief medication) tablet, 75 mg (milligram). Give one tablet by mouth twice daily as needed. Started on 6/18/25. From 9/3/25 to 9/20/25, she used that medication 19 times.*Hydrocodone 5 mg (an opioid)/acetaminophen 325 mg (an analgesic pain relief medication) combination tablet. Give 1 tablet by mouth every eight hours as needed for pain. Started on 9/8/25. From 9/8/25 to 9/30/25, she had used that medication 43 times.*Hydromorphone 2 mg (an opioid) tablet. Give one tablet by mouth every four hours as needed for pain for up to five days. Started on 9/3/25 and discontinued on 9/8/25. During that time, she used that medication 18 times. 10. Phone interview on 9/30/25 at 3:01 p.m. with CNA D revealed that on 8/29/25 at around 7:25 p.m., he was taking two residents out to the smoking area. He was pushing residents 1 and 2 at the same time. Resident 1 was on his right side, and resident 2 was on his left side. As they were passing by the round activity room, part of resident 1's wheelchair caught on the wall of windows and she began to fall out of her wheelchair. I went to grab her to lower her to the floor. He called for help over the walkie talkies. Two other CNAs and two nurses responded to help.He indicated that he felt that they were short-handed that evening as he felt rushed to get his four residents out to their last smoke break for the day. One of the residents was feeling anxious to go outside, so he transported two residents at one time. He confirmed that he knew the general rule was to transport one resident at a time in their wheelchairs.After the incident, the nurse asked him to write down his statement. No one else interviewed him about the incident. He confirmed there was no disciplinary action, and there was no follow-up education provided. He was reassigned to the other unit for about a week or two after the incident but had since been reassigned back to resident 1's unit.He confirmed that when resident 1 returned to the facility, he went to apologize to her and said, I was at a loss for words. 11. Phone interview on 9/30/25 at 3:16 p.m. with LPN I revealed that he was resident 1's nurse that evening shift on 8/29/25. He did not witness the incident. He was preparing for the evening medication pass when CNA D was pushing residents 1 and 2 out to the smoking area. He said that I was not comfortable with him [CNA D] pushing two residents at the same time. He said that he expected staff push one resident at a time in their wheelchairs.He heard the commotion as she [resident 1] was in excruciating pain. She was yelling out in pain. He and another staff attempted to roll the full body lift sling underneath her to pick her up, but resident 1 was in too much pain to roll her on her side. They decided to leave her lying on her back until the EMS employees arrived.He confirmed that no one interviewed him about his involvement in the incident and that there was no follow-up education provided about resident safety protocols or policies. 12. Phone interview on 9/30/25 at 3:29 p.m. with CNA L revealed that she witnessed part of the incident. She was filling in for the front desk representative that day and she was delivering residents' packages. She saw CNA D pushing two residents at one time towards the smoking area. She confirmed that resident 1's wheelchair was close to the wall of windows. After resident 1 fell out of her wheelchair, she took charge of the other residents in the area and brought them to a safe location to give everyone else more room.She confirmed that no one had interviewed her about what she saw or her involvement in the incident, and there had been no follow-up education provided about resident safety. She said that she was a newer CNA and that some staff members told her it was okay to transport two residents at once, and others said that was not okay to do. 13. The survey team attempted to contact RN J on 9/30/25 at 3:38 p.m. via phone and left a voicemail. 14. Interview on 9/30/25 at 4:34 p.m. with interim administrator A and MDS coordinator B revealed that it was both their expectations that staff should push one wheelchair at a time. MDS coordinator B confirmed she was the interim director of nursing. They said that everyone should have foot pedals. Interim administrator A said that since she started a couple of months ago, she had noticed a lack of wheelchair foot pedals and was in the process of obtaining more.They both confirmed that resident 1 did not like the normal wheelchair foot pedals due to the contractures in her knees. With the way resident 1's legs were positioned, the standard wheelchair foot pedals were too far forward for her comfort.Their investigation included gathering a statement from CNA D and resident 1 about what had happened. MDS coordinator B confirmed that RN J spoke with CNA D and educated him on pushing one resident at a time in their wheelchair. 