**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, interview, and policy review, the provider failed to assess for safe usage of a lift chair for one of one sampled resident (1) who had an unwitnessed fall and required hospitalization for injuries acquired from the fall and pain management. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include: 1. Review of provider's 5/27/25 SD DOH FRI for resident 1 revealed: *On 5/24/25 the resident was found on the floor in front of her lift chair laying on her right side. *Her lift chair was raised all the way up in the air. *She was unsure how she fell and ended up on the floor. *She had a large hematoma (collection of blood outside a blood vessel) to the left side of her forehead. *She had a skin tear and bruise on the top of her right hand. *She had adequate range of motion (ROM) to all four extremities. *Her neurological assessment was within normal limits (WNL). *She had good neck ROM from side to side and when looking down. *She had complained of discomfort when looking up towards the ceiling. *Ice was applied to her forehead after being assisted with a total lift from the floor into her wheelchair. *Her family was notified of fall. *Her primary care provider (PCP) was notified of the fall and he advised the staff to monitor and notify him of any change in the resident's condition. *On 5/27/25 she was having complaints of neck pain and was sent to the local clinic for evaluation. *A computed tomography (CT) scan was completed and revealed: -An acute nondisplaced fracture of the C2 (second cervical vertebra). -A suspected acute nondisplaced type 1 dens fracture (a break at the tip of the second cervical vertebra). *She was admitted to the local hospital on 5/27/25 for observation, and then admitted as an inpatient on 5/28/25 for pain control and a neurosurgery consult. *She returned to the facility on 5/29/25 at 2:57 p.m. and was admitted to hospice on 5/30/35. *No lift chair safety assessment had been documented for the resident prior to the fall on 5/24/25. 2. Review of resident 1's electronic medical record (EMR) revealed: *She admitted to the facility on [DATE]. *She was identified as having a high fall risk on her 3/6/25 and 5/24/25 fall risk assessments. *Her Brief Interview for Mental Status (BIMS) assessment score on 5/22/25 was three indicating she had severely impaired cognition. *She had the above fall with injury from her lift chair on 5/24/25. -She was admitted to the hospital on [DATE] and returned to the facility on 5/29/25. *She was admitted to hospice services in the facility on 5/30/25. *She had a lift chair safety assessment completed on 5/30/25, after her 5/24/25 fall. -That assessment found she needed total assistance from others to operate her lift chair. *Her lift chair was unplugged from the wall, and her family was notified. *She passed away on 6/4/25. 3. Interview on 6/26/25 at 9:14 a.m. with registered nurse (RN)/Minimum Data Set (MDS) coordinator C revealed: *She had worked for the facility for almost six years. *Resident 1 did not have a lift chair safety assessment completed before her 5/24/25 fall incident. *Resident 1 had a lift chair safety assessment completed after her return from the hospital on 5/30/25. *Nurses were responsible for resident assessments at the time of a resident's admission. *She completed the quarterly, significant change, comprehensive and annual assessments for residents with their MDS assessments. *Nurses should know resident assessments were due as they would be on the worklist in the resident's EMR to be completed at certain times. *She received education following the incident on 5/24/25 for resident 1 related to completing lift chair safety assessments and when they were due. *All residents who used a lift chair had lift chair safety assessments completed after resident 1's incident on 5/24/25. Interview on 6/26/25 at 9:26 a.m. with director of nursing (DON) B revealed: *She started her position on 5/19/25. *Floor nurses completed resident assessments which triggered on worklists in the EMR to be completed at certain times. *RN/MDS coordinator C would complete resident assessments when their MDS assessment was due. *She expected assessments to be completed when they were due. *She agreed that lift chair safety assessments had not been completed for any residents prior to the incident on 5/24/25 with resident 1. *She and RN D had completed all lift chair safety assessments for residents following the 5/24/25 incident. *She and RN D had also updated all resident care plans following that 5/24/25 incident. Interview on 6/26/25 at 9:52 a.m. with administrator A revealed: *She expected resident assessments to be completed when the resident assessment instrument (RAI)/MDS schedule stated they needed to be completed and upon the resident's admission to the facility. *She expected the provider's policies to be followed when they were implemented and development of a plan during the quality assurance and performance improvement (QAPI) process. *She agreed lift chair safety assessments had not been completed for residents prior to resident 1's 5/24/25 fall from her lift chair. 4. Review of the provider's October 2024 Lift Chair Safety Assessment Policy revealed: *A. Before a lift chair is used by a resident, a member of the intradisciplinary team will complete a lift chair safety assessment. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 6/26/25 after record review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding lift chair safety assessments and care plan updating. Interviews with nursing staff revealed they understood the education provided regarding the topics. Observation of lift chairs in residents' rooms were conducted. Audits were completed for newly admitted resident's, assessments were being completed, and residents' care plans were updated. Based on the above information, non-compliance at F689 occurred on 5/24/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 6/26/25, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to implement the following for one of one sampled resident (17): *Assess for the use of an audible chair alarm. *Document the use of the chair alarm. *Reassess for the continued use of the chair alarm. *Ensure the audible chair alarm was not causing harm. Findings include: 1. Observation on 7/9/24 at 9:58 a.m. in resident 17's room revealed: *She was seated in her recliner. *There were two alarm devices on her bedside table. One was connected to her bed, and the other was connected to her recliner and shirt. *She was wearing a pendant call light around her neck. *She pressed the pendant call light because she needed to use the bathroom. Staff promptly responded to the call light. 2. Observation and interview on 7/9/24 at 2:04 p.m. with resident 17 in her room revealed she: *Was seated in the same recliner. *Showed the surveyor a chair alarm was clipped to her shirt. *Was able to explain the purpose of the alarm. *Explained that it made a noise if she tried to move. *Said, I don't like it. It's loud and scares me. They don't want me to get up by myself. 3. Observation on 7/10/24 at around 12:55 p.m. near resident 17's room revealed that there was a loud and pulsating alarm emitting from her room. 4. Interview on 7/10/24 at 4:24 p.m. with certified nursing assistant (CNA) J about resident 17's chair alarm revealed: *She denied that the alarm physically restrained the resident, indicating that the resident could easily move, and the string attached to the resident's clothing would detach. *When she heard the alarm, she would have gone running to attend to the resident because she was a fall risk. *The resident had fallen previously and was bruised from the fall. *Resident 17 knew how to use the call light. *The resident usually attempted to get up by herself when she needed to use the bathroom. 5. Interview on 7/11/24 at 8:44 a.m. with director of nursing (DON) B about the chair alarms revealed: *If a resident tended to get up on their own and was not the safest to ambulate by themselves, they would place a tabs alarm on the resident. *The alarm would be clipped to the back of a resident's shirt so they would not be able to remove it easily. *She confirmed there was no assessment process prior to implementing a tabs alarm. *The bed alarms were silent. -If the bed alarm was triggered, the resident's call light would turn on. *The tabs alarms were loud and audible. -If the resident moved a certain way, the tabs alarm would become disconnected and emit a loud and audible alarm. *She confirmed there was no assessment to determine if the resident felt restrained by the device. *She had not considered if the resident could have been frightened by the audible chair alarm. 6. Interview on 7/11/24 at 9:34 a.m. with registered nurse (RN) N about the audible chair alarms revealed: *If a resident had an unwitnessed fall, the first intervention was usually to have placed the tabs alarm on the resident. *If a fall occurred, the resident's family would have been contacted to inform them of the fall and the implementation of the tabs alarm. *Other fall prevention interventions included signage in the resident's rooms to remind them to call don't fall. *Resident 17 was a patient in the adjoining hospital prior to her admission to the nursing home and received physical and occupational therapy to improve her strength and balance after she broke her hip from a fall at her previous living accommodations. *Resident 17 was more forgetful when she first admitted to the nursing home and would shout out for help rather than using her call light. -She understood how to use the call light now. -The resident had a habit of using the call light and standing up immediately rather than waiting for help to arrive. -She doesn't like to wait. 7. Review of resident 17's electronic medical record revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score was 11, which indicated she had moderate cognitive impairment. *There was no documentation of when the audible chair alarm was implemented. *There was no assessment to determine if the use of the audible chair alarm was appropriate or if it was a restraint. *There was no physician's order or duration of use for the audible chair alarm. *Her care plan included the following under the Fall risk problem initiated on 6/16/24: -An intervention of Mobility Alarm .sensory pad on in chair and in bed with a start date of 6/25/24. --A frequency of Every 8 Hours was attached to the intervention for the silent bed alarm only, not the audible chair alarm. -There were no other interventions for the audible chair alarm on her care plan. 8. Review of the provider's 6/23 Falls and Accidents policy revealed: *Purpose: To be proactive in preventing resident falls and accidents. *Policy Statement: To provide a systematic approach to fall and accident prevention and monitoring, including identifying and evaluating hazards and risk, individualizing approaches to reduce the risk of falls and accidents, and monitoring for effectiveness of interventions when necessary. *Definitions: Position change alarms: alerting devices intended to monitor a resident's movement. -The devices emit an audible signal when the resident moves in a certain way. -Types of position change alarms include chair and bed sensor pads, bedside alarmed mats, alarms clip[ped to a resident's clothing, seatbelt alarms, and infrared beam motion detectors. *Policy implementation: -2. Resident assessment and intervention --A. Upon admission/readmission, quarterly, and with status changes, staff will assess each resident's individual risk factors including fall risk, elopement risk, and risks and hazards within the physical environment. --B. Based on assessment of fall risk and elopement risk for each resident, staff will implement appropriate individualized, resident-centered