**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) complaint online report, interviews, records review, and policy review, the provider failed to ensure one of one resident (1) had been free from a significant medication error when he was administered two long-action insulins at the same time for four consecutive days. Findings include: 1. Review of the SD DOH 12/12/24 intake information revealed: *I am writing to file a complaint regarding [long-term care provider's name]. There was a sentinel event [not anticipated] that could have ended a resident's life. *[Resident 1] (4/5/1956) was transported to [name of hospital] on 12/12/24 for complaints of hypoglycemia and altered mental status. It was reported by [registered nurse (RN) K] (nursing home staff) that the patient's blood sugar was 24 at their facility. No interventions were completed by the nursing home staff at that time, only waiting for [ambulance name] to arrive. [RN K] reported that the patient has been having hypoglycemic episodes for the past 5 days. *Upon inspection of the MAR [medication administration record] sent with the patient to our facility, it was discovered that the patient was getting dosed with two different types of long-acting insulin types. The insulins that were administered were Touje [Toujeo] SoloStar 44 IU [international units] daily and Tresiba Flex INJ [injection] 40 IU daily. *The pharmacist at [hospital's name], [pharmacist's name], spoke with [provider's pharmacy name] regarding the two prescriptions for long-acting insulin. It was made to light that the brand of insulin was changed due to insurance funding issues. The patient was to change from Touje [Toujeo] to Tresiba because his insurance did not cover Touje [Toujeo]. There was a delay from when the Tresiba order was signed and when the medication arrived at the facility. Per [provider's pharmacy name], the facility was supposed to non-administer the Tresiba until the entirety of the Touje [Toujeo] insulin pen was administered. On 12/6/24 and 12/7/24 the Tresiba was non-administered by their pharmacy's directions. However, on 12/8/24 the patient started to receive both the Tresiba and Touje [Toujeo] every day until 12/12/24 when the Touje [Toujeo] order was discontinued per the estimated length of time for the pen to run out per [provider's pharmacy name]. Patient received both the insulins from 12/8-12/11/24. *The facility was updated when the patient was admitted for his hypoglycemia and blood sugar monitoring. A nursing report was given to [RN K] at [provider's name] and she stated she had no idea the patient was receiving two types of long-acting insulin. However, upon inspection of their MAR it seems that she potentially gave the does on 12/9/24 and 12/10/24 per their MAR user abbreviations. Review of resident 1's 12/12/24 ED note revealed: *[AGE] year-old male with type 2 diabetes on insulin presented to [hospital's ED name] via EMS [emergency medical services] due to being unresponsive secondary to hypoglycemia. Blood sugar was initially reported by nursing home staff to be 24. Blood sugar increased to 73 after receiving D10 [dextrose] by EMS. Patient was responsive and answering questions. He ate toast without difficulty. Serum blood sugar reading was 41. Suspected that patient may be receiving multiple long-acting insulin medications unintentionally which occurred related to insurance requesting changing insulin options and having to re-order new medication, apparently both Toujeo and Tresiba were administered for 4 days. *He last received double coverage of insulin yesterday morning. Concerned that he may have persistent hypoglycemia until insulin wears off. Recommended admission to [hospital's name] for observation to ensure his blood sugar levels return to baseline and adjust his diabetes medication. Review of resident 1's electronic medical record (EMR) revealed he: *Had an admission date of 8/26/24. *Had a diagnosis of Type 2 diabetes and was dependent upon the use of insulin to maintain his blood sugar levels. *Had a Brief Interview for Mental Status (BIMS) score of 11 that indicated he had mild cognitive impairment. *Was dependent upon the staff to: -Assist him with medication administration and ensure he received the right medication and the right dose. -Ensure they followed-up with the physician and pharmacy department regarding any medication order discrepancies and clarification of those orders. -Communicate with each other on order changes received from the pharmacy department or physician to ensure his safety from medication administration errors. Continued review of resident 1's electronic medical record (EMR) from 12/6/24 through 12/12/24 revealed: *On 12/6/24 at 2:57 p.m. there was a nurse progress note (PN) that indicated the resident to be given Tresiba Flex [insulin] 40 units once a day starting the next morning. -There was no documentation that supported the Tresiba should not have been given until the Toujeo insulin supply was all gone. *On 12/7/24 at 8:36 a.m. RN E documented that she had administered only the Toujeo. -There was no documentation that supported why she only administered the Toujeo. -There was no documentation that she had contacted the physician or the pharmacy department for clarification of the two long-acting insulin orders. *On 12/9/24 at 7:49 a.m. RN K gave the resident 6 ounces (oz) of orange juice. -There was no documentation that supported why she had given him orange juice. -The MAR documentation indicated that: --His blood sugar level had been checked and was low at 62. --She administered both the Toujeo and Tresiba insulins shortly after she had given him orange juice for a low blood sugar level. *On 12/10/24 the physician had seen the resident and decreased the Toujeo by 2 units. -There was no documentation that those two long-acting insulins had been clarified with the physician. *On 12/12/24 at 3:30 a.m. a certified nursing assistant (CNA) had observed the resident in the doorway of a shared bathroom. Another resident had been attempting to hold him up and telling him to hang on. The CNA attempted to direct the resident to sit down on the toilet but he could not follow directions. He was alert but unable to speak. The nurse and CNA were able to assist him to sit down in the wheelchair (w/c). -His blood sugar level had been checked and was low at 45. -The nurse administered a glucose injection into his abdomen per physician orders. -His blood sugar continued to drop to 40 and remained low at 44. -The nurse administered another glucose injection. He was able to drink a glass of orange juice and eat 1/2 a cup of ice cream. -His blood sugar level continued to rise from 49, 57, and 73. By 4:45 a.m. his blood sugar level had risen to 101. -A note regarding the resident's hypoglycemic episode was sent to the physician. *On 12/12/24 at 8:51 a.m. social services designee L had written a PN that the wife of the resident