15. RN J returned the survey team's phone call on 9/30/25 at 6:08 p.m. That interview revealed that she was working on the green wing, and she was preparing to administer resident medications. She heard someone yelling, My hip! My hip!She went out of the green wing and saw resident 1 on the floor. CNA D told her that resident 1's wheelchair brake got caught on the side of the window panels. She measured the resident's vitals. Resident 1 was experiencing 10 out of 10 pain. They were attempting to use the full body lift to lift her up off the floor, but resident 1 was not able to tolerate that movement due to the pain. She contacted the on-call emergency medical provider, and they ordered for resident 1 to be assessed that the ED.She reported the incident to administrator A and the director of nursing. She instructed CNA D to write out a witness statement. She did not obtain witness statements from anyone else.She said that it was her expectation that staff transport one resident at a time in their wheelchairs. She confirmed that she provided education to CNA D to utilize the walkie talkies to ask for help, and to transport one resident at a time rather than two at a time. 16. Review of the provider's 1/22/23 FALLS-CLINICAL PROTOCOL policy revealed:* .3. Documentation-Responsible Parties:--Nursing staff--Physicians (if required)*3.1. Incident Documentation-Fall Report: Document the details of the fall, including:--Date, time, and location of the fall.--Circumstances leading to the fall.--Observations of the resident's condition immediately after the fall.--Any witnessed reports or bystanders.--Interventions provided immediately after the fall.* .5. Post-Fall Evaluation and Prevention-Responsible Parties:-Nursing staff-Social Worker or Care Coordinator-Physical Therapists (if applicable)-Physician (if applicable)*5.1. Reassess Fall Risk-.Update Care Plan: Adjust the care plan to address fall prevention strategies, such as:--Increased supervision or assistance with mobility.*5.2. Family and Resident Education-Family and Resident Discussion: Educate the resident and their family about the fall and the potential consequences. Discuss preventative measures that can be implemented moving forward.-Environmental Modifications: Ensure the resident's environment is safe (e.g., removing tripping hazards, ensuring good lighting, and using non-slip rugs).*The policy did not include staff education to prevent falls.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, observation, record review, and policy review the provider failed to effectively implement and follow their policy for 5 of 8 sampled residents (1, 2, 4, 5, and 6) who smoked and accurately assess 1 of 1 sampled resident (3) who vaped. Findings include: 1. Review of the provider's SD DOH FRI regarding resident 1 revealed: *On 11/25/24 during her weekly skin check she was observed to have what appeared to be a cigarette burn on her abdomen. -That wound measured 0.6 centimeters (cm) x 1cm x 0.1cm. -A physician's order was obtained to apply bacitracin to wound once daily and cover with a band-aid. Change daily. Leave uncovered during bath/shower. *Resident 1 had reported she had been out to smoke and the wind caught her smoking apron and hit her cigarette causing the cherry (burning end) to fall off and burn her skin. 2. Interview on 12/30/24 at 2:20 p.m. with resident 1 revealed: *She had received a small burn from her cigarette about a month ago. -She recalled she wore an apron that day because the wind blew it up and hit her cigarette and knocked the tip off. -The hot end had fallen inside of her shirt. -She confirmed that the burn was on her belly and that she did not tell anyone about it because it wasn't a big deal. *A staff member was always outside with her when she smoked. *She confirmed that the staff had asked her to wear an apron and she had, at times, chosen not to wear it. 3. Observation and interview on 12/30/24 at 2:58 p.m. with resident 1 and registered nurse (RN) E revealed: *RN E was aware that resident 1 had received a burn to her abdomen while smoking that had healed. *The area appeared slightly pink, raised, about the size of the head of an eraser. *RN E stated that residents were supervised while smoking, although some staff supervised by observing the residents through the glass door and windows. 4. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnosis included cerebral infarction, fracture of the left tibia, Type 2 Diabetes, acquired absence of right leg above the knee, nicotine dependence, cigarettes. *Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. *Her care plan indicated The resident is a smoker. -Goals included, The resident will not suffer injury from unsafe smoking practices . and Resident will Adhere to the Substance Use Policies of the Facility . -Interventions included: --Instruct resident about the facility policy on smoking: locations, times, safety concerns. --Notify charge nurse immediately if it is suspected resident has violated facility smoking policy. --Observe clothing and skin for signs of cigarette burns. --The resident requires a smoking apron while smoking. --The resident requires SUPERVISION while smoking. *An 11/25/24 Smoking Safety Screen indicated: -Resident refused smoking apron and burned herself. -The resident's need for adaptive equipment indicated, Smoking apron and Supervision. -Team Decision indicated Safe to smoke without supervision. -Education [was] done with [the] resident to be safe during smoking and to always wear a smoking apron. *There was no