**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review, the provider failed to ensure that one of one sampled resident (3) who received dialysis (a treatment for kidney failure that removes waste and excess fluid from the blood), received services consistent with professional standards of practice by not having documented the resident's care needs and not having provided documented evidence that the resident was monitored for complications or significant changes in clinical status, including bleeding and hypotension (low blood pressure).Findings include:1. Interview on 8/12/25 at 9:16 a.m. with resident 3 in her room revealed:*She was lying in her bed, covered with a blanket.*She stated she received dialysis on Monday, Wednesday, and Friday mornings.*She was transported from the facility to receive her dialysis treatments.*On dialysis days, she had breakfast at the facility and was provided with a sack lunch to take with her to dialysis.*The staff would sometimes check her vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) when she returned after dialysis.*She stated, You have to be patient when you ask for help. You usually have to wait a long time. 2. Interview on 8/13/25 at 11:33 a.m. with certified medication aide (CMA) H about the process followed when resident 3 returned from dialysis revealed:*There was no formal process to follow when a resident returned from dialysis.*There was no post-dialysis assessment completed for resident 3 when she returned to the facility after dialysis.*It was up to resident 3 to decide what happened when she returned from dialysis. If she wanted to stay up after dialysis, they would help her into her chair, and if she preferred to lie down, they would assist her into her bed. 3. Interview on 8/13/25 at 11:38 a.m. with registered nurse (RN) I about the process followed when resident 3 returned from dialysis revealed:* She usually tells us what she wants to do when she gets back.*Resident 3 usually said she was hungry and wanted to eat her sack lunch when she returned.*There was no formal process for assessment or documentation of clinical status after dialysis. 4. Interview on 8/13/25 at 4:31 p.m. with lead resident care manager (LRCM) C about the process revealed:*The dialysis center would send a communication form back to the facility with resident 3.*She would expect the staff to be checking resident 3's vital signs and looking at the dressing over her port (a type of dialysis access surgically placed under the skin that allows for repeated needle access for dialysis treatments) to make sure the dressing was clean, dry, and intact.*She stated that it depends on what she [resident 3] wants. If she wants to go straight to the dining room, it may be later that day, after we get her back to her room and in bed before vital signs are checked.*She confirmed that without checking resident 3's vital signs and dressing after dialysis, it would be difficult to monitor for changes in her clinical status.*She stated there was room for improvement with that process. 5. Review of resident 3's electronic medical record (EMR) revealed:*She was admitted on [DATE].*She had a 5/23/25 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated her cognition was intact.*She had a 9/9/24 initiated care plan goal of The resident will have immediate intervention should any s/sx [signs/symptoms] of complications from dialysis occur through the review date.*The 9/9/24 care plan interventions associated with that goal included:-Encourage resident to go for the scheduled dialysis appointments. Resident receives dialysis three times a week; Monday, Wednesday, and Friday.-Monitor/document/report PRN [as needed] any s/sx of infection to access site: Redness, Swelling, warmth or drainage.-Work with resident to relieve discomfort for side effects of the disease and treatment.*Resident 3's blood pressure and heart rate documentation from January through July of 2025 indicated:-In January, her blood pressure and heart rate were documented once, on 1/25/25.-In February, her blood pressure and heart rate were documented on 2/14, 2/15, 2/16, and 2/28.-In March, her blood pressure and heart rate were documented on 3/8, 3/14, and 3/22.-In April, her blood pressure and heart rate were documented on 4/2, 4/5, and 4/19.-In May, her blood pressure and heart rate were documented on 5/3, 5/4, 5/17, 5/18, 5/19, 5/24, and 5/31.-In June, her blood pressure and heart rate were documented on 6/7, 6/14, and 6/21.--There were only twenty-one days from January through July 2025 that had a blood pressure and heart rate documented.---Only 5 of those twenty-one days were scheduled dialysis days. 6. Interview on 8/14/25 at 12:48 p.m. with chief nursing officer (CNO) B revealed:*They had just identified that they needed a post-dialysis assessment tool or form to clarify the expectations for vital sign monitoring and assessment of residents who received dialysis.*Staff had not received any dialysis-specific training.*She confirmed that without assessing a resident after dialysis, it would be difficult to monitor for changes in clinical status. 7. Review of the provider's 2001 End-Stage Renal Disease, Care of a Resident with policy revealed:*Policy Statement-Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care.*Policy Interpretation and Implementation-Staff caring for residents with ESRD, including residents receiving dialysis care outside the facility, shall be trained in the care and special needs of these residents.-Education and training of staff includes, specifically:--the nature and clinical management of ESRD (including infection prevention and nutritional needs);--the type of assessment data that is to be gathered about the resident's condition on a daily or per shift basis;--signs and symptoms of worsening condition and/or complications of ESRD;--how to recognize and intervene in medical emergencies such as hemorrhages and septic infections;--timing and administration of medications, particularly those before and after dialysis;- The resident's comprehensive care plan will reflect the resident's needs related to ESRD/dialysis care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the provider failed to ensure Abnormal Involuntary Movement Scale (AIMS) assessments were routinely completed to evaluate for signs of adverse effects of antipsychotic medication use as a means to potentially reduce the risk for adverse outcomes for five of the five sampled residents (4, 7, 8, 22, and 31) who received antipsychotic medications.Findings included:1. Record review of resident 4's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *He was diagnosed with type 2 diabetes (a condition involving disruptions in how the body regulates blood sugar), paranoid schizophrenia (a mental health disorder with symptoms of delusions and hallucinations), anxiety disorder, depression, and cognitive communication deficit. *His Brief Interview for Mental Status (BIMS) assessment score was a 15, which indicated his cognition was intact. *He was given one risperidone 0.25 milligrams (mg) tablet by mouth one time a day in the morning. Risperidone is an antipsychotic medication (a medication used to treat a variety of mental health conditions). *He was given two risperidone 0.25 mg tablets by mouth one time a day in the evening. *He was given one sertraline HCI 100 mg tablet by mouth one time a day for depression. *No documentation in his EMR indicated that an AIMS assessment had been completed. 2. Review of resident 7's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *She was diagnosed with Alzheimer's disease (a progressive disease that destroys memory and other mental functions), anxiety disorder, major depressive disorder, and delirium (a sudden change in thinking that leads to confusion). *Her Brief Interview for Mental Status (BIMS) assessment score was 5, which indicated she had severe cognitive impairment. *She was given one olanzapine 5 milligrams (mg) tablet by mouth, an antipsychotic medication, every evening and every twelve hours as needed. *She was given one lorazepam 0.5 mg tablet by mouth, a benzodiazepine medication (a medication used to slow activity in the brain to produce a calming effect), every eight hours as needed. *No AIMS assessment had been completed. 