was called and informed he was sent to the ED due to being nonresponsive and a low blood sugar. *On 12/12/24 at 9:03 a.m. RN K documented: -This RN went into this resident room after being notified by [nurse consultant A], [director of nursing (DON) B] instructed me to call the ED to give report, this RN left the room to call the [local ED] to give report on this resident being sent to ER for hypoglycemia, this RN updated this resident's name, birthdate, & is having hypoglycemia episodes to the ER nurse, [DON B] was in the room with this resident until the ambulance arrived, this resident's blood sugar was taking [taken] by the [DON B], [DON B] stated this resident blood sugar was 24, the blood sugar was stated to the ER nurse that it was 24, the ER nurse state you need to recheck the blood sugar & if it is still low give him some honey or glucose, or something, you can't send him here with a low blood sugar, so they need to recheck the blood sugar, this RN let the ER nurse know that a call back will be given, resident is in & out of consciousness & is not able to swallow at this time, the ambulance is here for transport, resident left by ambulance, resident's spouse was phone called, no answer left a voice mail on her phone message to call facility for update & this resident is being transferred to the [hospital's ED]. -At 12:40 p.m. the ED had called to inform RN K that the resident was admitted for observation due to hypoglycemia and a urinary tract infection. Review of resident 1's 12/6/24 through 12/12/24 MAR revealed he had been given both the Tresiba and Toujeo insulins every day at the same time on 12/8/24, 12/9/24, 12/10/24, and 12/11/24. There was no documentation that supported those nurses had contacted the physician or the provider's pharmacy for clarification of the insulin orders. Review of resident 1's 12/12/24 medication variance report revealed: *An internal report had been completed he had an hypoglycemic episode and required the activation of the EMS system. *He was found cool, clammy, unresponsive, eyes open, and he was grunting. *His blood sugar was tested and had been below the typical range of 80 to 130 milligrams (mg)/deciliter (dl). -The blood sugar level was 24. Review of the provider's 12/13/24 Safety Huddle meeting notes revealed that there was to be education on insulin administration and pharmacy training. 3. Interview on 12/17/24 at 4:10 p.m. with RN E revealed: *She was aware of the insulin medication errors that had been found the prior week regarding the resident 1. *She had worked during that time frame that he had two orders on his MAR for both of the long-acting insulins. *She only administered the Toujeo insulin to the resident and did not administer the Tresiba insulin. *She stated: -I thought it was strange that he had two long-acting insulins and just gave the one that we always had. -I charted that too. -The Tresiba was there, I just didn't remove it and give it to him. *The provider had a new pharmacy and a new process for entering the medication orders onto the resident's MAR. -The staff faxed the medication orders to the pharmacy and they would update the resident's MAR with the new or changed orders. *The Toujeo was not going to be covered by the resident's insurance and it was going to be replaced with Tresiba. *The pharmacy had expected there to be a delay with the delivery of the new insulin and the staff were to continue giving resident 1 the Toujeo until it was gone. -That information had not been communicated amongst the staff or from shift-to-shift. -The pharmacy had entered the new order on the resident's MAR but had not added to hold it until the Toujeo was completed. -There were two orders on the resident's MAR to administer both of those long-acting insulins at the same time every day. -The Tresiba had been delivered to the facility the next day and was available to be administered. *She had not: -Contacted the pharmacy or the physician to clarify those orders that were entered in the MAR for resident 1 to receive two long-acting insulins at the same time. -Communicated that discrepancy to the next nurse coming on shift. *She stated: -I got busy and forgot about it. -Besides common sense would tell you not to give two long-acting insulins. *The nursing staff had been educated to: -Not assume that another nurse would have known not to administer two long-acting insulins at the same time. -Make sure to report off to the next nurse coming on shift. Interview on 12/18/24 at 8:00 a.m. with resident 1 regarding the incident on 12/12/24 revealed he: *Was alert and oriented to self. *Remembered being sent to the hospital and that his insulin had to be adjusted. *Was not able to recall why he had been hospitalized . *Stated: My memory is poor. Interview on 12/18/24 at 9:25 a.m. with RN H revealed she: *Had been employed with the facility approximately three weeks. *Had been educated that morning on: -Not administering two long-acting insulins. -The importance of clarifying with the doctor if there were two orders to administer long-acting insulins. *Had worked the morning of 12/11/24 but could not recall if she had administered both of the insulins to resident 1. Interview on 12/18/24 at 9:45 a.m. with DON B revealed: *She had been the DON since November 2024. *Prior to November she had been the assistant DON from April 2024. *She did not recall if the prior DON had completed medication administration competencies for the nursing staff. *She was not able to find any medication administration competencies for the nursing staff. *They should have completed medication administration competencies yearly. -She knew that because they had just been placed on her desk. *They had not completed any recent medication administration competencies. Interview on 12/18/24 at 9:50 a.m. and again at 2:35 p.m. with licensed practical nurse (LPN) D revealed: *She filled-in as needed at this facility. *She had received education yesterday on: -The importance of contacting the physician or pharmacy on any orders that do not look correct. -An overview for insulin administration. -There was a double check verification process for new orders to make sure they were entered correctly. *To her knowledge there was no other education or competencies on medication administration initiated since this incident to ensure residents safety. Interview on 12/18/24 at 5:10 p.m. with administrator C, DON B, and nurse consultant A revealed: *They had recently changed pharmacies and the new process was implemented on 12/2/24. *The pharmacy was in charge of changing and updating all the physician orders in the residents' MARs. *The staff would have faxed any order changes to the pharmacy and they would make the changes. *The staff should have checked to make sure the orders had been implemented correctly. *The order change for resident 1 regarding the two long-acting insulins had come from the pharmacy because