indication in her EMR that a smoking safety screen had been completed on her 9/24/24 admission to the facility. *An 11/25/24 progress note (PN) indicated, Skin assessment done this morning after shower. New wound noted on R [right] side of upper abdomen. Approximately .75 cm circular burn. Resident states it happened a couple [of] days ago. Resident denies telling staff about it when it happened and had refused her smoking apron prior to the incident. *An 11/25/24 physician's order indicated, Apply bacitracin to wound once daily and cover with a band-aid. Change daily. Leave uncovered during bath/shower. *A 12/1/24 PN indicated, Noted that band aid on mid chest. Res [resident] states has been there since the 25th from a burn which occurred while on a smoking break with her apron on but it was windy and res. went to grab the apron as it flew off and a cherry from the cigarette landed on her chest. She tried to get it off immediately but ended up with a burn. Will monitor and obtain Dr. order for a dressing if needed. cleansed with soap and water and OTA [open to air] at this time . 5. Observation and interview on 12/30/24 at 2:30 p.m. of the smoking area with director of social services (DSS) C revealed: *There were separate smoking times for each neighborhood because of the number of residents who smoked. *A key fob and a code were required to open the door to the designated smoking area. *Staff supervised residents when they smoked. *The residents were not provided with the door code. *The outside designated smoking area had a red metal-covered pail and a sign that indicated no smoking beyond that point. -There was a fenced-in courtyard with walking paths beyond that sign. 6. Observation on 12/30/24 at 3:37 p.m. with RN D of the smoking area revealed: *RN D assisted the residents by opening the door and supervised the residents while they smoked. *Resident 3 was in a power chair and had used a vape. *Resident 4 was in a power chair, did not wear a smoking apron, and did not stay within the designated smoking area while smoking. *Resident 6 walked independently, wore a smoking apron, and walked beyond the smoking area while smoking. 7. Interview on 12/31/24 at 10:28 a.m. with certified nursing assistant CNA G revealed: *Residents had four smoking times each day. *He supervised residents when they smoked. *Residents were required to wear aprons when they smoked. -He stated, No apron, No smoke. -Some residents refused to fasten the Velcro straps on the apron so he tucked the apron into the side of the wheelchair. *The smoking area was not covered. -He would supervise from inside the doors when the weather was bad. -At times, he would take residents to smoke in the covered area at the front of the building. 8. Interview on 12/31/24 at 10:40 p.m. with ADM A revealed: *There was no vaping policy. -They had referred to the smoking policy. -She confirmed the provider's smoking policy did not include vapes. *She expected residents to stay in the designated smoking area. -If residents went beyond the designated smoking area, she expected staff to report that violation of the smoking policy to the charge nurse. -The front of the building was not a designated smoking area. 9. Review of resident 2's EMR revealed: *He was admitted on [DATE]. *His diagnosis included unspecified dementia, moderate with agitation, Wernicke's Encephalopathy, and nicotine dependence, cigarettes. *There was no indication that a smoking safety screen had been completed since his admission. *His care plan did not include that he smoked or what interventions were required to ensure his safety while smoking. Review of resident 3's EMR revealed: *He was admitted on [DATE]. *His diagnosis included quadriplegia C5-C7 incomplete, and acute and chronic respiratory failure with hypoxia. *A 10/25/23 SMOKING- SAFETY SCREEN indicated: -The resident's need for adaptive equipment indicated Supervision. -Team Decision indicated Safe to smoke with supervision. -Vape pen, resident able to operate independently. *There was no indication that an annual or quarterly smoking safety screen had been completed since his admission. *His care plan indicated: -Resident uses vape products. -Resident will maintain safe vape practices under the supervision of staff . -Notify charge nurse immediately if it is suspected resident has violated facility smoking/vaping policy and substance abuse policy. Review of resident 4's EMR revealed: *She was admitted on [DATE]. *Her diagnosis included paraplegia, depression, anxiety, and nicotine dependence, cigarettes. *An 8/22/24 SMOKING- SAFETY SCREEN indicated: -The resident's need for adaptive equipment indicated Smoking apron. -Team Decision indicated Safe to smoke without supervision. *There was no indication that a quarterly smoking safety screen had been completed since her admission. *Her care plan indicated The resident is a smoker. -Goals included, The resident will not suffer injury from unsafe smoking practices . -Interventions included: --Instruct resident about the facility policy on smoking: locations, times, safety concerns. --Notify charge nurse immediately if it is suspected resident has violated facility smoking policy or substance abuse policy. --Observe