Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI] report, interview, record review and policy review the provider failed to prevent staff to resident sexual abuse from occurring for one of one resident (29). Findings include: 1. Review of the SD DOH FRI report for resident 29 revealed: *On 9/21/24 at 11:35 p.m. certified nursing assistants [CNAs] reported to licensed practical nurse (LPN) H that resident 29 was complaining of CNA M being rough after she had used the bathroom and was being cleaned up. *LPN H assessed resident 29 in her room. *Administrator A and director of nursing (DON) B were notified. *Resident 29's power of attorney (POA) was notified. *Resident 29's primary physician was notified. *Administrator A contacted CNA M to suspend her pending investigation results. *Medical director C was contacted and he arranged for her transfer to the local emergency room for further assessment. *CNA M was terminated from the facility on 9/25/24. 2. Interview on 9/30/24 at 4:42 p.m. with resident 29 revealed: *She had a urinary tract infection (UTI) and was on antibiotics. *She stated she would get UTIs from her catheter. -I am on the strongest antibiotic you can be on for a UTI and I take my last pill tonight. *She stated staff treated her with respect and dignity and she had no problems with any staff. 3. Review of resident 29's electronic medical record revealed: *Her recent Brief Interview for Mental Status (BIMS) score was 15 indicating she was cognitively intact. *An order on 9/26/24 5:41 p.m. for, LevoFloxacin [antibiotic] 500 mg [milligrams] tablet dose ordered (1/2 tablet /500 mg) by mouth daily x 5 days Supper through: 9/30/24 for: urinary tract infections. *Her care plan dated 8/22/24 indicated she had a indwelling catheter, and history of UTIs. 4. Interview on 10/01/24 at 3:03 p.m. with resident 29 regarding the incident on 9/19/24 with CNA M revealed: *CNA M had been cleaning her up after she had used the bathroom. -She stated, I didn't think she should be cleaning me in that area. She clarified she was referring to her vagina. -The way CNA M cleaned her hurt her and she stated, I'm not sure she realized where she was going and was digging into my vagina from behind after I went to the bathroom and had a bowel movement. *She had no problems with any other staff. *She stated, I believe she did it intentionally because she told me I was dirty and she wanted to get me clean so I wouldn't get any infections, that was different from when my catheter gets pulled on. *She stated, She didn't tell me she needed to clean my vagina just that she needed to clean me. *She felt bad for reporting CNA M and stated, But what if she did that to someone else. *She went to the emergency room and had a video conference evaluation. They gave her a choice of a more thorough exam and she agreed to have the additional exam. -She stated they did not draw blood but did a swab of her vagina and she was told she did not have any open areas. -She did not know if she would get any results back from the exam but had not gotten any as of today (10/1/24). *She stated she thought the staff handled the incident well. *She was not aware of any new or different interventions or cares for her since this incident. 5. Interview on 10/01/24 at 4:01 p.m. with CNA K regarding providing peri cares for resident 29 revealed: *She would put on a gown and gloves and explain what cares she would be providing to resident 29. *She and another staff would use the mechanical lift to position her to clean the peri area. *She stated one staff would stand in front of resident 29 to keep her steady while the other staff would stand behind her to clean her. -She stated she cleaned her from front to back with wet wipes then with a washcloth and soap and water. She held the catheter to one side and cleaned the opposite side. *She was not aware of any new interventions for resident 29. *She was not aware of any abuse to residents. *She was not aware of any abuse education or training provided in the last month. 6. Interview on 10/01/24 at 4:27 p.m. with CNA N revealed: *He was not aware of any staff being rough with resident cares. *He thought he had abuse and neglect education in August. 7. Interview on 10/2/24 at 8:32 a.m. with certified medication assistant (CMA) J regarding abuse revealed: *She stated there had been staff to resident abuse in July or August a staff member had slapped a resident. -CNA M was no involved in this incident. -She was not aware of any allegations of staff to resident sexual abuse. *She had not had any sexual abuse education in the last couple of weeks. 8. Interview on 10/2/24 at 8:39 a.m. with social service designee E regarding the above incident involving resident 29 and CNA M revealed: *She stated she didn't know much but she knew that resident 29 had been in the mechanical lift. -Resident 29 had said 'ouch to the CNA when a nurse was putting in a catheter. -She stated she thought resident 29 had said ouch to the catheter being put in. *She said CNA M no longer worked there. *She was in the room when administrator A confronted CNA M about the incident. *She was not aware of any type of abuse education that had been provided since this incident. *She did not completed interviews or take part in the investigation regarding the incident, but administrator A did. *She did not put a social services note in resident 29's record regarding the incident on 9/19/24. 