3. Review of resident 8's EMR revealed: *He was admitted on [DATE]. *He had a diagnosis of dementia (a group of symptoms affecting memory, thinking, and social abilities). *His BIMS assessment score was 3, which indicated he had severe cognitive impairment. *He was given one-half of a 25 mg (12.5 mg) quetiapine fumarate tablet by mouth, an antipsychotic medication, at bedtime through his gastrostomy tube (a feeding tube inserted through the abdomen into the stomach). *No AIMS assessment had been completed. 4. Review of resident 22's EMR revealed: *She was admitted on [DATE]. *She was diagnosed with vascular dementia (problems with memory, thinking, and behaviors caused by disruption of blood flow to the brain) with agitation, and depression. *Her BIMS assessment score was 3, which indicated she had severe cognitive impairment. *She was given one quetiapine fumarate 50 mg tablet by mouth at bedtime, one 25 mg tablet at bedtime, and one-half of a 25 mg tablet (12.5 mg) by mouth at noon. *She was given one fluoxetine hydrochloride 20 mg tablet by mouth, a selective serotonin reuptake inhibitor (SSRI) medication (a medication used to treat a variety of mental health conditions), once daily. *Her last AIMS assessment was completed on 9/28/23. 5. Review of resident 31's EMR revealed: *She was admitted on [DATE]. *She had a diagnosis of Alzheimer's disease. *Her BIMS assessment score was 99 because she did not answer the questions, and the staff interview was completed. -She had memory impairment and severe difficulty with daily decision-making. *She was given one-half of a quetiapine fumarate 25 mg tablet (12.5 mg) by mouth daily at noon and bedtime. *Her last AIMS assessment was completed on 3/5/24. 6. Interview on 8/13/25 at 8:30 a.m. with lead resident care manager (LRCM) C revealed: *Residents who received psychotropic medications should have had an assessment completed routinely to monitor for adverse side effects. *She stated, AIMS assessments should have been completed upon admission, quarterly, and with any significant change in status for residents. *AIMS assessments should have been completed by MDS coordinator D to assess residents for psychotropic medication side effects. *She verified that she was unable to find recently completed AIMS assessments for residents on psychotropic medications. *She stated that the facility currently had no psychotropic medication policy and was unable to provide a related policy for review. 7. Interview on 8/14/25 at 11:25 a.m. with MDS Coordinator D revealed: *She confirmed that she had not completed any resident AIMS assessments upon admission or during the Minimum Data Set (MDS) process.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure four of four sampled residents (6, 7, 15 and 26) were screened for a history of trauma upon their admission to the facility.Findings include:1. Interview on 8/12/25 at 9:36 a.m. with resident 6 in her room revealed: *She was dressed and sitting in her recliner with a blanket and a stuffed cat on her lap. *Her room is decorated with lots of pictures and paintings of butterflies. She stated she enjoyed painting. *She stated that sometimes she would get “really mad,” and then she’s “not the nicest girl.” *She said, “I had a father, who you wouldn't call a father, because he would come home and he would use me. He would have his fun with me, and he would laugh about it. He was a mean man. But I got over it, I don't know how.” *Later in the interview, when asked about the food at the facility, she stated, “I should eat more, I want to be strong. I want to be strong because I don't ever want anyone touching me again, that's not supposed to be.” Review of resident 6’s electronic medical record (EMR) revealed: *She had a 7/9/25 Brief Interview for Mental Status (BIMS) assessment score of 6, which indicated she had severe cognitive impairment. *She had a 6/27/22 initiated care plan intervention to “Monitor for s/s [signs/symptoms] of depression, previous history of childhood abuse/PTSD [post-traumatic stress disorder] possible symptoms. Behavioral Health and her Physician have been made aware of this past history. Give her time to talk/express any feeling. Notify her Charge Nurse if symptoms persist.” *She did not have a diagnosis of PTSD (a mental health condition that can develop after experiencing a traumatic event) or depression, and had not been screened or assessed for trauma triggers. Interview on 8/13/25 3:08 p.m. with social services manager (SSM) E revealed: *She stated, “I do the MDS, [Minimum Data Set assessment] (a tool used to evaluate a resident’s health status and to develop an individualized care plan to manage the resident’s care needs), and if I notice a resident is depressed, I let the physician’s nurse know. I believe [medical director K] makes the referral for mental health services.” *She did not have a specific assessment to have screened residents for trauma history or to have addressed trauma triggers. *She stated, “Is that something we're supposed to be doing? We are not screening every resident for trauma. Is that something that is supposed to be done on admission?” Interview on 08/13/25 3:56 p.m. with lead resident care manager (LRCM) C revealed: *Psychiatry would screen all residents who have a psychotropic medication prescribed. *She stated, “We are not screening all residents for trauma now, but we will be in the future.” *Residents who did not have a mental health diagnosis were not being screened for a history of trauma. *She stated, “Trauma-informed care has never been a part of the training curriculum here, so we had to add it, and now everyone will be getting that training.” 2. Review of resident 7's electronic medical record (EMR) and comprehensive care plan revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 5, which indicated she had severe cognitive impairment. *She had diagnoses of anxiety disorder, major depressive disorder (a mental condition characterized by a persistently depressed mood and loss of pleasure or interest in life), and Alzheimer's disease (a progressive and irreversible brain disorder that affects memory, thinking, social abilities, and body functions). *She was taking medications daily to treat her depression, anxiety, and mood. *She had a history of abuse and trauma from her ex-husband. -She was hospitalized numerous times during their marriage. *She had a difficult time adjusting to her admission into the facility and being away from her son. *There was no documentation to support that she was screened for a history of trauma upon her admission to the facility. *She had a 4/22/24 initiated care plan with no identified focus that specifically addressed her trauma. 3. Interview on 8/14/25 at 2:00 p.m. with LRCM C and medical provider J regarding resident 7 revealed: *They both confirmed the resident had a history of trauma and abuse by her ex-husband during their marriage. *Resident 7 received therapy from medical provider J every two weeks. *Resident 7 experienced delusions and hallucinations, and medication management with adjustments was necessary. *LRCM C confirmed that no trauma screening was completed upon resident 7's admission. *LRCM C and medical provider J both agreed that trauma screenings should have been completed upon admission with residents with a history of abuse or trauma. *LRCM C confirmed that there was no current process in place for screening residents for trauma history on admission. *Interview with social service manager (SSM) E was attempted on 8/14/25 at 3:06 p.m., but she was unavailable due to scheduled resident care conference meetings. 4. Observation and interview on 8/12/25 at 10:39 a.m. with resident 26 revealed: *She was lying in bed with her knees bent and the blankets pulled up over them. *She stated she had been at the facility for two weeks. *She stated she had PTSD (post-traumatic stress disorder) from the Oklahoma City bombing. *She had seen a psychiatrist, but that was 20 years ago. Record review of resident 26's EMR revealed: *She was admitted on [DATE]. *Her BIMS assessment score was 15, which indicated her cognition was intact. *She was scheduled to see medical provider J on 8/14/25 to set up a scheduled psychiatric plan. *She had diagnoses of PTSD and hypertension (high blood pressure). *There was no documentation to support that she was screened for PTSD upon admission to the facility. *Her care plan had not mentioned her PTSD or any interventions. 