clothing and skin for signs of cigarette burns. --The resident requires a smoking apron while smoking cigarettes. *The care plan did not indicate what level of supervision was required while smoking. Review of resident 5's EMR revealed: *She was admitted on [DATE]. *Her diagnosis included unspecified dementia, unspecified severity with psychotic disturbance, and nicotine dependence, cigarettes. *A 2/22/24 SMOKING- SAFETY SCREEN indicated: -The resident's need for adaptive equipment indicated Smoking apron, and Supervision. -Team Decision indicated Safe to smoke with supervision. *Her care plan indicated Resident is a smoker. -Interventions included Assess for safety with smoking quarterly and as needed. *There was no indication that a quarterly smoking safety screen had been completed since 2/22/24. Review of resident 6's EMR revealed: *He was admitted on [DATE]. *His diagnosis included vascular dementia, mild, with agitation, and nicotine dependence, cigarettes. *His care plan indicated he was a smoker. *There was no indication that a smoking safety screen had been completed since his admission. 10. Interview on 12/31/24 at 8:31 a.m. with director of nursing (DON) B revealed that she expected the charge nurse or DSS C would have completed smoking assessments when a resident was admitted , quarterly, or when there was a significant change. 11. Interview and documentation review on 12/31/24 at 9:50 a.m. with ADM A revealed: *She expected smoking assessments to be completed for residents who chose to smoke on admission and quarterly after that policy was revised in November 2024. -The previous policy stated smoking assessments were completed on admission and annually. *She provided resident documentation for review. *She expected that resident 1 would have had a smoking assessment completed when she was admitted on [DATE]. -That had not been completed. *She expected resident 2 would have had a smoking assessment completed when he was admitted on [DATE] and that his care plan would have been updated. -There was no documentation that a smoking safety screen had been completed and the care plan did not contain a focus area on smoking. *She confirmed resident 3 vaped and the last smoking safety screen was completed on 10/25/23 when he was admitted . -She expected an annual smoking safety screen would have been completed in October 2024. --That had not been completed. *She confirmed that resident 4 had a smoking safety screen completed on admission. -She expected a quarterly safety screen would have been completed in December 2024 after the policy changed. --That had not been completed. *She expected resident 5 would have quarterly smoking safety screens completed because that was indicated on her care plan. -Resident 5 had smoking safety screens completed on 2/20/23 and 2/24/24. -Those had not been completed quarterly. *She expected resident 6 would have a smoking assessment completed when he was admitted on [DATE] and again quarterly in December 2024. -Those had not been completed. *A Temporary Smoking Policy Additions was added to the smoking policy on 11/27/24 to address inclement weather. Review of the provider's revised 11/6/24 Resident Smoking Policy revealed: *Smoking is defined as the use of tobacco products in the form of cigarettes, electronic cigarettes, pipes, or other methods of smoking tobacco. *Smoking is only permitted in the designated resident smoking area, located outside in the memory care courtyard, outside memory care doors. *The resident will be evaluated on admission to determine if he or she is a smoker or non-smoker. If a smoker the evaluation will include: -Current level of tobacco consumption; -Method of tobacco consumption (traditional cigarettes; electronic cigarettes; pipe etc.); -Desire to quit smoking, if a current smoker. *A resident's ability to smoke safely will be re-evaluated quarterly, upon a significant change (physical or cognitive), by show of noncompliance with facility smoking policy, and is determined by the staff. * Any smoking related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the care plan, and all personnel caring for the resident shall be alerted to these issues. *All residents with smoking privileges require monitoring/direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. Residents must remain with in 25 ft [feet] of a fire extinguisher, which is located inside the smoke break doors. Review of the provider's 11/27/24 Temporary Smoking Policy Additions revealed: *Facility supervised smoking times are subject to be canceled due to the inclement weather conditions including but not limited to extreme temperatures and high winds. The charge nurse on duty will be responsible for determining if weather is deemed safe for resident smoking. This is a temporary safety procedure the facility is required to immediately implement. In the meantime, the interdisciplinary team in consultation with the SD Department of Health and facility Ombudsman will work to determine long term facility policy changes. B. Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), interview, observation, and record review, the provider failed to ensure the safety of a resident by not providing adequate monitoring and supervision of a resident identified at a high risk for and with a known history of elopement (leaving the facility without staff knowledge) for one of one sampled resident (6) who was observed by staff (H) to have gone on an unsupervised walk outside and then left the property without staff knowledge of his location for over an hour. Findings include: 1. Review of the provider's 12/30/24 SD DOH FRI regarding resident 6 revealed: *On 12/30/24 at approximately 10:35 a.m. resident 6 exited the facility through the front doors to walk the emergency access road that circles around [the] facility. *At 10:52 a.m. receptionist H: -Requested maintenance look outside the building for resident 6. -Notified administrator (ADM) A and director of social services (DSS) C that resident 6 had not returned from his walk. -It had been 17 minutes since resident 6 had exited the building for his walk. *At 11:04 a.m. unable to locate resident 6, ADM A alerted the police department, and a community search was initiated. *At approximately 12:07 p.m. resident 6 returned to the facility with a friend who indicated that resident 6 had walked over to his apartment located behind the facility and they had hung out for a bit. *It had been 1 hour and 32 minutes since he had left the facility. *Skin check completed resident is uninjured. Resident POA [Power of Attorney] notified. Physician notified. 2. Interview on 12/30/24 at 3:58 p.m. with ADM A revealed: *The front sliding glass doors have an alarm that will sound but they open automatically. *Resident 6 had been allowed to walk the circle road outside the fenced area around the facility without someone with him. -That was a non-pharmacological (without medication) intervention to help with some of his behaviors. *Receptionist H was allowed to let resident 6 leave the building when he requested to walk the circle. -She expected receptionist H to alert additional staff if resident 6 did not return within 10 to 15 minutes. *Resident 6 had left the circle and walked to an apartment next door to visit a friend. -They had not been aware that he had a friend who lived at that apartment building. *Resident 6 had been provided a wanderguard after the incident on 10/9/24 to alert staff if he exited the building when there was no staff at the front reception area to turn off the alarm or if he attempted to exit the building in the evening, or without staff knowledge. *Resident 6 was allowed to leave the facility with a responsible party. -She expected him to be signed out when he left. *An elopement was reported to SD DOH a couple of months ago when resident 6 exited the building without a responsible party. *She did not consider resident 6 having been outside the facility on a walk that day an elopement. *She considered him leaving the property without a responsible party signing him an elopement. 3. A review of the provider's 10/9/24 SD DOH FRI regarding resident 6 revealed: *Resident 6 told the dietician that he was meeting his sister-in-law, and they were going to Sioux City for the night then exited the building. *Resident 6 was educated on the need to wait for his sister-in-law to come into the building and not wait outside. *Interventions put in place include: -Resident 6 was placed on 15-minute checks for 24 hours. -A whiteboard was put in resident 6's room to orientate him to the current date, upcoming events, and special instructions -The provider's Elopement and Wandering Residents policy was reviewed. -Resident 6's care plan was updated on 10/11/24 to reflect additional preventions and non-pharmacological interventions. -*An elopement drill was conducted with staff on 10/10/24. 4. Observations on 12/30/24 between 12:15 p.m. and 4:30 p.m. of the exterior of the facility and surrounding area revealed: *It was lightly raining, and it was 36 degrees. -There was no snow on the ground. *There was a circular driveway around the entire building. -That was an extension of the parking lot that went towards the back of the facility beyond the fenced-in areas. *There was an apartment building to the right of the facility approximately 500 feet from the facility according to a map. 5. Interview on 12/31/24 at 11:00 a.m. with receptionist H revealed: *She had turned off the alarm and allowed resident 6 outside to go for a walk yesterday (12/30/24). -She notified maintenance and ADM A when resident 6 had not returned after 15 minutes. *Resident 6 had been allowed to go for walks around the building alone, but now he needed to have someone with him. 6. Interview on 12/31/24 at 11:20 a.m. with resident 6 revealed he: *Enjoyed walking outside and knew he was not allowed to leave without notifying staff. *Had recently learned that his ex-brother-in-law lived next door. -His ex-brother-in-law had visited him at the facility and told him where he lived. *Had walked to that apartment yesterday (12/30/24) and had not told staff. -He said he asked his ex-brother-in-law to sign him out and his ex-brother-in-law had reassured him it was fine. 7. Review of resident 6's EMR revealed: *He was admitted on [DATE]. *He was [AGE] years old. *His diagnosis included vascular dementia, mild, with agitation, other stimulant abuse, wandering