9. Interview and on 10/02/24 at 8:51 a.m. with DON B regarding resident 29's hospital report dated 9/22/24 revealed: *She agreed the provided hospital report did not have the sexual assault nurse examiner (SANE) dictation or results. -She called the medical director C while this surveyor was in the room. -She placed the phone on speaker mode and informed him this surveyor was in the room and asked about resident 29's SANE report results that had been done via telehealth conference. -The medical director stated he would have to talk to the nurses and call back. *DON B said medical director was called during resident 29's emergency room visit. -Medical director C did not call back regarding resident 29's SANE report or results before the end of the survey. *She stated she would get this surveyor CNA M's employee file to review. -CNA M's file was not provided before the end of the survey. 10. Interview on 10/2/24 at 10:19 a.m. with CMA I regarding abuse revealed: *She was aware of a staff to resident physical abuse that involved a staff member who slapped a resident, but she was not aware of any sexual abuse allegations. *She had attended abuse education in August or September, and everyone in the building had to attend and sign in for the training. -She was not aware of any other training or education regarding sexual abuse. 11. Interview on 10/02/24 at 11:06 a.m. with LPN G regarding resident 29 revealed: *She had been informed by DON B about resident 29's sexual abuse allegation Monday because it was reported over the weekend. *She stated, It was kept hush hush, but staff were whispering about it. *The incident happened Thursday evening 9/19/24. -Resident 29 did not report what happened until Saturday 9/21/24 and she reported to the nurse aides who then reported to LPN H. -LPN G stated LPN H had contacted administrator A and DON B about resident 29's allegation. -LPN H had been told to file an incident report by DON B. -Resident 29 was sent to the ER for a rape kit to be done on Sunday 9/22/24 for vaginal swabbing. -Staff were told to monitor resident 29 for vaginal bleeding which there was none reported. *They had a safety meeting on Monday 9/23/24 with administrator A, DON B and human resource manager (HRM) F. -LPN G stated she had walked in during the discussion about resident 29 because she was late. -She stated she had asked DON B why there were no nurse's notes made regarding the incident and DON B told her LPN H would be coming back to make a nurse's notes. -LPN G stated DON B reassured her LPN H would make a late entry because she was a new nurse and was unsure how to chart the incident. *LPN G showed this surveyor the abuse audits she had done which were given at a nurses meeting on 9/19/24. -She stated abuse had been talked about along with incident reporting to the state, and both nurses and aides were in the meeting. -Nurse managers were to complete the abuse audits weekly and the audits would be given to administrator A. -She stated the audit was from the plan of correction from the previous abuse where staff slapped a resident. *LPN G stated CNA M had been terminated on 9/24/24 at 10:30 p.m. *LPN G said she had worked there for seven years and worked with resident 29 a lot. She stated, She has a BIMS of 15 and knows what is going on. -She did not think that resident 29's current UTI was from the alleged sexual abuse incident. -Resident 29 had a history of UTIs and had refused peri cares and did not want to be cleaned up because the nurse would ask her about moving her skin folds when she was being cleaned, and she would not let them. -Resident 29 had requested often that her catheter be advanced. 12. Interview on 10/2/24 at 11:50 a.m. with administrator A about abuse education and investigation revealed: -She had provided staff abuse education and was completing audits for abuse from the previous physical abuse incident. -She agreed she was using the same audits for the facility-reported incident regarding the alleged sexual abuse. -There was no education regarding sexual abuse provided after the incident with resident 29 and CNA M. -She stated, Abuse is abuse. *They terminated CNA M and had reported the incident to her employment agency which she thought would go on her record. -She stated she would print off CNA M's personnel information for this surveyor to review. -CNA M's information was not provided by the end of the survey. 13. Review of the provider's 8/19/24 abuse, neglect and misappropriation of resident property policy revealed, Residents will be treated with dignity and respect. There is a zero tolerance for abuse. each staff member is a mandatory reporter for the state of SD.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, observation, record review, and policy review, the provider failed to protect three of five sampled residents (2, 3, and 4) from mistreatment, intimidation, verbal abuse, and physical abuse by one of one certified nurse assistant (J). Findings include: 1. Review of the provider's FRI online report submitted to the SD DOH on 6/30/24 revealed: *Resident 2 was not feeling well on the evening of 6/29/24. She had vomited several times. *Certified nurse assistant (CNA) J was seen by another CNA to have been getting frustrated with resident 2, told resident 2 to shut up, and swatted resident 2's hands away from her incontinence brief. *CNA J was interviewed about the situation and CNA J denied saying shut up to the resident and swatting the resident's hands. *She was assigned educational videos to watch about coping skills, how to calm down in difficult caregiving situations, anger management, and people living with dementia. *CNA J was allowed to return to work after her time of suspension, completing the information noted above, and signing a performance improvement plan. 2. Observation and interview on 7/22/24 at 4:18 p.m. with resident 2 revealed: *She was appropriately dressed and sitting in her wheelchair in her room. *Her call light and teddy bear were on the floor at her feet, and her lap blanket appeared to have been pushed away slightly. *She was watching a show on the television. *She repeated I'm lost multiple times. *Her room was clean and free from clutter. *Surveyor picked up the call light from the floor and gave it to resident 2. She was able to understand the purpose of the button. *She pressed the button. 