insurance was no longer going to pay for the Toujeo. *The pharmacy had called to speak with the nurse in charge on 12/6/24 regarding the insulin medication change. -The staff were to continue giving the Toujeo until it was completed and the new Tresiba insulin arrived. -The Tresiba had come in right away and was placed in the medication compartment with the Toujeo for resident 1. -The charge nurse who had spoken with the pharmacy had failed to pass on the process to the on-coming nurse. *The pharmacy had put the order for resident 1's new insulin in the MAR to be started right away and did not delete the old insulin order. *RN E had caught the discrepancy with the duplicate order the next day but she had not: -Called the pharmacy or the physician to clarify the order. -Communicated this discrepancy with the other nurses to ensure a significant medication error had not occurred. *They would have expected RN E to have completed the above process and RN E was re-educated on that. *They initiated education with the nursing staff on 12/13/24. -They had educated the staff when they worked their next shift. -The education included recognizing duplicate orders and contacting the pharmacy and the physician to clarify the orders. -The 5 rights of medication administration. -Pharmacy training on the new process of verifying the orders in the resident's MAR had been entered correctly. *They could not locate or recall the last time medication administration competencies had been completed on the staff who administered residents' medications. *The only audit they had initiated to ensure the residents were safe from significant medication errors was a daily audit to compare the new orders with the resident's MAR to ensure the pharmacy had entered it correctly. *They had not initiated any other audits or medication administration competencies since the occurrence with resident 1 to ensure: -The staff had understood the process changes and implemented them correctly. -All residents who were dependent upon the staff to administer their medications had done so safely, correctly, and according to the 5 rights of medication administration. *They had not considered implementing those audits on medication administration for the safety of the residents. Review of the provider's December 2019 Medication Administration - General Guidelines policy revealed: *Medications are administered as prescribed in accordance with good nursing principles and practices *FIVE RIGHTS - Right resident, right drug, right dose, right route, and right time, are applied for each medication being administered. A triple check of these 5 rights is recommended at three steps in the process of preparation of a medication for administration: (1) when the medication is selected, (2) when the dose is removed from the container, and finally (3) just after the dose is prepared and the medication put away.

Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. * On 9/29/24, staff was notified by family that resident 1's right wrist was swollen. Nursing was unaware of the swelling, assessed the wrist, and notified the physician. The staff thought the swelling may have been caused by the sling during a transfer. It was also reported that resident 1 had a small bruise on his penis. Review of resident 1's 9/30/24 hospitalization medical records revealed: * Discharge plan had noted Additionally he [resident 1] fell a few weeks ago and hasn't been using his right hand. Nobody has evaluated his right hand and wrist in the clinic or emergency department [ED]. * Resident one was diagnosed with a right scapholunate ligament tear (tissue that connects the scaphoid and lunate bones in the wrist and most common cause is a fall on the wrist). * The assessment and plan on 10/1/24 indicated a right scapholunate ligament tear that required a splint. The resident was not a candidate for surgery. 2. Interview on 10/8/24 at 11:30 a.m. with certified nurse aide (CNA) H revealed: * On or around 9/27/24 she reported to the nursing staff an incident of possible abuse regarding two other CNAs. She reported that the CNA came out of resident 1's room and had stated, that motherfucker. When CNA H had asked the other CNA what had happened, the CNA stated that resident 1 had started fighting with them during a transfer so instead of using a total body mechanical lift as it was care planned, they decided to use a two-assist (two staff) transfer to get him on the toilet. CNA H reported the incident to an unidentified nurse. She was unsure if it was investigated. * On 9/29/24, she reported to the nursing staff a sore on resident 1's scrotum and a bruise on his penis. CNA H felt that the bruising may have been caused by the two-assist transfer a few days prior. * She was not sure if the bruising was investigated. No one had followed up with her regarding the incident. 3. Record review of nursing progress notes for resident 1 revealed: *A 9/15/24 nursing progress note indicated that the resident was complaining of left knee pain. Evaluation of the knee indicated that the left knee appeared swollen and tender to the touch. The resident had denied any injury that he could remember. A CNA had reported to the nurse that transferring the resident was difficult that day. It was noted that his left knee was wrapped, elevated, and ice was applied. An appointment would be considered for evaluation the next day. * A 9/29/24 nursing progress note indicated that resident 1's family was visiting during supper and had brought to the attention of the staff that resident 1's right wrist was swollen. It was noted that there were no reports of falls that day and the cause of the swelling was unclear. The physician was notified, and staff were instructed to apply ice to the area and to monitor overnight. If the condition had worsened, an x-ray would have been considered. 4. Interview on 10/8/24 at 12:45 p.m. through 1:00 p.m. with CNA K and director of nursing (DON) B revealed: *If CNA K had witnessed an incident of abuse or neglect, she would report it to the nurse on duty. * DON B stated that all reports to the nurses regarding abuse and neglect would have been taken very seriously and the administrator would have been notified immediately. Interview on 10/8/24 at 1:15 p.m. with administrator A revealed: * She had not been notified of the allegations of abuse regarding resident 1. * She was not able to provide documentation of any investigations to rule out abuse and neglect regarding the injuries of unknown origin related to resident 1's left knee and right wrist. * She stated that it was determined that the localized swelling in resident 1's left knee and right wrist was due to the resident 1's disease process. 