in diseases classified elsewhere, Diabetes Mellitus, and nicotine dependence. *His Brief Interview for Mental Status (BIMS) assessment score was 9, which indicated he was moderately cognitively impaired. *A 12/10/24 Wandering Risk Scale indicated he was able to walk, had a history of wandering, and had a high to wander. Review of resident 6's care plan revealed: *Resident is independent with ambulation. [Resident 6] likes to walk the halls and neighborhoods for exercise. *A 10/9/24 focus area indicated he had a high risk of wandering and elopement due to mobility and dementia. -Goals included: --Resident will have no elopements during the review period. --The resident's safety will be maintained through the review date. -Interventions included: --If available, offer to walk with [the] resident outside the facility loop. May walk [the] loop by self if front staff are available for observation. --Attempt to redirect or distract resident by offering to walk with him back to his room/wing for [a] snack, coffee, games, etc. --Wanderguard in place on resident's ankle. --Nurse to verify if wanderguard is functioning properly once a day. --Staff to verify wanderguard is working properly every shift. --Whiteboard calendar in [resident 6's] room to help with orientation. Appointments and visitations from friends and family to be noted on [the] calendar. Include time and instructions. *A 9/22/24 focus area indicated, The resident has impaired cognitive function/dementia or impaired thought process r/t [related to] vascular dementia. Resident short term memory is significantly impaired. Resident often repeats the same story multiple times in short spans of time. -Interventions included: --Cue, reorient and supervise as needed. --Resident wears [a] wanderguard on [his] ankle due to history of elopement/getting lost while walking at home. --Observe/document/report PRN [as needed] any changes in cognitive function, specifically changes in: decision making ability, memory, recall and general awareness, difficulty expressing self, difficulty understanding others, level of consciousness, mental status. 8. Interview on 12/31/24 at 11:42 a.m. with director of nursing B regarding resident 6's elopement revealed: *Resident 6 had a BIMS score of 9, which indicated he had moderate cognitive impairment. *She had completed a wandering assessment on resident 6. -The assessment had several questions that determined a number score. -That number score was coded High Risk to Wander. *She had been involved in the decision to allow resident 6 to walk outside around the loop when staff were aware of his location. *Resident 6 had episodes of forgetting but him walking outside had not been an issue before. *The facility contacted Dakota at Home regarding placement options as they had been aware of the need to balance resident 6's abilities with keeping him safe. *Resident 6 was to be checked on every 15-minutes. -It had not been determined how long those would be needed, possibly indefinitely. 9. Interview on 12/31/24 at 12:54 p.m. with DSS C revealed: *Resident 6 had been at the facility, was discharged home to reside with his brother, and then returned to the facility in September. -His brother had noticed resident 6 had increased behaviors and he was unable to care for him at home. *Resident 6 returned with increased behaviors that included outbursts of swearing and being short-tempered with staff. He was not aggressive. -Walking was an intervention that helped decrease those behaviors. *She initiated a referral with Dakota at Home in October for options planning, to seek alternative placement if it was needed. *She had completed his last BIMS assessment which indicated a score of 9 (moderately cognitively impaired), -She stated, Sometimes that score seems accurate, and other times it does not. *She had requested a neuropsychiatric evaluation to determine if resident 6 had an undiagnosed mental health condition. *Resident 6 had recently learned that a friend lived next door. -The staff had not been aware of that. -The friend was not familiar with the facility policies. --Education was provided to the friend and resident 6, that resident 6 needed to be signed out by a responsible party before he could leave the facility. 10. Interview on 12/31/24 at 1:30 p.m. with ADM A regarding resident 6's care plan revealed. *The person responsible for updating the care plan was unavailable for an interview. *She expected resident 6's care plan to accurately reflect his unique circumstances and specific needs. *She expected the care plan to be updated quarterly and with any changes. -On 12/30/24 she updated resident 6's care plan after the elopement to reflect the need for supervision when he walked outside. Review of the provider's revised 6/2/24 Elopement and Wandering Residents policy revealed: * This [provider's name] ensures that residents who exhibit wandering behaviors and/or are at risk for elopement receive adequate supervision to prevent accidents, and receive care in accordance with their person-centered plan of care addressing the unique factors contributing to wandering or elopement risk. *Elopement occurs when a resident leaves the premises or a safe area without