3. Observation on 7/22/24 at 4:32 p.m. with CNA P revealed: *She answered resident 2's call light. *Resident 2 was not able to verbalize any needs. -She repeated, I'm lost. *CNA P calmly reminded her that she was safe, her family knew where she was, she was in the nursing home, and that supper was soon. *Resident 2 calmed down and continued to watch her show. Interview at that time with CNA P revealed: *It was normal for resident 2 to repeat the same phrase. *She was taught to calmly remind the resident about where she was at and address any of her needs. *She was not aware of any recent allegations of staff having been rough or rude to resident 2. 4. Interview on 7/22/24 at 4:37 p.m. with resident 12 and at 5:05 p.m. with resident 13 revealed that neither of them had any concerns with their safety. They both felt free from abuse and neglect. 5. Interviews on 7/23/24 from 11:00 a.m. to 12:55 p.m. with residents 5, 6, 7, and 8 about feelings of safety revealed they all expressed positive feelings of living at that facility, and they had no concerns regarding their safety. 6. Interviews on 7/23/24 at 1:20 p.m. with CNA F and at 4:05 p.m. with CNA G regarding how staff treated residents revealed: *CNA F denied that she had witnessed any staff member mistreating a resident verbally or physically. *CNA G indicated she had no concerns about resident safety or how residents were treated by other staff members. 7. Interview on 7/23/24 at 1:42 p.m. with CNA L about reporting alleged violations revealed: *She was able to verbalize the correct reporting procedures. *She had not reported any incidents recently. *She was not aware of the situation with resident 2. *There were two incidents that she knew a different CNA reported last week. -Both incidents involved CNA J. -One incident involved resident 3 having been stuck behind a door, and CNA J yelled and banged on that door. -The other incident involved resident 4, but she could not recall the details. -She was not present for either incident but heard about them from a coworker. 8. Observation on 7/23/24 at 1:57 p.m. of resident 3 in her room revealed: *She was resting in bed with her eyes closed. *She was snoring. *Her bed was in a lower position. *There was a fall mat on the floor next to her bed. 9. Observation and interview on 7/23/24 at 1:59 p.m. with resident 4 revealed: *She was laying on her left side on her bed. She was covered by a blanket. *She was able to converse but was saying nonsensical words and was having difficulty expressing herself. 10. Interview on 7/23/24 at 2:36 p.m. with licensed practical nurse (LPN) D revealed: *She was aware of the incident between CNA J and resident 2, however, she was not there that day. *She was briefed about the situation. *She was not aware of any incident where a CNA was banging loudly on a resident's door. 11. Interview on 7/23/24 at 2:44 p.m. with CNA I about the incident between CNA J and resident 2 revealed: *She confirmed she had worked that day. *Resident 2 had vomited several times during that shift. *CNA J was assigned to resident 2 and had called for help with getting her cleaned up and changed. *A different CNA assisted CNA J, so she did not know all the details. *She believed the CNA who helped CNA J had a good working relationship with CNA J and would not try to get CNA J in trouble. 12. Interview on 7/23/24 at 2:56 p.m. with nurse aide (NA) M about the incidents involving residents 3 and 4 revealed: *One incident involved resident 3 and CNA J around supper time approximately two to three weeks ago. *Resident 3 wheeled herself into her room and closed the door behind her, had gotten her wheelchair stuck, and the staff were not able to open the door. -She walked by resident 3's room and heard banging. Resident 3 was saying, Help, I'm stuck. -She tried to provide verbal directions to resident 3 to maneuver herself away from the door. -She was not able to open the door. *NA M was not assigned to resident 3's hallway that day, and one of her assigned residents had pressed their call light. -NA M asked CNA J to assist resident 3 and went to answer her assigned resident's call light. *She heard CNA J yell and swear loudly at resident 3 to open the door. -She could not recall what specifically was said. *She reported that incident to administrator A the same day. *Another incident happened last Friday, 7/19/24. -She indicated this incident was the most concerning to her and stated it broke my heart. *Last week, CNA J became upset with resident 4. -Resident 4 was at risk for falling and had repeatedly attempted to stand up and walk herself without assistance. -CNA J wheeled resident 4 out of her room and to the CNA station. -Resident 4 attempted to stand up from her wheelchair. -CNA J forcefully put her hands on resident 4's shoulders and sat her back down in her wheelchair. -CNA J said to the staff at the CNA station, Here, you watch her, and walked away. *CNA G asked CNA J what was going on and if she was okay. -CNA J talked loudly back at CNA G in a rude manner. -CNA G requested that CNA J not speak to her in that manner. -NA M waved at registered nurse (RN) C to get her attention so she could help diffuse the situation. -NA M volunteered to switch residents with CNA J. -She reported that incident to administrator A immediately. *Later that evening, while NA M was helping resident 4 get ready for bed, resident 4 was agitated, fidgeting, and repeatedly said, He's a hateful person. He's a hateful person. -She