**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review and policy review, the provider failed to ensure one of one sampled resident (90) was protected from verbal and physical abuse by his roommate (resident 89). Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he: *Was sitting in his recliner. *Had been admitted earlier in the month because he had fallen at home and fractured his pelvis. *Had communicated during the interview that his roommate (resident 90) was in the room touching his belongings. He had asked him to stop and the roommate had continued to touched his personal items. *Then pushed the roommate. *Was able to slide up to the front of the recliner seat and displayed how he pushed his rommate back behind the privacy curtain by using a motion with his arm. *Stated the roommate had stumbled back, had fallen, and staff came into the room and picked him up off the floor. *Stated that if his roommate touched his belongings again he would 'lay him out'. *Then expressed he understood resident 90 was not well and had not always understood what was going on. Review of resident 89's medical record revealed: *He was admitted on [DATE]. *His 2/15/23 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnoses included: fracture of superior rim of right pubis, contusion right shoulder, fracture of unspecified parts of the lumbosacral spine and pelvis, chronic kidney disease, pain, repeat falls, pressure-induced deep tissue damage of the left heel, and obesity. Review of resident 89's 2/24/23 care plan revealed his mood and behavior had not been addressed so there had been no goals or interventions put in place. 2. Observation on 2/27/23 at 3:54 p.m. of resident 90 revealed: *He was confused wandering in the hallway outside of his room. *His speech was garbled. *He could not answer questions when asked. *He had not appeared to have any injuries or bruising. Review of resident 90's medical record revealed: *He was admitted on [DATE]. *He was unable to complete the BIMS due to his cognition. *His 2/16/23 Medical Data Set assessment indicated he had short and long-term memory problems. *His diagnoses included: Alzheimer's disease, cellulitis of left upper limb, heart failure, anxiety disorder, and amnesia. *He had fallen on 2/11/23, 2/19/23, and 2/20/23. Review of resident 90's interdisciplinary progress notes from 2/11/23 through 3/1/23 revealed he was having multiple behaviors that included: -Wandering throughout the facility and into other resident's rooms. -Looking through other residents' belongings. -Exit seeking. -Becoming verbally and physically abusive with staff. -Removing his clothing in public areas. Review of resident 90's Fall Reports revealed on: *2/11/23: -He had an unwitnessed fall in the dining room. -No investigation had been completed. -No interventions had been put into place to prevent another fall. *2/19/23: -He had been found lying on the floor in his room. -No investigation had been completed. -No interventions had been put into place to prevent another fall. *2/20/23: -He had been found on the floor in his room and had been incontinent of bowel. -No investigation had been completed. -No interventions had been put into place to prevent another fall. Review of resident 90's 3/1/23 care plan revealed: *He had a Potential for falls r/t [related to] impaired cognition. *Interventions were: *Appropriate non-slip footwear. *Be sure call light is within reach and encourage to use it for assistance as needed. *Coordinate with appropriate staff to ensure a safe environment with: Floors even and free from spills or clutter, Adequate, glare-free light, Call light, Personal items within reach. *PT evaluate and treat as ordered or PRN [as needed]. *No new fall interventions had been added to the care plan since 2/13/22. *He had behaviors related to dementia and from being in a new environment. *His behaviors were wandering, exit-seeking, and going through other's personal belongings. *The interventions included the following: -Anticipate and meet needs of resident including toileting on a schedule every 2 hours at the least. -Attempt non-pharmacological interventions such as giving resident a magazine, the tinkering box with locks and latches, a snack. -Ensure that hallways are free from spills, clutter and other hazards. -Redirect resident to a new activity if he is wandering into other's rooms or getting into other's stuff. 3. Review of resident 89's 2/22/23 nursing progress note revealed: *Resident became angry at roommate and started shouting at him. *The nurse intervened just as the resident was about to kick and hit his roommate [resident 90]. *The resident was talking to his son on the phone during that time. *The nurse immediately removed the roommate from the situation. *It appeared the roommate [resident 90] was previously just standing in the room. *[Resident 89's] son called nurse and spoke to nurse expressing concern for the situation and worried that his dad has a temper. *DON [director of nursing] notified of situation. 