5. Review of the SD DOH facility incident reporting database revealed: * No report was made regarding staff reporting to family that resident 1 had fallen on or around 8/21/24. * No report was made regarding the resident's swollen left knee and the cause was undetermined on 9/22/24. * No report was made regarding the report to staff of resident 1's swollen wrist and the cause was noted to be unclear. * No report was made regarding the bruise on resident 1's penis that was identified on 9/29/24. 6. Review of the provider's 7/31/24 Incident reporting policy revealed: * The provider would report any serious injury sustained by a resident that was not an expected outcome of the disease process would have been reported. * An incident that does not result in serious injury will not be reported. * The policy defined that physical harm did not include skin tear or bruise or something that could be covered with a band-aid. But that physical harm included a fracture or blood flow not stopped by a band- aid or hospital treatment that involves more than diagnostic evaluation only with subsequent finding of no injury do not need to be reported. Review of the provider's 7/12/24 abuse and neglect policy revealed: * Injury of unknown origin were injuries that met all three criteria according to the SOM [State Operations Manual]: - The source of injury was not observed by any person. - The source of injury could not be explained by the resident. - The injury was suspicious because of the extent of the injury or the location of the injury (the injury was in an area not generally vulnerable to trauma) or the number of injuries at one particular point in time or the incident of injuries over time. * Examples of possible reportable injuries that may fall under the definition of injuries of unknown origin included: - Unobserved/unexplained fractures, sprains, or dislocations. - Unobserved/unexplained scratches or bruises found in suspicious locations such as the head, neck, upper chest, and back. - Unobserved/unexplained swelling that was not linked to a medical condition. - Unobserved/unexplained bruising or other injuries in the genital area, inner thighs, or breasts. - Unobserved/unexplained injury requiring transfer to the hospital for examination and/or treatment. - Any injury that was explained and appeared to be a result of abuse must be reported. * If abuse was suspected the provider would have: - Took immediate steps to assure the protection of the residents. - Notified the appropriate/designated authorities or organization. - Conducted a careful and deliberate investigation centering on facts, observations, and statements from the alleged victim and witnesses. - Notified authorities if the abuse was also a case of a crime. - Report investigation findings to the state health department.

Based on a 10/7/24 complaint intake report review, interview, record review, and policy review. The provider failed to ensure a thorough investigation was completed to rule out if abuse and neglect occurred for one of one sampled resident (1) who had bruising and swelling of unknown origin on the left knee, right wrist, and penis and to report the incidents to the South Dakota Department of Health. Findings include. 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake revealed: * On 8/21/24, staff notified the family that resident 1 had fallen in the bathroom and had a small skin tear. * On 9/22/24, staff notified the family that resident 1's knee is swollen, and it was unknown what had happened. * On 9/29/24, staff was notified by family that resident 1's right wrist was swollen. Nursing was unaware of the swelling, assessed the wrist, and notified the physician. The staff thought the swelling may have been caused by the sling during a transfer. It was also reported that resident 1 had a small bruise on his penis. Review of resident 1's 9/30/24 hospitalization medical records revealed: * Discharge plan had noted Additionally he [resident 1] fell a few weeks ago and hasn't been using his right hand. Nobody has evaluated his right hand and wrist in the clinic or emergency department [ED]. * Resident one was diagnosed with a right scapholunate ligament tear (tissue that connects the scaphoid and lunate bones in the wrist and most common cause is a fall on the wrist). * The assessment and plan on 10/1/24 indicated a right scapholunate ligament tear that required a splint. The resident was not a candidate for surgery. 2. Interview on 10/8/24 at 11:30 a.m. with certified nurse aide (CNA) H revealed: * On or around 9/27/24 she reported to the nursing staff an incident of possible abuse regarding two other CNAs. She reported that the CNA came out of resident 1's room and had stated, that motherfucker. When CNA H had asked the other CNA what had happened, the CNA stated that resident 1 had started fighting with them during a transfer so instead of using a total body mechanical lift as it was care planned, they decided to use a two-assist (two staff) transfer to get him on the toilet. CNA H reported the incident to an unidentified nurse. She was unsure if it was investigated. * On 9/29/24, she reported to the nursing staff a sore on resident 1's scrotum and a bruise on his penis. CNA H felt that the bruising may have been caused by the two-assist transfer a few days prior. * She was not sure if the bruising was investigated. No one had followed up with her regarding the incident. 3. Record review of nursing progress notes for resident 1 revealed: *A 9/15/24 nursing progress note indicated that the resident was complaining of left knee pain. Evaluation of the knee indicated that the left knee appeared swollen and tender to the touch. The resident had denied any injury that he could remember. A CNA had reported to the nurse that transferring the resident was difficult that day. It was noted that his left knee was wrapped, elevated, and ice was applied. An appointment would be considered for evaluation the next day. * A 9/29/24 nursing progress note indicated that resident 1's family was visiting during supper and had brought to the attention of the staff that resident 1's right wrist was swollen. It was noted that there were no reports of falls that day and the cause of the swelling was unclear. The physician was notified, and staff were instructed to apply ice to the area and to monitor overnight. If the condition had worsened, an x-ray would have been considered. 4. Interview on 10/8/24 at 12:45 p.m. through 1:00 p.m. with CNA K and director of nursing (DON) B revealed: *If CNA K had witnessed an incident of abuse or neglect, she would report it to the nurse on duty. * DON B stated that all reports to the nurses regarding abuse and neglect would have been taken very seriously and the administrator would have been notified immediately. Interview on 10/8/24 at 1:15 p.m. with administrator A revealed: * She had not been notified of the allegations of abuse regarding resident 1. * She was not able to provide documentation of any investigations to rule out abuse and neglect regarding the injuries of unknown origin related to resident 1's left knee and right wrist. * She stated that it was determined that the localized swelling in resident 1's left knee and right wrist was due to the resident 1's disease process. 