asked resident 4, Who's a hateful person? -NA M stated CNA J came into resident 4's room, [resident 4's] face fell, and she whispered [to NA M], 'Him, he's a hateful person,' and she pointed at [CNA J]. -NA M again reported her concerns to administrator A that same day. 13. Interview on 7/23/24 at 4:23 p.m. with CNA J about the above incidents revealed: *She most often as assigned List A which included residents 3 and 4. *Regarding the incident resident 2: -She felt really bad for resident 2 because she [resident 2] was vomiting a lot. -She did what she was trained to do and cleaned her up, changed her, and repositioned her, and evidently someone that was working with me thought I told her [resident 2] to shut up. I would never tell a resident to shut up. -She denied saying Shut up to the resident. -She denied swatting the resident's hands. -She received education after that incident about coping skills and residents with dementia. *She had worked at that facility for six years. *If she needed help from another staff member, she would have used the radios to call for help. -She stated, Sometimes I feel the other staff ignore me. *She denied any other reportable incidents. 14. Interview on 7/23/24 at 4:49 p.m. with administrator A regarding the above incidents revealed: *She confirmed CNA J needed reminders to Watch her words, her tone. *One of the other CNAs came to her The other day and told her [CNA J] is a little cross with the residents. *She said regarding CNA J, she doesn't understand dementia. *After NA M reported the incidents to her the previous week, she texted director of nursing (DON) B. -DON B had worked a nurse shift that evening. -She told DON B to tell [CNA J] she has to watch her interactions. *Administrator A said, [CNA J] has a hard time with 'those residents' as in dementia. *She confirmed she knew about the incident between CNA J and resident 3. *She initially denied knowledge of the incident between CNA J and resident 4. -[CNA J] has had trouble with [resident 4] but I'm not aware of that particular incident. -However, when detailing the incident further, especially when resident 4 expressed He's a hateful person, administrator A did remember that incident. *She kept a daily log of conversations she has had throughout the day. -She could not remember exactly when NA M reported those incidents. 15. Interview on 7/24/24 at 9:33 a.m. with RN C revealed: *She was currently the staff development coordinator and would resume the DON role when DON B moved. *She was not aware of any of the incidents regarding CNA J. *Last Friday (7/19/24), she was at the nurse's station and a CNA flagged her down. -CNA G and O were heated because they didn't think CNA J was treating residents the best. -She denied hearing the staff yell at each other. -She denied observing CNA J forcefully sit resident 4 down into her wheelchair. *She coordinated the monthly staff training day. *If a CNA needed more experience or training on a particular subject, DON B would have taken care of that as she was directly responsible for the nursing staff. *She confirmed that CNA J was up to date with the required training topics. 16. Interview on 7/24/24 at 10:28 a.m. with DON B regarding the above incidents revealed: *She had addressed CNA J's gestures and facial expressions with her before as people with dementia pick up on that. *She had provided quite a bit of informal training to CNA J about her attitude. *After the incident with resident 2, she provided formal training to CNA J on teamwork. *Regarding other incidents with CNA J: -Staff brought up concerns regarding her yelling. -On 7/19/24, she started her shift at 10:00 p.m. and she spoke with CNA J about her actions. She informed her that was the last warning before termination. -Once you bring her [CNA J's] attention to a problem, she fixes it for a while. 17. Interview on 7/24/24 at 11:03 a.m. with administrator A about the above incidents revealed: *She confirmed she was not informing the other department heads, like RN C the staff development coordinator, about certain incidents in an attempt to maintain confidentiality. -If an incident involved a CNA, she would have only let DON B know about the situation. -She had not considered bringing the staff development coordinator into the conversation. *Her investigation process included to: -Review schedules. -Interview those staff who were on shift and were involved. -Speak to each person individually. -Try to maintain confidentiality. *She felt the incidents involving CNA J and residents 3 and 4 were probably true because the staff member that reported those incidents was reliable. 18. Interview on 7/24/24 at 12:12 p.m. with CNA K about the incident between resident 2 and CNA J revealed: *She had worked that day and that resident 2 was not feeling well. *It was stressful. *She helped CNA J with resident 2 as she had vomited multiple times. *She confirmed she heard CNA J tell the resident to shut up. *Later on during that same shift, while she helped CNA J to get resident 2 to bed: -Resident 2 had been pulling at her incontinence brief. -She confirmed she saw CNA J swat resident 2's hands and said, You don't need to be messing with that. *She was not aware of any other specific incidents involving CNA J. *Each shift [CNA J] has some behavioral issues, such as being rude to residents and staff or raising her voice. 19. Review of resident 2's electronic medical record (EMR) revealed: *On 6/29/24, she vomited and had loose stools that began early in the morning. *There was no indication of the 6/29/24 allegations of verbal or physical abuse in the progress notes. *There was no indication in the progress notes that her family or representative was contacted regarding the alleged verbal or physical abuse on the evening of 6/29/24. *Her care plan included the following: -I was admitted because I need your help and support to manage with these health issues: .Anxiety disorder .