4. Interview on 2/28/23 at 3:15 p.m. with DON B and social services designee (SSD) G regarding the situation between residents 89 and 90 revealed: *They both were unaware that resident 89 had pushed resident 90. *DON B was aware of the incident that occurred between the residents on 2/22/23. *DON B had not really identified that the incident on 2/22/23 was resident-to-resident abuse. *The nurse involved in the incident had educated resident 89 that it was not appropriate to yell or threaten his roommate. *There was no documentation of resident 89's education by the nurse. *Since there had been no other incidents since 2/22/23 the residents had not been moved or separated. *Residents were not monitored twenty-four hours a day. *Staff may not have been aware of another incident that had occurred between the residents because the residents had not been monitored twenty-four hours a day. *They had not completed an investigation of the incident that occurred on 2/22/23 between the residents. Interview on 3/1/23 at 8:18 a.m. with DON B regarding the situation between residents 89 and 90 revealed: *They had planned on moving resident 90 into another room but had been waiting on a family consent to move another resident first. *No other resident safety interventions had been put into place to protect resident 90 until the room move was completed. *No investigation for the resident-to-resident incidents had been started. Interview on 3/1/23 at 8:58 a.m. with administrator A and DON B regarding the situation between residents 89 and 90 revealed: *SSD G had spoken with resident 90 yesterday about his behaviors. *Had been waiting for resident 22's family to call and consent to a room change so the residents could be moved away from each other. *Staff had been observing the residents when they were awake but not when they were asleep. *Agreed either resident could have awoken and staff would not have known if they were up and moving. *They did not have one-to-one staff monitoring in place for resident 89 or 90 to ensure their safety. *Agreed they had not investigated the verbal abuse that had occurred on 2/22/23. 5. Interview on 3/2/23 at 10:52 a.m. with DON B regarding falls revealed: *Nurses did not document interventions put into place after a resident had fallen. *Falls had only been reviewed by the interdisciplinary team (IDT) on Monday mornings. *The IDT did not complete an investigation or implement new interventions when a resident had a fall. Refer to F610 finding 1 for policies.

Based on interview, record review, and policy review, the provider failed to investigate and report alleged abuse to the South Dakota Department of Health (SD DOH) for two of two sampled residents (89 and 90) who had inappropriate verbal and physical behavior between each other and one of the residents (90) was cognitively impaired. Findings include: 1. Observation and interview on 2/27/23 at 3:54 p.m. with resident 89 in his room revealed he had pushed his roommate (resident 90) causing his roommate to fall. Refer to F600 finding 1 and F610 finding 1. Review of resident 89's 2/22/23 nursing progress note revealed: *Resident 89 had been found to be shouting at resident 90 and threatening to hit and kick him when a nurse intervened. *There was no investigation related to that incident. -This incident had not been reported to the South Dakota Department of Health (SD DOH). Refer to F610 finding 1. Interview on 2/28/23 at 3:15 p.m. with director of nursing (DON) B and social services designee (SSD) G revealed: *They were not aware resident 89 had pushed resident 90 causing him to fall. *DON B was aware of the incident that had occurred between residents 89 and 90 on 2/22/23 but there had been no investigation completed. *Neither incident had been reported to the SD DOH. Refer to F610 finding 1.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Observation on 2/27/23 at 12:22 p.m. of resident 21's room revealed: *She was not in her room. *A sign attached to the wall above her bed that read, Blue heel protectors to be worn in bed. Observation on 2/28/23 at 2:23 p.m. and at 3:01 p.m. of resident 21 in her room revealed: *She was in her bed with her eyes closed. *She did not have on blue protector boots. *There were blue protector boots on floor at the end of her bed. Observation on 3/02/23 at 7:50 a.m. of resident 21 revealed: *She was in her bed with her eyes closed. *Her legs were covered with a blanket. *There was one blue protector boot on the floor next to the bed. Interview on 3/1/23 at 1:58 p.m. with CNA J regarding resident 21 revealed: *She was to wear the blue protector boots when in bed and up in her chair. *Sometimes she would kick off her blue protector boots. Review of resident 21's medical record revealed: *She was admitted on [DATE] and her diagnoses included: a 1/24/23 diagnosis of pressure-induced deep tissue damage of her left and right heels, pain, dementia, mood disturbance, and anxiety. *Her 1/25/23 BIMS score was a 3, meaning she had severe cognitive impairment. *Review of her hospital notes from 1/18/23 to 1/24/23 revealed she had bilateral heel pain during her hospital stay. *Her 1/30/23 Braden scale score was 18, meaning she was at low risk for development of pressure ulcers. Review of resident 21's 1/25/23 nursing admission assessment