5. Observation and interview on 8/12/25 at 11:20 a.m. with resident 15 revealed: *He was in his closet sorting his clothes. *He was clean-shaven and well-dressed. *He stated he had been at the facility for seven and half months. *He had PTSD and was seeing a psychiatrist at the local VA (United States Department of Veterans Affairs). Record review of resident 15 EMR revealed: *He was admitted on [DATE]. *His BIMS assessment score was a 15, which indicated his cognition was intact. *He had diagnoses of bipolar disorder (a disorder with episodes of mood swings) and PTSD. *There was no documentation to support he was screened for trauma for PTSD upon admission to the facility. *His care plan had mentioned his PTSD. Review of the provider's 2001 Trauma-Informed Care and Culturally Competent Care policy revealed: Purpose: To address the needs of trauma survivors by minimizing triggers and/or re-traumatization. Resident Screening: 1. Perform universal screening of residents, which includes a brief, non-specialized identification of possible exposure to traumatic events. 3. Screening may include information such as: a. trauma history, including type, severity and duration; b. depression, trauma-related or dissociative symptoms; c. risk for safety (self or others); d. concerns with sleep or intrusive experiences; e. behavioral, interpersonal or developmental concerns; f. historical mental health diagnosis; g. substance use; h. protective factors and resources available; and i. physical health concerns. 4. Utilize initial screening to identify the need for further assessment and care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interview, the provider failed to protect the resident's right to be free from verbal abuse by one of one cook (J) during the supper meal for one of one sampled resident (3). This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Review of the provider's 5/8/25 SD DOH FRI revealed: *During the supper meal on 5/8/25, resident 3 was seated at her table in the dining room using her tablet when she noticed cook J looking at her. She asked what, and cook J responded in a tone and attitude resident 3 found inappropriate. Resident 3 expressed that she would not eat due to his attitude. *Cook J then used vulgar language and told her to starve. *Resident 3 left the dining room table and had seen certified nursing assistant (CNA) G and told her what had happened. CNA G reported it to licensed practical nurse (LPN) D. *LPN D spoke with cook J, who denied directing vulgar language specifically at resident 3 but admitted to using vulgar language. LPN D then informed the lead resident care manager (CM) B about the incident. *CM B notified the director of environmental services (EVS) C, who was cook J's supervisor and he responded by terminating cook J's employment and escorted him from the facility on 5/8/25. EVS C also apologized to resident 3 and informed her that cook J was no longer employed at the facility. *Following the incident, dietary supervisor F initiated education with all dietary staff on verbal abuse towards residents. 2. Review of resident 3's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated she was cognitively intact. 3. Interview on 6/26/25 at 11:06 a.m. with resident 3 revealed: *She reported that while she was seated at the table during supper, using her tablet, she believed her tablemates were ordering. *Upon looking up, she noticed cook J was looking at her. She asked what and stated that cook J responded with an inappropriate tone and attitude, she expressed she did not like his attitude, he then used vulgar language and told her to starve. *Following the incident, she left the table and informed CNA G about the incident with cook J. *She expressed to staff that she did not want to eat any food prepared by cook J. Staff went downtown and had gotten a chicken salad for her for supper. *She indicated this was not the first time cook J had used an inappropriate tone with her. 4. Interview on 6/26/25 at 1:30 p.m. with CNA G regarding the 5/8/25 FRI for resident 3 revealed: *Resident 3 had informed her of the incident with cook J right after it happened. *CNA G had offered to get resident 3 a room tray for supper that evening, but the resident declined. *Resident 3 requested CNA G not to report the incident, but CNA G knew that was verbal abuse by cook J and she needed to report the incident. *CNA G reported it to LPN D, charge nurse on duty that night. 5. Phone interview on 6/26/25 at 1:39 p.m. with LPN D regarding the 5/8/25 FRI for resident 3 revealed: *He had been informed about the incident of cook J towards resident 3 by CNA G. *He initially went to visit with resident 3, but she was upset, he chose instead to speak with cook J. *Cook J admitted to using vulgar language that evening but denied directing any directly at resident 3. *Later that evening, LPN D spoke with resident 3 who reported that cook J had used an inappropriate tone and language toward her and told her to starve. 6. Interview on 6/26/25 at 1:58 p.m. with director of EVS C regarding the 5/8/25 FRI for resident 3 revealed: *He had received a call from CM B informing him of the incident involving cook J. *He entered the facility through the kitchen's backdoor, approached cook J, and informed him that his employment was terminated. [NAME] J was then escorted out of the building. *Upon exiting the building, cook J directed vulgar language toward director of EVS C. *Following the incident, EVS C apologized to resident 3 and informed her that cook J was no longer employed at the facility. 7. Interview on 6/26/25 at 2:09 p.m. with dietary supervisor F regarding the 5/8/25 FRI for resident 3 revealed: *He completed the education that included how to talk to residents for the all dietary staff on 5/13/25. *He continued to visually monitor staff interactions with residents to ensure appropriate conduct. *He was bringing all relevant information to the QAPI (Quality Assurance and Performance Improvement) meetings. *Prior to the incident with resident 3 cook J had received multiple write-ups for other violations including smoking on the premises, inappropriate behavior toward staff and management, and call-ins. 8. Review of cook J's personnel file revealed: *His pre-employment background checks identified no areas of concern. *He had received abuse and neglect, patient rights, and service excellence trainings on 12/11/24. *On 2/23/25 he received a written warning for smoking on campus. *On 4/3/25 he received a written warning for not being courteous to another caregiver or the supervisor/manager. *On 4/17/25 he received a final warning for refusal to follow the policy for call-ins. *On 4/21/25 no warning but a write-up for refusal to follow directions from management. *On 5/8/25 was his last day of employment. 9. Interview on 6/26/25 on 3:30 p.m. with CM B regarding the 5/8/25 FRI for resident 3 revealed: *She had received a call from LPN D that evening informing her of the incident with cook J. *She contacted director of EVS C, who stated he would address the situation. *Director of EVS C later called back to inform her that cook J's employment had been terminated and that he had been escorted out of the facility. *CM B stated LPN D completed an internal incident report, which was used for safety and QAPI meetings. *She conducted an all-staff meeting on 5/14/25, which included education on recognizing and reporting all forms of abuse. The provider implemented actions to ensure the deficient practice does not recur was confirmed after record reviews and interviews revealed the facility had followed their quality assurance process, education was provided to all staff regarding recognizing and reporting abuse. Dietary staff education was provided on how to speak to residents, 10 strategies for communication with nursing home residents, and professional conduct. Monitoring of staff interactions with residents to ensure appropriate conduct. Observation and interviews revealed staff understood the education provided. Based on the above information, non-compliance at F600 was determined on 5/8/25, and the provider's implemented 5/14/25 corrective actions for the deficient practice confirmed on 6/25/25, the non-compliance is considered past non-compliance.