5. Review of the SD DOH facility incident reporting database revealed: * No report was made regarding staff reporting to family that resident 1 had fallen on or around 8/21/24. * No report was made regarding the resident's swollen left knee and the cause was undetermined on 9/22/24. * No report was made regarding the report to staff of resident 1's swollen wrist and the cause was noted to be unclear. * No report was made regarding the bruise on resident 1's penis that was identified on 9/29/24. 6. Review of the provider's 7/31/24 Incident reporting policy revealed: * The provider would report any serious injury sustained by a resident that was not an expected outcome of the disease process would have been reported. * An incident that does not result in serious injury will not be reported. * The policy defined that physical harm did not include skin tear or bruise or something that could be covered with a band-aid. But that physical harm included a fracture or blood flow not stopped by a band- aid or hospital treatment that involves more than diagnostic evaluation only with subsequent finding of no injury do not need to be reported. Review of the provider's 7/12/24 abuse and neglect policy revealed: * Injury of unknown origin were injuries that met all three criteria according to the SOM [State Operations Manual]: - The source of injury was not observed by any person. - The source of injury could not be explained by the resident. - The injury was suspicious because of the extent of the injury or the location of the injury (the injury was in an area not generally vulnerable to trauma) or the number of injuries at one particular point in time or the incident of injuries over time. * Examples of possible reportable injuries that may fall under the definition of injuries of unknown origin included: - Unobserved/unexplained fractures, sprains, or dislocations. - Unobserved/unexplained scratches or bruises found in suspicious locations such as the head, neck, upper chest, and back. - Unobserved/unexplained swelling that was not linked to a medical condition. - Unobserved/unexplained bruising or other injuries in the genital area, inner thighs, or breasts. - Unobserved/unexplained injury requiring transfer to the hospital for examination and/or treatment. - Any injury that was explained and appeared to be a result of abuse must be reported. * If abuse was suspected the provider would have: - Took immediate steps to assure the protection of the residents. - Notified the appropriate/designated authorities or organization. - Conducted a careful and deliberate investigation centering on facts, observations, and statements from the alleged victim and witnesses. - Notified authorities if the abuse was also a case of a crime. - Report investigation findings to the state health department.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on complaint intake report review, record review, observation, interview, and policy review. The provider failed to ensure adequate fluid intake, monitoring, and interventions for 6 of 6 sampled residents [1, 2, 3, 4, 5, & 6] resulting in dehydration and hospitalization for one of six sampled residents [1]. Findings include: 1. Review of the 10/7/24 South Dakota Department of Health (SD DOH) complaint intake report revealed: *On 7/29/24, it was observed by resident 1's family member that he was having difficulty eating and was asking for more water. He had already had his liquid limitation for supper. Resident 1's family member asked for additional fluids for resident 1 and was denied additional fluids due to resident's fluid restriction. *On 8/29/24, it was observed by a family member that resident 1's water pitcher was out of reach for the resident, it was unmarked and sitting next to his roommate's urinal. The straw wrapper was still on the straw that was placed in the water pitcher. *On 9/30/24, Resident 1's family requested reports on resident 1's vital signs, weights, and intake and output records. The provider was unable to locate the intake and output in the records. Review of resident 1's 9/30/24 hospitalization medical records revealed: * Resident was hospitalized on [DATE] * History and physical on 9/30/24 reported weakness that was multifactorial due to acute dehydration and malnutrition. * Resident had drank three liters of fluid on the day of admission to the hospital. * Discharge plan on 9/30/24 reported dehydration and weakness. * Laboratory findings included: - Potassium was low at 3.4. - BUN (blood urea nitrogen) was high at 27. - Albumin was low at 3.2 and is an indicator of poor nutrition. 2. Observation on 10/7/24 at 11:21 a.m. revealed: * Resident 2's water pitcher was out of reach. * Resident 3 did not have a water pitcher. * Residents 4 and 5 both had a full water pitcher sitting on their nightstands. The pitchers were not cold and there was no visible ice in the water. 3. Interview on 10/7/24 at 1:15 p.m. with dietary aide I revealed: * She would document the resident's fluid intake on the daily nutrition intake form and enter it into the residents Electronic Medical Record (EMR). * The daily fluid intake forms would have been filed at the nurse's station. Interview on 10/7/24 at 1:30 p.m. with certified nurse aide (CNA) H revealed: *Resident 3 should have had a water pitcher and should have been offered water between meals and during care. *Residents who were to have their liquids thickened would not normally have fluids offered to them between meals. Interview and observation on 10/7/24 at 2:00 p.m. with CNA E revealed: * She had been employed with the provider for 45 years. * Resident 3 required thickened liquids and residents with thickened liquids would sometimes not have water available at their bedside. * There would have been thickened liquids in the fridge to offer resident 3. * There was no thickened liquid in the fridge where CNA E stated it would be. * She thought resident 3 should have had water or liquids offered to her during resident checks and when providing her care. * Resident 3 would need assistance to drink and could not communicate her needs to staff. Interview on 10/7/24 at 2:10 p.m. with CNA F revealed: * The resident's water pitchers were filled with water and ice twice during the day shift. * It was not in her normal procedure to encourage residents to drink water between meals. Interview on 10/7/24 at 3:30 p.m. with Administrator A revealed: * Resident 1 was on a 2000 milliliter (mL) a day fluid restriction related to heart failure. * Dietary staff were to provide Resident 1 with 960 mL per day. * Nursing staff were to provide Resident 1 with 1040 mL per day. * Resident 1's fluid intake should have been documented in two places in the resident's EMR. * Administrator A stated that Resident 1's EMR fluid intake