[Unspecified] dementia . -I have the potential to have problems communicating and have problems with my memory because I have Alzheimer's dementia . I show this by having the inability to remember things that happened a short time ago, .a short attention span, increased disorientation, confusion about time, .at this time I repeatedly cry out 'help', talk about being 'lost' . --I need my aides to help me the same way every time, tell my nurse about any pain I have, offer me fluids, allow me to wander while assuring me that I am safe/give me directions if I start talking about being 'lost', acknowledge that you understand me, remind me of where I am, keep my items in the same place, face me and speak clearly when talking to me, allow time for me to respond . -I like to be comfortable because I have suspected pain. I show this by having changes in facial expression especially putting shoes on. --I need my aides to be extra gentle with me, ask me if I hurt, tell the nurse if I hurt, be patient with me, distract me with conversation. 20. Review of resident 3's care plan revealed: *I was admitted because I need your help and support to manage with these health issues: Adult failure to thrive .other symptoms and signs involving cognitive functions and awareness, other encephalopathy, unspecified severe protein-calorie malnutrition. *I have problems with my memory because I was hospitalized due to failure to thrive, abnormal weight loss, severe protein-calorie malnutrition, psychiatric or mood disorder (depression, anxiety), [hypertension], behaviors. I show this by having a BIMS [Brief Interview for Mental Status] score suggesting severe cognitive impairment, impulsivity, wandering, agitation. -I need my aides to help me the same way every time, tell my nurse about any pain I have, offer me fluids, make sure I am active and kept busy, allow me to wander, acknowledge that you understand me, keep my items in the same place, use safety devices .allow time for me to respond .make sure I'm wearing my glasses. *I have the potential to feel sad, anxious, I may also experience side effects from my medications because I have a diagnosed mood disorder (depression and anxiety) .have a cognitive impairment, can't move around well, .take psychotropic medications, .BIMS suggests severe cognitive impairment, behavioral symptoms, sundowning . -When I feel this way I feel down or depressed, can't relax or sleep, may not feel like eating, yell, shout, or scream . --I need my aides to ask me if I'm having pain, offer me a snack or drink, help me call my family, check on me, reassure me, offer me choices, ask me how I'm feeling today, .help me do as much for myself as I can, record my behaviors . *I like to be comfortable because I sometimes hurt, have arthritis . I show this by [complaints of] pain in my abdomen related to previous bladder cancer and surgery, back pain. -I need my aides to ask me if I hurt, tell the nurse if I hurt, be patient with me, distract me with conversation, help me to change position. 21. Review of resident 4's EMR revealed: *She was admitted on [DATE]. *She had a pattern of frequently standing up and ambulating without assistance, which resulted in a few falls. *A Summary Note on 6/13/24 read, Late onset Alzheimer's disease, able to redirect during the day with behaviors but increased agitation during the evening hours. Wears tabs monitor, she will frequently staff, walks with the assist of 2 [staff]. Often strikes out at staff, try to redirect by walking with her the assist of 2, assist her to the bathroom, offer snacks and attempt 1:1 [one to one] sessions. Speech is unclear, can't verbalize needs. *A Progress Note from 6/18/24 read, .Last evening, she required 1:1 staffing to assure her safety - she repeatedly stood up while holding on to her [wheelchair]. She insists on following a couple staff, but did not seem to tire .Agitated state lasted more than 1.5 hrs [hours] with [1:1] staffing. *She was experiencing increased agitation on 7/13/24 when she was continually attempting to stand by herself, was resistive to cares, and she was attempting to bite and scratch staff. *There were no progress notes related to any behaviors or increased agitation on 7/19/24, which was when the alleged physical abuse occurred, and NA M said that resident 4 showed fear and repeated He's a hateful person. *There was no indication that her family or representative had been notified regarding the alleged abuse that occurred on 7/19/24. *Her care plan included the following: -I was admitted because I need your help and support to manage with these health issues: Alzheimer's disease with late onset, Dementia in other diseases classified elsewhere with mood disturbance, Major depressive disorder . -I have problems communicating, and am forgetful because I have a history of Alzheimer's dementia, do not hear well, emotions affect my ability to communicate, problems with my speech patterns. I show this by having a BIMS that suggests severe impairment, having the inability to recognize people, the inability to remember things that happened a short time ago . --I need my aides to help me the same way every time, tell my nurse about any pain I have, offer me fluids, make sure I am active and kept busy, allow me to wander, acknowledge that you understand me -I have the potential to feel anxious, angry, sad, confused or forgetful, I may also experience side effects from my medications because I have a diagnosed mood disorder (depression and anxiety), moved here recently, have a hard time carrying on a conversation, have a cognitive impairment . --I need my aides to ask me if I'm having pain, offer me a snack or drink, present tasks to me one at a time, follow my toileting plan, check on me, reassure me, be aware of my stressors . -I need to have someone help me because I am unaware of safety risks . I have the potential to fall down and hurt myself because I have dementia/Alzheimer's disease. In the past I have fallen, and I have a history of getting anxious, upset, or angry (pinch, grab and scratch staff), trying to move around without help . --I need my aides to use a pressure pad in bed, [wheelchair] and recliner; use the following assistive devices to be able to better help me: walker .wheelchair; .frequently check on me; encourage me to use assistance . 