revealed: *She had no open areas, ulcers, or other skin issues identified. *Both of her heels were boggy, reddened, but blanchable and she had reported pain to both heels. Review of resident 21's physician orders revealed: *On 1/24/23 to complete skin assessments weekly. *On 2/2/23 to treat her left heel SDTI per AMT guidelines. *On 2/8/23 to have pressure Injury treatment/prevention on each shift two times a day related to pressure-induced deep tissue damage of her right and left heels. --To check that air mattress was on the bed and operating correctly. --To ensure bilateral heel protectors were worn at all times except during transfers. --To ensure dressings were in place as ordered. --To have a pressure redistribution cushion in her wheelchair. --Reposition her every two to three hours. Review of resident 21's 2/8/23 care plan included: *She required extensive assist of two staff members for care including repositioning in bed. *A 1/25/23 focus of a potential for pressure ulcer related to her impaired mobility and incontinence. -Her goal for the focus was to have intact skin, free of redness, blisters, or discoloration. -Interventions on 1/25/23 for the focus and goal included weekly skin inspections by licensed staff and daily skin inspections with care, turn and reposition every two to three hours and as needed (prn), and to float heels. --Interventions added on 2/8/23 included heel protectors in bed and shoes for transfers only. -Her care plan had not included that she had SDTI of her left and right heels or that she kicked off her heel protectors at times. Review of resident 21's progress notes revealed: *On 2/4/23 her heels were slightly reddened, and she was wearing blue protector boots when in bed for her boggy/painful heels. -Staff floated her heels using pillows under her legs. -She had a pressure redistribution mattress on her bed and a pressure redistribution cushion in her wheelchair. -She was repositioned every two to three hours and prn. *On 2/8/23, Brought to nurse's attention this morning that resident's heels have dark spots. Nurse assessed and sees dark purple/maroon area of discolored in tact [intact] skin to bilat [bilateral] heels. Upon admission, resident had reddened, boggy heels. Area is oval in shape. Peri-wound is slightly reddened and boggy. Resident does c/o pain to heels. Does wear heel protectors/booties at all times except for transfers. Air mattress to be placed on bed. Review of resident 21's weekly wound documentation assessments revealed: *They had been completed on 2/8/23, 2/16/23, and 2/23/23 and included: -Wound onset date of 2/8/23 with the wounds being classified as SDTI. --Measurements of her left heel included: ---On 2/8/23 2.7 cm (centimeters) x 1.7 cm. ---On 2/16/23 2.7 cm x 1.7 cm. ---On 2/23/23 2.5 cm x 2 cm. --Measurements of her right heel included: ---On 2/8/23 2 cm x 1.5 cm. ---On 2/16/23 2 cm x 1.5 cm. ---On 2/23/23 1.9 cm x 2.5 cm. Observation and interview on 3/2/23 at 10:31 a.m. of resident 21 with physical therapist (PT) H in the therapy room revealed: *She had dark brown areas to bilateral heels. -The left was about the size of a nickel. -The right was about the size of a dime. *Resident stated she had pain to those areas on her heels. *PT H stated they had tried not having any heel protectors on when resident 21 was first admitted but she was digging her heels into her footrest, so the heel protectors were put on her feet. *PT H confirmed that resident 21 often rubbed her heels on the bed. Interview, record review, and AMT guidelines review on 3/2/23 at 11:07 a.m. with registered nurse D revealed: *Resident 21's wound assessments were completed weekly by a nurse unless the CNA's notified the nurse of a skin concern. -She confirmed they had not been following the 2/2/23 physician's order or AMT guidelines for SDTI. --She stated the AMT guidelines indicated to assess the wounds daily. --There was no designated wound care nurse on staff, the charge nurse for the day would have been responsible for assessing the wounds. Interview, record review and AMT guidelines review on 3/2/23 at 11:39 a.m. with DON B regarding resident 21's SDTI revealed: *The charge nurses completed weekly wound assessments on all wounds. *CNAs would observe the wounds daily when providing routine personal care. -There was no documentation to reflect daily CNA observing and reporting wound observation to the nurse(s). *She confirmed they had not been following the 2/2/23 physician's order or AMT guidelines for the SDTI for resident 21's bilateral heels. 4. Review of 2013 AMT guidelines for SDTI revealed: *Avoid topical agents until wound had fully evolved; eschar is present and begins to separate; and/or drainage is present with the exception of moisture barrier products for incontinence prone areas. *Eliminate pressure as much as possible. *Off-load heels. *Monitor diligently and document tissue characteristics daily, as DIT [deep tissue injury] can change rapidly. 