report was not an accurate account of the resident's actual fluid intake. * There was no process in place to accurately document resident's fluid intakes. Interview on 10/7/24 at 4:00 p.m. with registered nurse (RN) G revealed: * If a resident was on a fluid restriction, the CNAs would have given him the fluid intake report at the end of the shift. He would have noted the amount left in the resident's water pitcher and then documented in the treatment administration record (TAR). Interview on 10/8/24 at 9:00 a.m. with dietary aide J revealed: * She would document the resident's fluid intake on the daily nutrition intake form and enter it into the resident's EMR. * If she noticed a resident had not drunk any fluids all day, she would only record this in the EMR but not report it to the nursing staff because she is not part of the medical staff. Interview 10/8/24 at 9:44 a.m. with director of nursing (DON) B and (DON) D revealed: * On 10/7/24 Resident 5 had not consumed any fluids for breakfast, lunch, or supper. * On 10/7/24 Resident 6 had not consumed any fluids for breakfast, lunch, or supper. * The resident's recorded fluid intakes from the daily nutrition intake form that would have been entered into the EMR would have not alerted nursing staff if a resident was not drinking fluids. 4. Review of residents 1's 7/17/24 care plan revealed: * He had impaired skin integrity. * Interventions included: - Staff were to encourage good nutrition and hydration. Review of Resident 2's 8/28/24 care plan revealed: * Resident 2 was at risk for alteration in nutritional status related to: recent admission, poor PO [oral] intake and a skin wound. * She required assistance with [ADLs] activities of daily living. This included eating. * She had impaired skin integrity. * Interventions included: - Staff were to encourage good nutrition and hydration in order to promote healthier skin. - Staff were to monitor for signs and symptoms of dehydration and weight loss. - She would sit at the assisted table for meals for eating assistance. Review of Resident 3's 5/1/24 care plan revealed: * She was at risk for impaired skin integrity. * She was at risk for alteration in nutritional status. * Interventions included: - Staff were to offer extra fluids. - Staff were to encourage good nutrition and hydration in order to promote healthier skin. - Staff were to encourage fluid intake to help liquefy secretions. - She was dependent on staff for all care needs. - She was dependent on staff for assistance with meals. Review of resident 4's 7/18/24 care plan revealed: * He had required assistance with ADLs including eating. * He was at risk for altered skin integrity. * Interventions included: - He was dependent on staff for eating and drinking. - Staff were to encourage good nutrition and hydration. Review of resident 6's 7/18/24 care plan revealed: * He had the potential for impaired skin integrity. * He was at risk for dehydration due to use of a diuretic. * Resident took Lasix related to edema (fluid retention). * Interventions included: -Staff were to assess for signs of dehydration. -Staff were to encourage good nutrition and hydration in order to promote healthier skin. -Staff were to monitor for any sign and symptoms of fluid deficit. Review of the provider's 7/30/24 Hydration policy revealed: * The purpose of the policy was to ensure that residents are adequately hydrated. * Staff were to encourage fluid intake unless contraindicated. * Staff were to ensure that during meals, residents have fluids with their food. * Staff were to ensure that during meals, there is an available source of hydration when a resident asks for it. * Staff were to ensure that residents who are able to drink and pour themselves water have water pitchers *Those residents with physician orders for strict intake and output (I & O) will have their intake and output strictly measured and recorded in their I & O record.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident's (12) medicated topical cream had a physician's order. Findings include: 1. Observation on 11/7/23 at 8:30 a.m. of licensed practical nurse (LPN) F during the medication administration revealed: *Certified nursing assistant (CNA) staff had approached LPN F and explained that resident 12 had requested BioFreeze cream to her right hip and upper right thigh. *LPN F had stated that the resident had a different cream that she preferred to use in the resident's room. *Upon entering resident 12's room, LPN F searched and eventually found a tube of Arthritis Relief Pain Relieving Cream with Aloe on the resident's bedside table. *After confirming with resident 12 that the tube of cream was hers, LPN F administered the topical cream. 2. Review of resident 12's EMR revealed: *She had a physician's order for the BioFreeze. *There was no order for the Arthritis Relief Pain Relieving Cream with Aloe that LPN F had administered. *There was no documentation on the treatment administration record (TAR) or medication administration record (MAR) that the Arthritis Relief Pain Relieving Cream with Aloe was to have been administered to the resident. 3. Observation on 11/8/23 at 8:53 a.m. in resident 12's room revealed: *A basket was sitting next to the sink that contained a tube of cream stacked on top of various lotions. *The label on the tube of cream identified it as Arthritis Relief Pain Relieving Cream with Aloe 10% trolamine salicylate. *There was no label on the tube indicating whose cream it was. *There was no date written on the tube indicating when the cream had been opened. 4. Interview on 11/8/23 at 10:09 a.m. with LPN F revealed: *Resident 12 had a physician's order for the BioFreeze but the resident did not like the cold sensation or the smell of the BioFreeze. *She would make a note in the resident's medical record that the cream had been administered. *She agreed that there was no physician's order for the Arthritis Relief Pain Relieving Cream with Aloe. *She agreed that the Arthritis Relief Pain Relieving Cream with Aloe should not have been stored in the resident's room. Interview on 11/8/23 at 2:44 p.m. with ADON E and regional nurse consultant D revealed they agreed that there should have been a physician's order for the arthritis cream found in resident 12's room and that it should not have been kept in her room. 5. Review of the providers undated MEDICATION STORAGE IN THE FACILITY policy revealed: *B. Administration *1. Medications are administered only by licensed nursing, medical, pharmacy or other personnel authorized by state laws and regulations to administer medications. *2. Medications are administered in accordance with written orders of the prescriber. *D. Documentation (including electronic) *3. Topical medications used in treatments are listed on the treatment administration record (TAR/e[electronic]TAR). *4. The resident's MAR/e[electronic]MAR is initialed by the person administering the