22. Review of CNA J's employee file revealed: *She started on 4/11/18 and passed all the reference and background checks. *She was up to date with the required education topics. *After the allegations against CNA J on 6/29/24, an investigation was initiated. -Verbal accounts were gathered from resident 2 and all staff on shift at the time of the incident. -CNA J was suspended from work on 6/30/24 while the investigation was completed. -She returned to work on 7/1/24. *An Employee Performance Improvement and Disciplinary Action Plan - Written Warning was given to CNA J. -Identify problem: Failure to consistently fulfill duties of [a] CNA according to facility standards in a manner that promotes dignity of each person and treating them with respect, consideration and kindness. -Standard not being met: allegation of verbal abuse and intimidation of a resident. -Employee fails to meet standard for following reasons: On June 29, 2024 there were reported interactions with a resident who was ill . [CNA J] denied yelling 'shut up' to a resident and she denied touching the resident's hands (which was reported as swatted her hands away from the brief) . There is no reason to believe that the party who reported the allegation has anything against [CNA J]. She was told that there have been other instances in which she was guided to lower her volume and/or be attentive to her tone of voice. -The allegation made appears to be credible although [CNA J] adamantly denies . -There were no signatures or dates anywhere on the document. *DON B followed up with CNA J on each day she worked to audit her actions and behaviors. -7/14/24 - I [DON B] worked 6p-10:30p nursing shift: .[resident 4] tried to bite the nurse after using the bathroom .she was pushing her and pinching her during the shift. [CNA J] was supported in managing/coping with behaviors by DON. She gave evidence of her frustration (body language and facial expression) and was reminded about people with dementia being able to pick up on such things . -7/15/24 - [Resident 3] [was] very busy during the shift .trying to get up without assistance multiple times; She said that [resident 3] was yelling out and this makes her frustrated. She was reminded about coping techniques including working as a team. -7/19/24 - [Resident 3] was yelling at others .[CNA J] was observed to be tense, but admitted that other than trying to make sure [resident 3] is safe, there is not a lot to do that is effective in redirecting her when she is like this. -7/20/24 - Soke with [CNA J] about concerns from co-workers being impatient and loud when giving directions/guidance with behavioral issues. *The provider had a system where progress notes could be submitted associated with each employee: -7/20/24: concerns about quality of care - the administrator has heard concerns from [CNA J's] co-workers about her being impatient and being loud in giving guidance/intervening in behavioral issues. [CNA J] was counseled about the need to be attentive to how her actions and verbalizations are being interpreted. She was told that with her last warning, it was noted that if there would be an allegation that is anything other than unsubstantiated, this would result in termination of employment. -6/6/24: .At times, when a resident is particularly agitated, you might need reminders to speak at a lower volume and to remember 'Q-TIP' (quit taking it personally). -6/6/23: Other CNA came walking by the desk with a resident and said that she voided in another resident's closet. While that CNA took the resident to get cleaned up, [CNA J] was asked by the nurse to 'Please go clean the urine up out of that resident's room, because housekeeping is out of the building and said resident has family in their room' Instead of doing what was asked of her she went into another resident's room, not cleaning up the mess. Staff finally emerged from the other resident's room once she heard that the urine was cleaned up by someone else. -10/12/21: concerns about quality of care .received report that [CNA J] spoke very harshly to a resident in dining room. Spoke to another resident who reported the issue .Spoke to [CNA J] about this witnessed behavior, she informed me that she had already spoken to [administrator A] .discussed what resident reported (CNA yelling at resident across room in dining room) .discussed better ways to handle the situation instead of yelling at resident .discussed understanding the perception of someone watching what was occurring and how it may have looked to them .discussed walking across the room and speaking discreetly to a resident, not yelling from across the room. -6/29/21: spoken to concerning some reported incident of saying 'shut up' to resident, [CNA J] denies this happening, also reminded not to speak about personal things in front of residents when taking care of them. -5/13/19: resident came back from living room [at 2:30 p.m.] requesting to use the bathroom; [CNA J] said ok and walked the opposite way; 15 minutes later writer found [CNA J] in cafeteria eating a donut; writer stated '[resident] needs to use the bathroom,' [CNA J] said 'I'm going.' 