2. Observation and interview on 2/27/28 at 11:25 a.m. with resident 28 revealed: *She had been here a couple of months. *There were bilateral assist bars on her bed, an air mattress on her bed, and a cushion in her chair. *She was able to easily engage in conversation. Review of resident 28's medical record revealed: *She had been admitted on [DATE]. *Her 1/12/23 brief interview for mental status (BIMS) score was a 15, meaning she was cognitively intact. *Her diagnoses included multiple medical conditions and a Stage II pressure ulcer of the sacral region. *She had required staff support to ensure all her needs had been met. -Stage II pressure ulcer identified as oval-shaped and present on her coccyx. --1.5 centimeters (cm) x 0.6 cm. --No drainage was noted. --Had 100% granulation. --The pressure ulcer caused the resident pain. -Treatment and interventions for pressure ulcer included cleanse with normal saline (NS), apply hydrogel gauze cut to fit, and cover with foam dressing. --Reposition approximately Q [every] 2-3 hours. --Pressure relieving mattress and pressure reducing cushion in chair. --Air mattress to bed. *Family or resident notified of wound and educated on 01/06/2023. Review of resident 28's care plan revealed: *The plan was initiated on 1/6/23, with a focus area pressure ulcer related to diagnoses of severe malnutrition and impaired mobility. *Goal to have pressure ulcer show signs of healing and remain free from infection through review date of 1/24/23. *Identified interventions included the treatment interventions as well as assist rails to aid in turn and repositioning. *Weekly skin inspections by licensed staff with daily skin inspections with cares. Review of resident 28's Weekly Wound Documentation revealed: *From admission on [DATE] through 1/13/23, the pressure ulcer had increased and worsened in size from an oval-shaped 1.5 centimeters (cm) by 0.6 cm Stage II pressure ulcer on her coccyx with no drainage and 100% granulation (an indicator of healing) to 2.0 cm by 1.5 cm with serous drainage (thin, watery fluid), and deteriorated to 75% granulation and 25% slough (dead tissue). *On 1/23/23, ten days later, the wound assessment identified two separate pressure ulcers. -The first identified on admission 1/6/23, remained the same as noted on 1/13/23. -The new, facility-acquired circular shaped pressure ulcer was on her right buttock and measured 0.3 cm by 0.3 cm with serous drainage, 75% granulation and 25% slough. On 1/31/23, the wound assessment identified the first pressure ulcer and noted an increase in size to 2.5 cm by 1.5 cm, serous drainage and 100% granulation. -The facility-acquired pressure ulcer was not addressed. On 2/7/23, the wound assessment addressed both pressure injuries. -The first pressure ulcer remained the same as noted on 1/31/23. -The facility-acquired pressure ulcered was indicated as an onset of 2/7/23 and was noted as 0.2 cm by 0.2 cm with serosanguineous (thin, watery pink tinged fluid) drainage with 90% granulation and 10% slough. --Same treatment for coccyx wound and right middle buttock wound. *From 2/8/23 through 2/21/23, there were no documented wound assessments. *On 2/22/23, the wound assessment addressed both pressure ulcers. -The first pressure ulcer on her coccyx measured 1.5 cm by 0.5 cm with serous drainage and 100% granulation. -The facility-acquired pressure ulcer on her right buttock had increased in size to 0.6 cm by 0.4 cm by 0.1 cm and had serosanguineous drainage with 90% granulation and 10% slough. Review of resident 28's treatment administration record (TAR) revealed: *Her January 2023 TAR included the treatment plan for the pressure ulcer to her coccyx. -It did not reflect any plan for care for the facility-acquired right buttock pressure ulcer identified on 1/23/23. *Her February 2023 TAR reflected change on 2/7/23, to include care for both coccyx and buttock pressure ulcer. Interview and review about resident 28's wound assessment, wound care, and documentation on 3/2/23 at 1:11 p.m. with DON B revealed and confirmed: *Resident 28 had been admitted on [DATE], with the pressure ulcer to her coccyx. *The pressure injury was deteriorating on 1/13/23. *On 1/23/23, a facility-acquired pressure injury was identified by registered nurse D. -She had not documented notification of family or physician. -No new treatment plan had been initiated from 1/23/23 through 2/6/23. -There was no assessment of the new pressure ulcer on 1/31/23 -On 2/7/23, the physician was notified of the facility-acquired pressure ulcer with treatment orders. - --Family was not notified. *No wound assessments of either pressure ulcer were conducted from 2/8/23 through 2/21/23. *The only intervention change reflected the initiation of wound care for the right buttock pressure ulcer on 2/7/23. Based on observation, interview, record review, and policy review, the provider failed to assess and document timely, implement, monitor, and review and update care for three of four sampled residents (21, 28, and 89) who had multiple medical conditions and were at risk for pressure ulcer development. Findings include: 1. Review of resident 89's medical record revealed: *He was admitted on [DATE]. *His 2/15/23 Brief Interview for Mental Status (BIMS) score was 15, indicating his cognition was intact. *His diagnoses included the following: fracture of superior rim of right