medication . *5. When PRN [as needed] medications are administered, the following documentation is provided: *a. Date and time of administration, dose, route of administration (if other than oral), and, if applicable, the injection site. *b. Complaints or symptoms for which the medication was given. *c. Results achieved from giving the dose and the time results were noted. *d. Signature or initials of [the] person recording administration and signature or initials of person recording effects, if different from the person administering the medication. A. Based on observation, interview, and record review, the provider failed to clarify one of one sampled resident's (35) medication dosage from a physician's order which resulted in the resident receiving 8 times the intended prescribed dose of an antipsychotic medication for 14 days, which potentially contributed to his increased lethargy during that time. Findings include: 1. Observation and interview on 11/6/23 at 2:19 p.m. with resident 35 revealed: *He was hard of hearing and could not answer questions. *He was sitting in a Broda chair. *He appeared very thin, his eyes and temples were sunken, and was calling for his mother and father. 2. Review of resident 35's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *Relevant diagnoses included unspecified dementia, diffuse traumatic brain injury, and bilateral hearing loss. *A 9/14/23 physician's fax order for Start Zyprexa 205 mg [milligrams] po [orally] BID [twice daily] from a hospital in Sioux Falls. *The physician's order that was entered into the resident's EMR on 9/14/23 was for 20 mg, not 205 mg as the faxed physician's order had read. *He received 20 mg of Zyprexa twice daily from 9/14/23 to 9/28/23. *He experienced increased episodes of lethargy between 9/14/23 when the Zyprexa was started, to 9/28/23 when the Zyprexa order was decreased. *A nurse's progress note from 9/28/23 at 4:21 p.m. indicated, Writer had phone conference today with the [hospital] team. During conference writer was informed that on the notes that we received 2 weeks ago .there was a typo. Order was supposed to be for [Zyprexa] 2.5mg BID. [Hospital team] stated this is why he is having so many episode[s] of lethargy. Orders received today was to decrease [Zyprexa] to 2.5mg TID [three times daily]. *A 9/28/23 physician's order for Reduce olanzapine [Zyprexa] to 2.5 mg po TID from the same hospital in Sioux Falls. *The resident had received eight times the intended prescribed dose of Zyprexa from 9/14/23 to 9/28/23. 3. Interview on 11/8/23 at 10:22 a.m. and again at 3:28 p.m. with assistant director of nursing (ADON) E revealed she: *Confirmed she had entered the order for Zyprexa as 20 mg BID on 9/14/23. *Should have clarified the physician's order from 9/14/23 as the initial faxed physician's order for 205 mg was out of the ordinary. *Confirmed she had not called the physician to clarify the order. Interview on 11/8/23 at 2:51 p.m. with Administrators A and B revealed their expectation was that all medication orders that were out of the normal dosage for a medication should have been clarified prior to administration of that medication. 4. A policy for resident prescription verification was verbally requested on 11/8/23 at 3:30 p.m. from ADON E. She indicated there was no such policy.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review, and policy review, the provider failed to adequately assess one of four resident's (43) ability to safely smoke unsupervised that resulted in the resident falling outside on two separate occasions and sustaining head injuries. Findings include: 1. Interview on 11/7/23 at 3:56 p.m. with registered nurse (RN) V about the residents who smoked revealed: *None of the residents who chose to smoke were supervised while they were outside. -They had been evaluated and determined to be safe to smoke independently. *It was the expectation that the residents were responsible for notifying staff when they wanted to be let back inside via the doorbell on the wall outside. *The doorbell was out of the resident's reach if they were to have fallen outside. Interview on 11/8/23 at 8:58 a.m. with licensed practical nurse (LPN) F about the residents who smoked revealed: *Resident 43 had fallen at least twice while outside smoking in the courtyard. *She said, We don't have enough staff to have someone sit out there to supervise. 2. Observation on 11/8/23 at 9:59 a.m. revealed that resident 43 was outside in the courtyard smoking without any supervision. Observation on 11/8/23 at 10:10 a.m. in the courtyard revealed: *There was a doorbell on the wall to the left of the door. -When pressed, a doorbell sound was audible inside. *There was one glass ashtray available with several cigarette butts and ashes in the tray. *There were two lawn chairs and one bench just outside the patio door. *A white plastic garbage can with a lid and a plastic liner was to the left of the door. -The garbage can was filled with empty cigarette cartons and visibly burnt, used cigarette butts. *A red metal bucket with a lid was to the left of the corner of the building. -Inside the bucket, there were several visibly burnt, used cigarette butts and cigarette ashes. 3. Interview on 11/8/23 at 10:19 a.m. with regional nurse consultant (RNC) D about the provider's smoking rules and resident 43's falls revealed: *She explained that resident 43 had fallen because directly before going outside to smoke, the resident had been given her bedtime medications. -Resident 43 became dizzy due to her medications. As a result, she fell and hit her head. *She confirmed that staff now give the resident her bedtime medications after her final cigarette for the day. *Resident 43 was assessed for smoking safety and was determined to not need supervision while smoking outside. *They had discussed with the residents previously about establishing a smoking schedule to provide more supervision; however, the residents were not in favor of a schedule. *She was not aware that residents had been placing their burnt and used cigarette butts in the white garbage can. She confirmed that was an unsafe practice due to the risk of a fire. 4. Review of the resident's electronic medical record revealed that she was hospitalized overnight from 9/29/23 to 9/30/23, and again on 10/1/23 to 10/2/23 due to her falls. Review of a nurse's progress note on 9/29/23 at 11:21 p.m. revealed: *Resident left the facility per ambulance at 2315 [11:15 p.m.]