Based on South Dakota Department of Health (SD DOH) complaints report review, interview, and record review, the provider failed to correctly administer narcotic (pain relieving) medications as ordered for two of two sampled residents (1 and 15). Failure to administer narcotic medications as ordered may have contributed to residents 1 and 15 having increased pain, discomfort, and side-effects of narcotic withdrawal. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented immediately following the discovery of the medication errors. Findings include: 1. Review of the two 6/27/24 SD DOH complaint reports revealed: *Resident 1 had not received her Fentanyl (a controlled medication for severe pain) medication as ordered by her physician. -She was supposed to have received a new Fentanyl topical patch every 72 hours (3 days). *Her Fentanyl patch was applied on 6/8/24. -It had not been replaced from 6/8/24 through 6/21/24. *She did not receive four doses. -She had increased pain and migraine headaches during that time. *She had called a friend and was reported to have been crying because of her increased pain and migraine headaches. 2. Interview on 7/23/24 at 9:23 a.m. with resident 1 revealed: *She was receiving hospice care for end-stage kidney failure. *She stated, I started having pain and looked at the calendar and found out it (Fentanyl patch) hadn't been changed in several weeks. It was supposed to be changed every three days. -She stated she had increased back pain and severe migraine headaches during that time. -She stated, It was a doozy for a few days. It was a hell of a migraine. *She stated a hospice nurse told her the Fentanyl patch medication was prescribed correctly to indicate it would be replaced every 72 hours (three days), but the pharmacy had changed it to be replaced every 72 days. *She stated that while a nurse was speaking to her about the medication error, an aide was also in her room and informed her there was another resident (15) who had the same problem with her Fentanyl patches. -She stated resident 15 had dementia and was unable to communicate her needs and she was worried about medication errors happening to other residents who were unable to defend themselves. 3. Review of resident 1's electronic medical record (EMR) and June 2024 medication administration record (MAR) revealed: *She had received hospice services that had begun in April of 2024 for stage 5 renal failure. *She had a Brief Interview for Mental Status (BIMS) score of 15, which indicated she was cognitively intact. *She had an order for: Fentanyl Transdermal Patch 25 mcg/hr [micrograms per hour]. Apply 1 patch every three days. Remove patch after 72 hours (3 days) and fold in half and dispose of according to facility procedures. -Her MAR indicated the Fentanyl order had been changed on 6/8/24 to Apply one patch transdermally one time a day every 72 days. *She had a new patch applied on 6/8/24 and it had not been replaced until 6/21/24. Four applications were missed over thirteen days. 4. Review of resident 15's EMR and May 2024 MAR revealed: *She was on hospice care for terminal breast cancer. *She had a BIMS score of 4, which indicated she had severe cognitive impairment and was non-interviewable. *She had an order for: Fentanyl Transdermal Patch 25 mcg/hr. Apply 1 patch transdermally one time a day every 72 hours. -Her May 2024 MAR indicated the Fentanyl order had been changed on 5/9/24 to state Apply one patch transdermally one time a day every 72 days. -She had a new patch applied on 5/9/24 and it had not been replaced until 5/16/24, missing two applications over seven days. 5. Interview on 7/23/24 at 3:24 p.m. with licensed practical nurse (LPN) H and LPN I revealed: *The pharmacy entered medication orders into the EMR's MAR in Point Click Care (PCC). -If the pharmacy was closed, the nurse would have entered the order into PCC and the order would have been verified by the night nurse. 6. Interview on 7/25/24 at 9:00 a.m. with assistant director of nursing (ADON)/resident care manager C revealed: *The Fentanyl orders had been entered into PCC incorrectly and indicated staff were to have applied a patch every 72 days and not every 72 hours as prescribed. The MARs on the computer only showed what was to be given each day, according to what had been entered into PCC, so those Fentanyl orders had not appeared on the daily MAR screen to be given and were missed. *She stated that when the Fentanyl medication errors had been identified, pharmacist F implemented two secondary order verification systems. -All medication orders were verified by a second person in the pharmacy and a MAR was printed to verify the accuracy of new orders. -All Fentanyl orders had a daily patch monitor prompt to be signed off on the daily MAR which was separate from the MAR's Fentanyl order. *She was included in all the pharmacy medication error reports and medication errors were reviewed by the pharmacy and nursing administration every week. They were also reviewed by a multidisciplinary team during the monthly quality assurance and safety meetings. -All medication aides and nurses were educated on the new Fentanyl patch monitoring process on 7/1/24. 7. Interview on 7/25/24 at 10:30 a.m. with pharmacist F regarding the above findings revealed: *The physicians would enter their orders in an EMR system called EPIC and the pharmacy staff would enter those orders into PCC. *Both Fentanyl orders were entered incorrectly by pharmacist X. When that repeated medication error was discovered, the two-party verification, printing of MARs, and daily patch monitoring systems were implemented. *The pharmacy had increased the monitoring of medication errors from monthly to weekly and included nursing administration, quality assurance, and the safety team, in all reports. *He stated the quality assurance and safety team had been discussing the re-implementation of a medication error committee for increased focus on medication and documentation errors. The provider's implemented systemic changes to ensure the deficient practice does not reoccur was confirmed on 7/25/24 after record review revealed the facility had followed their quality assurance process, education was provided to the pharmacy and nursing staff regarding the two-person order verification process, pharmacy printing and double checking the MARs for correctness, daily monitoring of resident's Fentanyl patches, and a review of the medication error report revealed no further Fentanyl medication errors had occurred. Based on the above information, non-compliance at F760 occurred from 5/9/24 through 5/16/24 and again from 6/8/24 through 6/21/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/25/24, the non-compliance is considered past non-compliance.