pubis, contusion right shoulder, fracture of unspecified parts of lumbosacral spine and pelvis, chronic kidney disease, pain, repeat falls, pressure-induced deep tissue damage of left heel, and obesity. *His Braden Scale score (used to predict risk of developing a pressure ulcer) on 2/15/23 was 20, indicating he was not at risk. Review of resident 89's nursing progress notes from 2/14/23 through 2/28/23 revealed: *On 2/14/23 he had a discoloration to his left heel measuring 0.5 centimeters (cm) x 0.9 cm. -He was places on a list for physician to see him on 2/16/22. *On 2/16/23 he was seen by a physician. The nurses note addressed a sore behind his ear and a corn on his left lateral foot, but had not addressed the area to his heel. *On 2/23/23 Brought to nurse's attention that resident continues with left heel discoloration. Upon assessment, wound is oblong in shape, 1.2 cm x 1 cm, black/blue in color. Resident states area is very tender, but when he is walking on it the pain goes away. It was brought to [physician's name] attention on 2/16/23 with no new orders. Resident does off load pressure on boney surfaces himself. He does reposition himself. Is mobile with assist of one r/t [related to] safety. Wears shoes while walking. Pressure relieved mattress and cushion to chair. *On 2/24/23 the dietary manager was informed of the suspected deep tissue injury to his right heel and consulted with a registered dietician (RD) to increase his protein intake. Review of resident 89's 2/16/23 physician's long-term care progress note revealed there was no documentation about the suspected deep tissue injury to his left heel. Review of resident 89's 2/24/23 weekly wound documentation revealed: *The wound to his left heel was a suspected deep tissue injury (SDTI) and measured 1.2 cm x 1 cm. *Date of onset was 2/14/23. *The wound was not open or draining. *AMT (American Medical Technologies) guidelines would have been followed for treatment of the wound, and no treatment was required at the time of the nurse's assessment. Continued review of resident 89's medical record revealed: * On 2/24/23 the nurse faxed the physician a copy of the 2/24/23 weekly wound documentation. *On 2/24/23 the physician returned a fax back to the facility that read Noted, deep tissue injury precautions noted for left heel area. Monitor closely. Review of resident 89's February 2023 medication and treatment administration records revealed: *A physician order for a skin assessment to have been completed weekly on Tuesdays and as needed. *A physician order with a start date of 2/24/23 for the following: -Pressure Injury Treatment/Prevention on each shift two times a day. --1. Check that air mattress is on bed and operating correctly. --2. Float heels when in bed. --3. Pressure redistribution cushion in w/c [wheelchair]. --4. Reposition q2-3h [every two to three hours]. --5. Pericare as indicated. --6. Heel protectors while in bed. *They had not addressed the resident had a SDTI or where it was located. *There had been no treatment or daily monitoring orders of the SDTI to his left heel. Review of resident 89's 2/23/23 care plan revealed it had been updated on 2/23/23 to include: *The SDTI to his left heel. *1. Float heels while in bed *2. Wear heel protectors as tolerate while in bed *3. Weekly wound assessments *4. Encourage resident to keep shoes off except while transferring. Interview on 3/1/23 at 2:31 p.m. with registered nurse (RN) D regarding resident 89 revealed: *She had found the spot on his heel on 2/14/23. -She did not put any interventions in place at that time. -She added him to the list to have been seen by his physician on 2/16/23. *His physician had seen him on 2/16/23 and all he seen was a corn on his foot so nothing further was ordered for SDTI to his left heel. *When she observed it again during his next skin assessment on 2/24/23 it was larger. *The area would only have been assessed weekly during his skin assessment. *There were no treatments ordered because the wound was not open. Interview and observation on 3/02/23 at 10:20 a.m. with RN D of resident 89's SDTI to his left heel revealed: *He had a discolored brownish area to his left heel about the size of a quarter. *He denied pain to the area. *There was no dressing on the area of his left heel and it was left open to air. Interview on 3/2/23 at 10:52 a.m. with director of nursing (DON) B regarding pressure ulcers revealed: *The week after the physician had assessed at the wound on resident 89's left heel it had worsened. *After the area had worsened then it was decided it was a SDTI. *Staff was encouraging resident 89 to take his shoes off when not up walking and to elevate his heels off the mattress when he was in bed. *Nurses only assessed SDTI's to heels weekly when scheduled skin assessments were completed. *Certified nursing assistants (CNAs) looked at residents skin during personal care and would let the nurse know if there had been a change. *It was not in the CNA's scope of practice to assess resident wounds. *AMT guidelines were used when deciding on a treatment for wounds. *Having the nurse assess SDTIs weekly had not followed the AMT guidelines.