authorization . and/or any necessary supervision to do so. *The facility shall establish and utilize a systematic approach to monitoring and managing residents at risk for elopement or unsafe wandering, including identification and assessment of risk, evaluation, and analysis of hazards and risks, implementing interventions to reduce hazards and risks, and monitoring for effectiveness and modifying interventions when necessary. *The interdisciplinary team will evaluate the unique factors contributing to risk in order to develop a person-centered care plan. *Interventions to increase staff awareness of the resident's risk, modify the resident's behavior, or to minimize risks associated with hazards will be added to the resident's care plan and communicated to appropriate staff. *The effectiveness of interventions will be evaluated, and changes will be made as needed. Any changes or new interventions will be communicated to relevant staff.

Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and observation, the provider failed to prevent an injury to one of one sampled resident (1) who developed a skin burn wound on her abdomen from hot food that was prepared for her by staff in a microwave. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 10/10/24 SD DOH FRI regarding resident 1 revealed: *On 9/26/24 at 8:30 p.m. resident 1 requested registered nurse (RN) B to make a freezer meal in the microwave for her. *RN B cooked the meal according to package instructions. *RN B provided education to the resident that the item was hot and to let it sit for a while. *RN B returned to assist the resident into bed at 1:00 a.m. -She noted a red circle mark on resident 1's abdomen. -Inside the red circle were four blisters. *The physician was notified. *Orders were obtained for dressing in the burn area. *Resident 1 had a diagnosis of paraplegia. *Her hot liquid assessment completed on 7/15/24 score was 1 which indicated she could consume hot beverages independently. 2. Interview on 10/22/24 at 9:12 a.m. with RN B revealed: *Resident 1 had asked her to prepare a microwave meal for her. *She prepared the meal according to package directions. *When she brought the meal to resident 1, she told her it was hot and to let it cool before eating. *She assisted the resident into bed around 1:00 a.m. and found a red mark and four blisters on her abdomen below her breast line. *She completed a skin note in resident 1's chart. *She applied a Mepilex (absorbent foam) dressing to the blistered area. *She had not completed a risk management report. *She reported resident 1's burn to the morning nurse. *She had not faxed the primary care provider to get orders for the burn. 3. Interview on 10/22/24 at 3:10 p.m. with administrator A revealed: *She started audits to review microwave temp logs every morning. *The director of nursing received education on reportable incidents. -She did not think it was reportable due to the education the RN B had provided to resident the night of 9/26/24. *She planned to complete audits three times weekly until 100% compliance was met for 2 weeks. *Provider's next QAPI (Quality Assurance and Performance Improvement) meeting was scheduled for 10/23/24 and they planned to review new policies to ensure they are effective in preventing the reoccurrence of this type of injury. *QAPI committee will review yearly education and incorporate bi-annual reeducation of staff. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 10/22/24 after a record review revealed: *The provider followed their quality assurance process and education was provided, to all nursing care staff. -The nursing staff had been educated on their Hot Liquid and Food Safety Policy update, competencies were conducted, and audits were completed on 10/22/24 with the expectation to complete three times per week until 100% compliance for two weeks by the administrator or designee. *These will be reviewed during the QAPI meeting on 10/23/24 and after until compliance. *The provider's Abuse and Neglect Policy was updated to include language on failure to comply with the facility policies and procedures. *A Heating Food in Microwave Policy was created on 10/14/24. This included proper temping of food after microwaving, and temping food before serving the food to the residents. *All coffee machines in the facility have been adjusted to a 120-degree serving temperature. *The director of nursing was educated on food serving, reporting expectations, and procedures for when a resident is found to have a burn from a hot object. *All nurses were educated on procedures for when a resident is found to have a burn as a result of hot object. *All resident care plans were reviewed and updated as necessary based on policy changes. *Record review of other resident care plans after 9/26/24 showed they were following their new and updated policies. *Observations and staff interviews revealed the staff understood the education provided and the revised processes. Based on the above information, non-compliance at F689 occurred on 9/26/24, and based on the provider's implemented corrective action for the deficient practice confirmed on 10/22/24, the non-compliance is considered past non-compliance.