Based on observation, interview, and record review, the provider failed to ensure two of two sampled residents (11 and 27) who received a specialized diet were served the correct portion sizes and nutritional values for one of three observed meal services. Findings include: 1. Observation on 7/23/24 from 11:45 a.m. through 12:35 p.m. of the memory care unit lunch meal revealed: *The menu for lunch that day consisted of spaghetti, a lettuce salad, and bread with an alternate meal of chicken and rice soup. *Residents 11 and 27 were served an approximate one-half cup round scoop of ground spaghetti centered in the middle of their plate. -No other food items were served with their meal. *Administrator A was present in the dining room and an unidentified aide notified him of their meal portions. -Resident 27's husband was visiting during the meal and administrator A offered more food items to which the husband responded he would wait and see if she ate the spaghetti first. -Resident 27 ate the spaghetti and a prepackaged cup of pudding the husband had offered. *Resident 11 showed little interest in eating her spaghetti. *By the end of the lunch meal, no further offers of food items were made to resident 11 or 27. Interview on 7/23/24 at 11:50 a.m. with resident 27's husband while he sat with her in the memory care dining room revealed: *He stated his wife had lost nearly 60 pounds since she had been sick with COVID-19 and her dementia had worsened. -He stated because of her weight loss and dementia her dentures no longer fit correctly, and she would have refused to wear her dentures even when they did fit. -He stated his wife liked eating soup, but it was rarely offered to her. -He stated she was able to eat soft foods without difficulty and had not understood why they gave her pureed food as she did not like it. Interview on 7/23/24 at 5:00 p.m. with registered dietitian (RD) D and administrator A regarding the above observed meal service revealed: *RD D stated she worked for the provider as a consultant. *RD D agreed the meal served to residents 11 and 27 was not visually palatable, accurate in portion size, or nutritionally balanced. *Administrator A agreed the full nutritional menu was not served to those residents. -He stated dietary cook R was hired within the last 90 days and he expected the dietary manager (DM E) to have ensured cook R had been educated on serving sizes and specialized diets. -He stated that DM E was newly hired around the same time as cook R and he (DM E) was working on obtaining his dietary manager's certificate. *Their expectation was for all the food groups listed on the menu, or a nutritionally equal substitute, was to have been served in the correct portion sizes. *They both confirmed they had not observed a meal service to ensure the meals were proportioned correctly and served appropriately. Interview on 7/24/24 at 1:30 p.m. with DM E revealed: *He stated he was hired as a cook in January of 2024 and became the DM around March of 2024. -He stated he had not worked as a DM in a long-term care facility before this employment and he was currently working on his dietary manager's certificate. *He stated the past DM had resigned in March of 2024 and the DM training he received from her was slim to none and lasted about four days in total. -She had shown him how to order supplies, complete the Minimum Data Set (MDS), and fill out the dietary staff schedules. -He stated he had no training on specialized diets, portion sizes, or the required education he needed to provide to his dietary staff. *He thought dietary cook R had been trained by dietary cook S on specialized diets and portion sizes. Interview on 7/24/24 at 2:30 p.m. with dietary cook S revealed she: *Had worked as a cook for about one and a half years. -Had been trained on serving sizes by dietary cook T and had not received any formal training from a DM or a dietitian. *Stated she had trained cook R for nearly two weeks and had provided her with some training on plate presentation, serving sizes, recording temperatures, and specialized diets. *Was unable to identify the portion sizes for ground or pureed foods and stated she usually filled up a bowl until it would look like a four-ounce portion. -Stated there were no guides on portion sizes for specialized diets located in the kitchen. *Stated, Some people don't eat as much so we give smaller portions to them. -Was not aware if the dietitian had been notified of this practice. *Stated, We need more education on this (portion sizes). Interview on 7/24/24 at 2:40 p.m. with RD D regarding the above dietary staff interviews revealed: *She stated she was not aware the current DM and cooks had not been properly trained on portion sizes or dietary types and was not aware there were no serving guides available to staff. *She was not aware the cooks were serving smaller portions to those who did not eat well and had initiated a review of each resident's diet and food consistency orders. -She stated the only time residents should have been served smaller portions was if they had a specific order for smaller portions. *She agreed there was a need for further food service monitoring and dietary staff education. Review of resident 11's medical record revealed: *She received Hospice services and had a diagnosis of a major neurocognitive disorder due to Parkinson's disease with behavioral disturbance. -She had a brief interview for mental status (BIMS) of 99, which indicated she was severely cognitively impaired and was unable to participate in the assessment. *Her diet order was for an NDD3 (National Dysphagia Diet level 3) texture that omitted dry, hard, crispy foods. *She was to receive an Ensure nutritional supplement drink three times a day. *On 01/23/2024, the resident weighed 117 lbs. On 07/20/2024, the resident weighed 95.5 pounds which was an -18.38 % weight loss. -A decrease of 10% or greater in 180 days was considered a significant weight loss. Review of resident 27's medical record revealed: *She was diagnosed with a major neurocognitive disorder due to Alzheimer's disease with behavioral disturbance, anxiety, depression, and hallucinations. *She had a BIMS of 04, which indicated she had a severe cognitive impairment. *Her diet order was for a regular diet as tolerated with mechanical texture, regular consistency, gravy on meat, pureed vegetables, and finger foods. -She also had an order for a nutritional supplement drink three times a day. *On 01/22/2024, the resident weighed 134 lbs. On 07/22/2024, the resident weighed 116 pounds which was an -13.43 % weight loss. -A decrease of 10% or greater in 180 days was considered a significant weight loss. Review of the provider's 2012 Weight Assessment and Intervention policy revealed: *The multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss for our residents. -2. The Physician and the multidisciplinary team will identify conditions and medications that may be causing anorexia, weight loss, or increasing the risk of weight loss. For example: f. Increased need for calories and/or protein; i. Inadequate availability of food or fluids. Review of the provider's initial hire and annual dietary training revealed DM E, cook S, and cook R, had not received training on the following topics: Food Safety, Serving/Distribution, Leftovers, Time/Temp Controls, Nutrition/Hydration, and Sanitation.