23. Review of the provider's 7/19/24 updated Abuse, Neglect and Misappropriation of Resident Property policy revealed: *Policy: Residents at [facility] will be treated with dignity and respect. No resident of this facility will be mistreated, abused or neglected. *This abuse plan has been implemented to protect our residents. The responsibility for carrying out this plan will ultimately lie with the Administrator and the staff employed by [facility] but involves every person in contact with residents. *Residents have the right to be free from verbal, .physical, and mental abuse, involuntary seclusion, neglect . Residents must not be subjected to abuse by anyone . *Neglect is defined as the failure to provide the goods or services necessary to maintain the health or safety of a resident. Neglect is also defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. *Physical Abuse is defined as the use of physical force that may result in bodily injury, physical pain, or impairment. It may include .striking, hitting, beating, pushing, shoving, shaking, slapping, kicking, pinching . *Emotional or Psychological Abuse is defined as the infliction of anguish, pain, or distress through verbal or nonverbal acts. It includes .verbal assaults, insults, threats, intimidation, humiliation, and harassment.Examples of verbal abuse include .yelling, screaming, using demeaning language to ridicule; insulting; and swearing at residents.Signs associated with emotional or psychological abuse include recent or sudden changes in behavior, unjustified fear, unwarranted suspicion, .new or unexplained depression, lack of interest, or change in anxiety level. *The following could happen if abuse is not reported: The situation could get worse, the resident could get seriously injured, the resident could become ill, the resident could die, the person could abuse other residents . *Conflict between residents, between residents and staff, or between staff members directly influences the quality of life of residents. Often, abuse situations occur as a result of conflicts that get out of control. *Prevention: Information will be provided to residents, families and staff informing them on how and to whom they may report concerns, incidents and grievances without the fear of retribution. The facility will provide feedback regarding the concerns that have been expressed. The facility will identify, correct and intervene in situations in which abuse, neglect and/or misappropriation of resident property is likely to occur. *The most frequent abusers are caregivers and family members. Abuse usually happens because the person is overwhelmed by their own problems as well as those of the person for whom they are providing care. *Many factors contribute to abuse by staff including low staff ratios, inadequate supervision of staff, lack of empathy for elderly, staff personal problems, more severely ill residents, low wages, abusive or belligerent residents, job frustration, high staff turnover, cultural differences, lack of skills training and high stress. - .Mental and emotional signs and symptoms of stress include .anger; .inappropriate behavior like screaming, yelling, striking or hitting . *Process: -Identification: Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse; staff will determine the direction of an investigation. -Investigation: Alleged violations will be investigated and will be reported to proper authorities by the administrator, director of nursing or their representative -Protection: Residents will be protected from harm during an investigation. Staff may need to be reassigned to other areas or suspended until the investigation is completed. -Reporting/Response: The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries on unknown source and misappropriation of resident property immediately to the administrator or their representative. -The SD Department of Health must be notified immediately but not later than 2 hours if serious bodily injury occurred, within 24 hours of incident if no serious bodily injury. -Notify law enforcement only for an incident or event where there is reasonable cause to suspect abuse or neglect of any resident by any person. -The results of the investigation must be reported to the SD Department of Health, [the local police department] (if required to notify), and the SD Department of Human Services (if required to notify) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. -The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further abuse while the investigation is in progress. The facility must analyze the occurrences to determine what changes are needed, if any, to policies and procedures to prevent further occurrences. -If the alleged violation is verified, appropriate corrective action, which may include termination of employment, will be taken to prevent further occurrences.

Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) had an investigation completed following falls with injuries. Findings include: 1. Observation and interview on 8/7/23 at 4:25 p.m. with resident 27 while he was sitting in his wheelchair revealed: *He had fallen a few times but could not remember when. *He used his wheelchair for mobility. *He had worn glasses and was hard of hearing. Review of resident 27's electronic medical record (EMR) revealed: *On 5/26/23 at 3:30 p.m. he had an unwitnessed fall. *He was able to move all of his extremities. *He had complained of head pain and the loss of vision in his left eye. *Vital signs were taken and documented as follows: -Temperature: 97.3 -Pulse: 50 beats per minute normal is (60-100) -Respirations: 20 per minute -B/P: 119/79 -Oxygen level: 83% on room air normal is (90-100%) --Oxygen had been applied. *Resident was transferred by staff to his bed using the total mechanical lift. *The resident did have a few scratches on his head and one large goose egg on the left side of his head and another one on the top side of his head. *His neurological exam was within normal limits. (assessment of mental status, level of consciousness, eyes reaction to light, arms and legs strength, sensation, and gait) *He was taking Eliquis (blood thinner) 2.5 mg twice a day to prevent blood clots. *The resident was transferred to the emergency room for further evaluation. Interview on 8/9/23 at 4:30 p.m. with director of nursing (DON) B regarding the investigation and the reporting of the above fall revealed: *She was on medical leave when the incident occurred. *The nurse who was working at that time is no longer employed with the provider and had not reported the incident. *Certified nursing assistant could have completed the incident reports. *No report or through investigation had been completed by any other member of the nursing staff. 2. Observation on 8/8/23 at 10:30 a.m. of resident 32's wounds to her left leg during a dressing change revealed: *She had a medial wound measurement of 5.0 centimeter (cm) x 2.0 cm. *She had a lateral wound measurement of 7.0 cm x 5.0 cm *Both areas were painful to the touch. Review of resident 32's EMR revealed the following: *On 4/26/23 at 9:19 p.m. resident was transferred by a certified nurse aide (CNA) I with the sit-to-stand lift when the resident begun to allow her arms to chicken wing and hung from the waist strap on the lift rather than standing straight up. *CNA I unhooked the safety belt and assisted the resident to the floor and then called for help. *On 6/17/23 at 11:36 a.m. the resident was being transferred by CNA J with the sit-to-stand mechanical lift when the resident started to bend her legs and put arms straight up and started to fall. *CNA J attempted to return the resident to her chair, but she was slipping out of the sit-to-stand mechanical lift and caught her left lower leg against the lift causing two skin tears and a hematoma (bruise). Review of resident 32's updated August 2023 care plan revealed: *She was suppose to have been transferred with the help of 1 person and the mechanical Hoyer lift (total body lift). *The resident should have been transferred with one person and the sit-to-stand mechanical lift. Interview on 8/9/2310:33 a.m. with CNA H regarding the different types of mechanical lifts and the staff required to use them revealed: *The Hoyer was a full-body mechanical lift which requires two staff persons to operate. *The sit- to- stand mechanical lift could have been operated by one staff person depending on the resident it may have required two staff persons. Interview on 8/9/23 3:37 p.m. with CNA G regarding resident 32's wound to her left legs revealed: *She had received the wounds as a result of using the sit-to-stand mechanical lift. Interview on 8/10/23 at 8:33 a.m. with DON B regarding resident 32's two incidents with the sit-to-stand mechanical lift, reporting of the event, and completing a through investigation revealed: *Resident 32 was discharged from physical therapy on 4/4/23. *The resident wanted the nursing staff to pull her up from a seated position instead of standing while using the sit-to-stand mechanical lift. *She was not re-evaluated by the physical therapists for transfer safety with the sit-to-stand lift. *Therapy participates in weekly Medicare meetings and that was when the resident falls were discussed. *They had discussed resident 32's 6/17/23 incident in their Medicare weekly meeting, but no re-evaluation by therapy had been completed. *CNA's could have used a different mechanical lift if the resident's condition had required more staff assistance. *DON B had not felt that the incident with resident 32 was reportable due to the resident's pre-existing fragile skin. *All nursing staff were able to report incidents on their internal reporting system. *Once a report had been made, then a email would be sent to the administrator A and DON B for follow up. Interview on 8/10/23 at 1:47 p.m. with administrator A regarding reportable incidents revealed she: *Stated that the CNAs had just recently gained access to report incidents. *Was not aware of the incident with resident 27. *Stated that she was unsure about whether or not resident 32's incident was reportable. Review of the provider's July 2023 Policy for Abuse, Neglect and Misappropriation of Resident Property policy revealed: *Staff will identify events, such as suspicious bruising of residents, occurrences, patterns, and trends that may constitute abuse: staff will determine the direction of an investigation. *Alleged violations will be investigated and will be reported to proper authorities by the administrator, director of nursing or their representative. *The facility must report all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property immediately to the administrator or representative. *The results of the investigation must be reported to the SD Department of Health within five working days of the incident.

Based on observation, interview, record review, and policy review the provider failed to ensure that two of two sampled residents (27 and 32) who had falls with injuries were reported to the South Dakota (SD) Department of Health after falls with injuries. Finding include: *One of one sampled resident 27 required a transfer to the emergency room for further evaluation and treatment. *One of one sampled resident 32 had sustained injuries to her left leg from improper use of the sit-to-stand mechanical lift. *Refer to F609.