. Dr. [name redacted] [gave order] to have a scan completed due to resident's complaint of severe [head pain] and she is currently taking Eliquis [an anticoagulant medication]. *There were no other progress notes with a description of the fall from 9/29/23. *She returned to the facility on 9/30/23 at 2:30 a.m. Review of the resident's hospital discharge paperwork that was sent to the facility on 9/30/23 at 1:24 a.m. revealed the clinical impressions included contusion of head and acute hip pain. Review of the resident's September 2023 medication administration record (MAR) revealed she received the following medications at 8:00 p.m. per physician's orders on 9/29/23: *tiZANidine HCl Oral Tablet [a muscle relaxant] 4 MG [milligrams] Give 1 tablet by mouth at bedtime for muscle spasms. *traZODone HCl Oral Tablet [an antidepressant and sedative] 50 MG Give 0.5 tablet by mouth at bedtime for Insomnia. *Zolpidem Tartrate Oral Tablet [a sedative] 5 MG Give 2 tablet by mouth at bedtime for Insomnia. -Only one tablet was administered. Review of the resident's October 2023 MAR revealed she received the following medications at 8:00 p.m. per physician's orders on 10/1/23: *tiZANidine HCl Oral Tablet 4 MG Give 1 tablet by mouth at bedtime for muscle spasms. *traZODone HCl Oral Tablet 50 MG Give 0.5 tablet by mouth at bedtime for Insomnia. *Zolpidem Tartrate Oral Tablet 5 MG Give 2 tablet by mouth at bedtime for Insomnia. Review of a medication administration note on 10/1/23 at 7:41 p.m. revealed: *Note Text: LORazepam Oral Tablet 0.5 MG. Give 1 tablet by mouth every 4 hours as needed for anxiety and agitation for 14 Days. resident request for anxiety. Review of an incident note on 10/1/23 at 11:30 p.m. revealed: *Incident Summary: Called to patio outside facility where resident had been [to go] out for a cigarette. Resident is observed lying on the concrete on her [right side] propped up by her elbow. Her seated walker is behind her. *Resident reports that she hit her head and has [a headache]. She said she got 'dizzy' and fell. *Resident is observed for injury. Lump to back right side of her head is noted. *Small amount of blood with bruising is seen. Resident is [sic] staff assisted to her walker and brought back into the facility. VS [vital signs] are obtained and neuro checks are initiated. *Calls placed to [name redacted] POA [power of attorney] at 2119 [9:19 p.m.] and resident's [ex-spouse] to inform her of resident's fall. *Resident was declining to be seen and was showing signs of confusion, agitation and hypotension. With some encouragement resident did agree to go to [the hospital] to be evaluated. *DON [director of nursing], ADON [assistant director of nursing], Administrator and Regional Nurse consultant were notified at 2056 [8:56 p.m.] of fall. Notified again at 2203 [10:03 p.m.] of resident being sent to [the hospital] for evaluation. Resident was sent via EMS [emergency medical service] at 2215 [10:15 p.m.]. Review of the resident's hospital discharge paperwork that was sent to the facility on [DATE] at 12:24 a.m. revealed: *The clinical impressions included contusion of head and concussions. *The patient specific instructions read, Do not give zolpidem, [A]tivan, tizanidine, trazodone or any other sedating medications before patient is in bed for the evening and had her final trip outdoors for the night. Patient appears to have concussion from multiple falls. Headache, confusion are to be expected . Review of resident 43's undated care plan revealed: *She was admitted on [DATE]. *Relevant diagnoses included absence epileptic syndrome, not intractable, without status epilepticus [a seizure condition in which the person stops all activity, and appears to be staring into space, may affect the person's situational awareness, does not last longer than five minutes, and is able to be controlled by medications]; nicotine dependence; vitamin D deficiency; hypothyroidism; essential hypertension; depression; chronic obstructive pulmonary disease; immune thrombocytopenic purpura; anxiety disorder; type 1 diabetes mellitus with diabetic neuropathy; insomnia; unspecified severe protein-calorie malnutrition; portal hypertension. *There was the following intervention: The resident has been assessed according to facility policy and has been determined to be a safe smoker, capable of following the applicable rules. That was initiated on 9/22/23. *There was no documentation in her care plan that she had sustained falls with injury while smoking or any additional precautions staff should have taken regarding safe smoking, such as administering her bedtime medications after her final cigarette for the day. Review of the resident's assessments titled Smoking Program (Evaluation for Risk) - V 2 completed on 9/22/23 and again on 10/4/23 revealed: *The following statement was check-marked with both assessments: Resident is considered a safe smoker and May use/access smoking materials consistent with facility policy. Staff is not required to remain in attendance while resident is smoking. RESIDENT AGREES TO FOLLOW SMOKING RULES. *The assessments had not taken into consideration contributing factors to smoking safety such as risk for falls, diagnoses, or medications that might have put the resident at risk for accidents while smoking. 5. Review of the provider's September 2019 Smoking policy revealed: *Policy: This facility shall establish and maintain safe resident smoking practices while protecting the rights of the individual resident. *Facilities, at their discretion, may not allow smoking on their premises or may allow smoking only when the resident requires no supervision to smoke, or may offer smoking times and supervised smoking only. *Procedures: .If the facility allows smoking, all residents who smoke will be assessed for their ability to safely smoke with or without assistance or supervision and such will be included on the care plan. The Smoking Assessment will be completed at admission, readmission quarterly, annually, and with a change in condition. -a. Facility will provide staff, family or volunteer supervision when assessment determines supervision is required . -b. The facility may impose smoking restrictions on residents at any time if it is determined that the resident cannot smoke safely with the available levels of support and supervision. *Designated smoking areas include: - .e. A suitable number of noncombustible ashtrays will be provided in smoking areas. --1. To reduce the potential for a burning cigarette to fall out of the ashtray and onto nearby combustibles, only ashtrays designed with holders inside the ashtray will be used. --2. Cigarettes or other smoking materials will not be left unattended in ashtrays. -g. Smoking areas will be provided with metal containers equipped with self-closing covers to be used solely for the disposal of cigarette butts and ashes. --1. A sign to that effect will be posted on the containers. --2. All cigarettes and other smoking materials will be promptly disposed of in these containers and are not allowed to be discarded elsewhere. *The staff shall consult with the Attending Physician and the Director of Nursing to determine any restrictions on a resident's smoking privileges. *Any smoking-related privileges, restrictions, and concerns (for example, need for close monitoring) shall be noted on the resident's individual care plan.