Based on South Dakota Department of Health (SD DOH) complaint report review, interview, record review, and policy review, the provider failed to ensure prompt identification of loss or potential diversion of controlled (high risk for addiction and dependence) medications and prompt identification of medication errors. Failure to accurately monitor controlled medications and medication errors may have placed the residents at increased risk of adverse effects of not receiving medications as ordered, such as increased pain. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the identification of the incident. Findings include: 1. Review of the 6/27/24 SD DOH complaint report revealed: *Resident 1 had not received her Fentanyl (a controlled medication for severe pain) medication as ordered by her physician. -She was supposed to have received a new Fentanyl topical patch every 72 hours (3 days). -She had a new patch applied on 6/8/24 and it had not been replaced until 6/21/24. Four applications were missed over thirteen days. -She had increased pain and migraine headaches during that time. 2. Interview on 7/23/24 at 9:23 a.m. with resident 1 revealed: *She confirmed the above medication error had occurred and stated she had suffered from increased pain and migraine headaches because of the medication error of not receiving that medication. *She stated while a nurse was speaking to her about the medication error, an aide was also in her room and informed her there was another resident (15) who had the same problem with her Fentanyl patches. -She stated the nurse had told the aide to be quiet and leave the room. She was unable to recall the aide's name. -She stated resident 15 had dementia and was unable to communicate her needs and she was worried about medication errors happening to other residents who were unable to defend themselves. 3. Review of the provider's January through July 2024 medication error tracking log revealed: *There were 100 medication errors with approximately 60 of those errors related to controlled medications including oxycodone, Tramadol, morphine, Percocet, hydrocodone, Fentanyl (all pain relievers), and Ativan (antianxiety medication). -The Summary of occurrence area of the tracking log showed many of those errors were identified as Pulled med but not documented on Mar. -The number of medication errors had decreased in July of 2024 with only five documented errors. 4. Interview on 7/25/24 at 9:00 a.m. with assistant director of nursing (ADON)/resident care manager (RCM) C revealed: *The pharmacy tracked the medication errors, and she received their Omnicell (an automated medication dispensing machine) medication error summary reports weekly. -She reviewed every medication error report and tracked them for any trends. -She provided staff reminders in stand-up meetings about medication documentation and accuracy. *She identified one medication aide (MA) as having numerous medication errors. That MA was placed on a performance improvement plan (PIP) and was closely monitored. 5. Interview on 7/25/24 at 9:40 a.m. with medication aide (MA) Y revealed: *All scheduled and as-needed (PRN) controlled medications are retrieved individually from the Omnicell at the time of administration. -There were no controlled substances kept in the medication carts. *Both the nurses and the medication aides had access to the Omnicell to remove controlled medications. 6. Interview on 7/25/24 at 10:30 a.m. with pharmacist F regarding the above findings revealed: *He was aware of the facility's medication errors because he wrote the medication error reports. *He felt many of those errors were documentation errors and not actual medication errors. *He stated he used to only write up error reports on actual medication errors (i.e. wrong med, wrong dose, wrong patient) but within the last month he wrote medication error reports on all the Omnicell discrepancies, including missed documentation, so the discrepancies could be tracked and monitored for diversion more closely. *He stated he provided those reports to the nurse supervisors, and they would have decided what actions were to be taken with the staff. -He stated, We are now tracking every narcotic medication error and writing up each one. -He identified narcotics (medications for severe pain) retrieved for hospice patients were the medications most frequently not documented on the MARs and he felt the immediate need of the patient likely caused a delay in or absence of documentation. *The pharmacy had increased the monitoring of medication errors from monthly to weekly and included nursing administration, quality assurance, and the safety team, in all reports. *He stated the quality assurance and safety team had been discussing the re-implementation of a medication error committee for increased focus on medication and documentation errors. 7. Review of the provider's 2/7/12 Medication Error Prevention Plan policy revealed: *3. All medication errors will be reported to the quality assurance, process improvement team for recommendation. *4. Disciplinary Action may occur after 3 consecutive medication errors in 3 months and/or after any significant medication error. LTC management may decide to implement a Performance Improvement Plan prior to disciplinary actions being taken. The provider's implemented systemic changes to ensure the deficient practice does not reoccur was confirmed on 7/25/24 after record review revealed the facility had followed their quality assurance process, followed their policy, provided staff education, and implemented a PIP. Interviews revealed changes had recently occurred that included increased monitoring and of medication documentation and medication errors. Based on the above information, non-compliance at F755 occurred on 6/11/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 7/25/24, the non-compliance is considered past non-compliance.

5. Observation on 7/22/24 at 4:30 p.m. in the memory care unit revealed: *Two of the three recliners had dark brown discoloration on the headrest and the armrest. *One of those recliners had a worn-down discolored spot on the headrest and was worn-down along the seams at the armrests. *Two high-back chairs had multiple spots on the seat and the back cushions of the chairs. *One of one couch had multiple unidentified light brown stains on the armrest and down the front of the armrest and multiple light brown spots on the seat and back cushions. Interview on 7/25/24 at 9:30 a.m. with the environment service supervisor G revealed: *He had been the manager for nine years. *The housekeepers have a cleaning checklist that they completed daily. *The housekeepers should have done a deep clean immediately when they saw the stains on the chairs and couch. *He would have expected the housekeepers to have notified him that one of the recliners had a worn-down discolored spot on the headrest and was worn-down along the seams at the armrests. -He would have discarded that recliner immediately. A review of the provider's housekeeping daily cleaning checklist revealed: *They wiped down the chairs in the day room daily. *There was no mention of cleaning the couch in the day room. *There was no mention of deep cleaning the chairs or the couch in the day room. An undated Standard Precautions Policy revealed: F. Environmental Control 1. See Environmental cleaning procedures for the routine care, cleaning, and disinfection of environmental surfaces, beds, bedrails, bedside equipment, and other frequently touched surfaces, and manager is to ensure that these procedures are being followed. Interview on 7/25/24 at 4:30 p.m. with RN/infection control coordinator U about hand hygiene and glove use revealed she: *Had been doing monthly audits. *Had identified hand hygiene was an issue. *Had opened a performance improvement project (PIP) for hand hygiene as a priority and planned to have opened a glove use PIP. 3. Observation on 7/22/24 at 5:15 p.m. of certified nursing assistant (CNA) O during the dinner meal revealed she: *Removed a glove from her right pants pocket. *Put that same glove on without sanitizing her hands. *Wiped her face with the back of her gloved hand. *Then wiped her face, wiped resident 11's mouth, touched another resident's straw, moved her hair behind her ear, and assisted resident 8 with eating, all with the same gloved hand. Observation on 7/23/24 at 12:10 p.m. of CNA W during the noon meal revealed she: *Had gloves on, removed them and started to feed residents. *Did not sanitize her hands and touched resident utensils. *Touched resident 8's hand with her unclean. Resident 8 then put her hand in her mouth. Review of the provider's undated Hand Hygiene policy revealed: *2. All employees will perform hand hygiene after: d. Removing gloves. *3. All employees providing direct patient care will: a. Use gloves since gloves reduce hand contamination by 70-80%, prevents cross contamination and protects, patients/residents and staff from infection. 4. Observation and interview on 7/23/24 at 8:56 a.m. to 7/25/24 at 8:21 a.m. with resident 51 in her room revealed: *She was on oxygen therapy and used a nasal cannula (tubing that delivers oxygen into the nose). *She did not know when it was last replaced. *Tape was applied to the nasal cannula (NC) tubing and had the date 7/01/24 written on it. Observation and interview on 7/23/24 at 9:29 a.m. with resident 43 in his room revealed: *He was on oxygen therapy and used NC tubing. *The NC tubing had a piece of tape with the date 6/2/24 written on it. *He did not know when it was last replaced. Record review of both resident 43's and resident 51's revealed, there was no documentation of when the nasal cannula had been replaced. Interview on 7/24/24 at 4:55 p.m. with licensed practical nurse (LPN) K regarding NC tubing replacement revealed: *The NC tubing were replaced monthly and documented in the treatment administration record (TAR). *She was not able to find documentation in the TAR for NC tubing replacements for resident 43 or resident 51 nor able to produce the policy for NC tubing replacement. Interview on 7/25/24 at 8:33 a.m. with LPN L revealed she: *Thought that NC tubing replacements were documented in the TAR. *Was not able to find any documentation of NC tubing replacement for residents 43 or 51. Interview on 7/25/24 at 9:46 a.m. with LPN H revealed he: *Placed the tape on resident 8's nasal cannula with the date 7/1/24. *Assumed the tubing was replaced at the beginning of the month but was not certain. *Said the changes were notated in the TAR. *Was not able to find documentation for the nasal cannula changes for either of the above residents. *Was not able to produce a policy for when nasal cannula or oxygen tubing was to be changed. Interview on 7/25/24 at 11:59 a.m. with RN/ infection control coordinator U revealed she: *Was not sure when nasal cannulas or oxygen tubing was to be changed. *Did not know about any policy involving tubing changes. *Said that staff should not touch their face or hair prior to resident cares. *Said staff are trained annually on proper hand hygiene. Interview on 7/25/24 at 2:01 p.m. with assistant director of nursing (ADON)/ resident care manager (RMC) C revealed: *Her expectations were that staff would conduct proper hand hygiene and change oxygen tubing in accordance with the facility policy. *She said that nasal cannula tubing was to be changed at the beginning of the month. Interview on 7/25/24 at 10:59 a.m. with administrator A revealed: *Oxygen tubing was to be changed at the beginning of the month. *He could not find the facility policy for oxygen tube changing. Review of the provider's February 2006 Nasal Cannula in Audit provided by administrator A revealed: *He provided a copy of the adjacent hospital's nasal cannula audit. *Infection Control: - Nasal Cannulas should be changed every 14 days or if visibly soiled. Based on observation, interview, record review, and policy review, the provider failed to ensure: *Proper hand hygiene, glove use, containment of soiled linen, and disinfection of a mechanical lift, by two of two staff (M and N) during one of one sampled resident's (46) mechanical lift transfer and personal hygiene care. *Proper hand hygiene, glove use, containment of soiled linen, and suprapubic catheter (connected through the abdomen to the bladder) care by one of one medication aide (Q) during one of two sampled resident's (1) catheter care observations. *Proper hand hygiene and glove use by two of two dietary aides (O and W) while assisting two of two residents (8 and 11) during two of three dining room observations. *Oxygen tubing was changed according to facility policy for two of four (43 and 51) sampled oxygen-dependent residents. *Cleaning and sanitization of five of six multi-use facility recliners and one of one couch located in the memory care unit. Findings include: 1. Observation on 7/23/24 at 10:29 a.m. with nurse aide (NA) M and certified nurse aide (CNA) N during a mechanical lift transfer and personal hygiene care of resident 46 revealed: *A multi-resident use mechanical lift was removed from the hallway and brought into resident 46's room. *NA M and CNA N sanitized their hands, applied clean gloves, and transferred resident 46 onto her bed using a sling attached to the mechanical lift. -Her open-backed skirt was partially wet with urine, was removed by NA M and placed directly onto the floor. *CNA N removed the resident's urine-soaked incontinence brief and cleansed the resident's genital and rectal areas. -Using those same gloved hands, he applied a barrier cream to the resident's rectal area first and then her genital skin folds. *NA M removed his gloves and without cleansing his hands he: -Opened the resident's closet door and obtained a clean incontinence brief and clothing. -Applied a clean pair of gloves and assisted CNA N while they applied the resident's incontinence brief and clothing. -Removed the trash and placed her soiled clothing in a plastic bag for transport. *They both removed their gloves and without cleansing their hands they: -Adjusted her bed linens. -Touched the bed's remote and adjusted the bed height. -Moved the overbed table closer to her bed and placed her drink cups within her reach. -Opened the hallway door, removed the mechanical lift from the room, and placed it in the hallway. *They then sanitized their hands in the hallway, but had not sanitized the mechanical lift. Interview on 7/23/24 at 10:50 a.m. with NA M and CNA N regarding resident 46's personal hygiene, hand sanitization, glove use, and mechanical lift cleaning revealed: *CNA N stated he was a contract CNA and had been working for the provider for about three months. -Stated he was trained by other staff while working on the floor. -Verified he had some new hire orientation but was unable to recall what it was. *NA M stated he was taught hand hygiene and glove use during his new hire orientation. *They both stated hand hygiene and glove use should have been performed before and after resident care. -Neither one had identified hand hygiene and glove use when going from a dirty task to a clean task. *NA M identified he had placed the resident's soiled linen directly on the floor and stated he was, Sorry about that. -He stated he thought the mechanical lift should have been sanitized after each resident use, but was not sure if that was what they were supposed to do. 2. Observation on 7/24/24 at 2:10 p.m. of medication aide (MA) Q during resident 1's suprapubic (SP) urinary catheter care revealed: *Resident 1 was on enhanced barrier precautions due to having an indwelling SP urinary catheter. *MA Q stated the resident had a bowel movement and had requested to be cleaned up before the surveyor's entrance into the room. -The soiled bed linens were folded and lying directly on the floor next to the bed. *MA Q sanitized her hands and applied a disposable plastic gown and clean gloves. -She removed a split gauze dressing that was located around the SP tubing insertion site on the resident's lower abdomen. -She cleansed the skin and catheter tubing around the insertion site with a specialized disposable wipe made for that purpose. *With those same gloved hands, she: -Opened a cabinet door, removed a clean split gauze dressing package, opened it, and applied the gauze dressing to the catheter tubing insertion site. -Adjusted the resident's dressing gown over the site and pulled up the bed linens to cover the resident. -Retrieved a urinal from the bathroom, opened the catheter bag's drainage port, and drained the urine into the urinal. -Returned the drainage port into a plastic holder on the catheter's drainage bag without having cleansed the drainage port. -Emptied the urinal's contents into the toilet, then turned on the sink's faucet handle and rinsed the urinal with water, and again dumped the urinal contents into the toilet. -Flushed the toilet. *She removed her gown and gloves then touched that same faucet handle to wash her hands. *With ungloved hands she: -Removed the soiled linen off the floor and placed it into a plastic transport bag. -Removed the resident's garbage bag for transport. -Opened the resident's hallway door and carried those items to a soiled linen closet located in the hallway. Interview on 7/24/24 at 2:20 p.m. with MA Q regarding the above observation of resident 1's SP catheter care revealed: *She identified she had not cleansed the catheter bag's drainage port after emptying the urine into the urinal stating, I missed that. *She was not aware she had missed the following hand hygiene and glove use opportunities: -When she moved from a dirty task to a clean task during the resident's SP catheter dressing change. -When she touched the resident's clothing cabinet, clean dressings, SP tubing, clothing, bed linens, faucet handle, and toilet handle with soiled gloves. -When she placed soiled linens directly onto the floor and when she handled those soiled linens without wearing gloves. -When she opened the hallway door without sanitizing her hands after she handled the soiled linens. Review of the provider's 2009 Cleaning and Disinfection of Resident-Care items and Equipment revealed: *3. Durable medical equipment (DME) must be cleaned and disinfected before reuse by another resident. *4. Reusable resident care equipment will be decontaminated and/or sterilized between residents according to manufacturers' instructions. Review of the provider's 2010 Catheter Care, Urinary, policy revealed: *Infection control. -Maintain clean technique when handling or manipulating the catheter, tubing, or drainage bag. *The policy had not addressed the step-by-step procedure for routine emptying of the urine collection bag, SP catheter care, disinfection of the drainage port, or hand hygiene and glove use protocols during routine catheter care. Review of the provider's undated Hand Hygiene policy revealed: *Procedure -1. All employees will perform hand hygiene before: b. Administering patient care. -2. All employees will perform hand hygiene after: a. Toileting self or assisting patients. b. Handling body secretions. c. Giving care to patient or handling equipment. d. Removing gloves. -3. b. Gloves will be changed after each patient/resident encounter. *The policy had not addressed hand hygiene and glove use when moving from a dirty procedure to a clean procedure when providing resident care.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure four of twenty-four sampled residents' (13, 24, 43, and 50) Advanced Directives had been: *Completed upon admission and available in the medical record. *Periodically reviewed with the resident or the resident's representative. Findings include: 1. Review of resident 13's medical record revealed: *Her admission date was 5/3/22. *Her Brief Interview for Mental Status (BIMS) score was 3, indicating severe cognitive impairment. -Her husband was listed as the Power of Attorney (POA) for healthcare decisions. *Her admitting physician ordered her code status to have been 'do not resuscitate' (DNR) on 11/30/21. *There was no documentation in the medical record that indicated the Advanced Directive had been addressed with the POA upon the resident's admission to the facility or periodically thereafter. 2. Interview on 5/8/23 at 9:06 a.m. with resident 43 and review of his medical record revealed: *His admission date was 5/19/22. *His BIMS score was 11, indicating moderate cognitive impairment. -His daughter was listed as the POA for healthcare decisions. *He had been unable to understand questions about Advanced Directives and said his daughter handled all his stuff. *His admitting physician had ordered his code status to have been 'full code' cardiopulmonary resuscitation on 5/19/22. *There was no documentation in his medical record that indicated the Advanced Directive had been addressed with the POA upon the resident's admit to the facility or periodically thereafter. 3. Review of resident 24's medical record revealed: *He was admitted on [DATE]. *His BIMS score was 5, indicating severe impaired cognition. *admission physician's order was signed on 1/11/23, indicating the resident's code status was DNR. *Resident 24's medical record did not have an Advanced directive acknowledgment form. *The DNR status was not addressed in his care plan. 4. Review of resident 50's medical record revealed: *She was admitted on [DATE]. *Her BIMS score was 6, indicating severely impaired cognition. *admission physician's order was signed on 3/14/23, indicating the resident's code status was DNR. *The resident's medical record did not have an Advanced Directive acknowledgment form. On 5/9/23 at 8:30 a.m., a request was made to the director of nursing (DON) B to provide a copy of residents' 13, 24, 43, and 50's Advance Directives. On 5/9/23 at 10:00 a.m. DON B indicated there were no copies of the above residents Advance Directive in their medical records. Interview on 5/9/23 at 1:28 p.m. and again at 4:45 p.m. with DON B regarding the above findings revealed: *In the resident admission packet, there was an Advanced Directive form for the resident or the POA to have completed and signed. -The admitting nurse was expected to have completed the Advanced directive form with the resident or the POA upon admission. *They [copies of resident advance directives] are not there, and why is because it was sent home with family and never returned. *Agreed Advance Directives should have been in the residents' medical records and periodically reviewed with the resident or POA. Review of the undated Advance Directives policy revealed: *Purpose: -To provide an atmosphere of respect and caring and to ensure that each patient's ability and right to participate in medical decision making is maximized during care . *Procedure: -During admission process Advance Directive Acknowledgement form is completed and placed in the front of the residents chart. -It is the Provider's responsibility to ensure that the patient, significant other or agent understand the provided advance directive information -All education and interaction with the patient, significant other or agent will be documented in the medical record by the provider.