interventions to reduce the likelihood of falls and elopement and communicate the risk and intervention to the staff through the plan of care. --C. Effectiveness and modification of interventions is monitored on a regular basis by the QAPI [quality assurance and performance improvement] program. - .4. Hazards in the physical environment --A. Staff will ongoingly assess the physical environment with regard to potential hazards, including .position change alarms .resident mobility devices . Any deficiencies in the safety of the physical environment will be immediately addressed. -- .C. The resident care plan will specifically address any risk factors that provide a benefit, such as use of a side rail or mobility device. -- .E. The facility will provide adequate supervision through assessing the appropriate level and number of staff, the competency and training of staff, and the frequency of supervision needed based on resident needs. 9. Review of the provider's 5/24 Restraint Policy revealed: *Policy Statement: It is the philosophy of [NAME] LTC [long term care] to keep residents unrestrained and as independent as possible. -If the results of a comprehensive, interdisciplinary assessment determine that there are no alternative to provide resident safety, or that the alternative methods have been unsuccessful, a physical and/or chemical restraint will be recommended for use. *Definitions: Physical restraint: any manual or physical device, material or equipment attached to or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body. -Physical restraints include but are not limited to leg or arm restraints, bolster mattresses, hand mitts, soft ties or vests, leg cushions and lap trays the resident cannot remove, and tucking a sheet around a resident so that resident cannot move. *Policy Implementation: -1. Members of an interdisciplinary team (IDT) will evaluate the resident's safety needs. -2. If a problem is identified, the least restrictive method will be tried first and the results documented. The use of restraints shall require clinical justification and shall be employed only to protect a resident from self-injury or from injuring others. -Restraints must not be used to limit mobility, for convenience of staff, for punishment, or as a substitute for supervision . -3. If a restrains is found to be necessary, appropriate health professional will complete the Pre-Restraining intervention in the electronic health record (EHR). The assessment will include medical condition requiring need for restrain and will be documented in the intervention. -4. Physician notification is required for all restraints initiated and a [physician's] order must be obtained prior to implementation. Restraint orders must be specific and include: type of restraint, specific periods of time restraint is to be used, medical symptom for restraint use, check by staff every 30 minutes, release every 2 hours, and specific times when restraint can be removed. -5. Resident and family will be educated on restraint use, reasons for use, assessment results, and risks and benefits associated with restraint use. -6. Resident or resident's family must sign a consent form for restraint use. - .8. Interdisciplinary team and physician will evaluate restraint usage monthly at minimum and will be reviewed at quarterly care conference by care planning team, resident and resident's family. -9. Restraints must be routinely observed and assessed. The restraints are to be periodically removed and range of motion, massage, or exercise applied, and hygiene, nutrition, and toileting offered. -a. Staff will check the resident's restraint every 30 minutes. -10. Quarterly documentation of attempted restraint reduction will be completed in the Restraint Assessment and noted on all applicable MDS [Minimum Data Set] assessments on the CAAs [care area assessments]. Early release and alternatives to restraint are to be continually explored. 10. Review of the provider's 3/24 Transfers policy revealed: *Purpose: To establish a protocol for staff for proper transfer techniques and decrease risk of injury to self and patient. *Protocols: Transfer Set-up: - .7. Put on tabs monitor or safety devices if needed and give call light (if inpatient or NH [nursing home]).

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the South Dakota Department of Health (SD DOH) online report, observation, record review, interview, and policy review, the provider failed to ensure one of three sampled residents (20) received appropriate care to prevent a burn from a warm pack. 1. Review of the SD DOH online report revealed the following: *On 1/20/24 restorative aide F applied a warm pack on the back of resident 20's neck. -The warm pack was a heated wet hand towel wrapped in Chux (disposable waterproof-under pad). -Resident 20's cognition score was a 4. Observation and interview on 1/30/24 at 12:22 p.m. resident 22 in his room revealed: *He was seated in a Broda [a specialized wheelchair] chair. *He made no eye contact, and was unable to respond coherently to questions. Review of resident 20's electronic medical record revealed his: *12/27/23 Brief Interview of Mental Status score was a 4, meaning he was cognitively impaired. *Diagnoses included Alzheimer's Disease and Lewy Body dementia with behavioral disturbance, and anxiety. *Medication administration record included a 1/20/24 physician order for Silver Sulfadiazine (Silvadene 1%) to the right side of the neck for a burn. *Care plan included the following: -Resident blank stares and is verbally unresponsive to family and staff. -Staff will anticipate needs. -Chronic Pain-as evidenced by: hx [history] of headaches, GERD [gastroesophageal reflux disease], monitor for facial grimacing and nonverbal s/s [signs and symptoms] of pain. -He required the assistance of two staff members for most activities of daily living. Interview on 1/30/24 at 10:44 a.m. with restorative aide (RA) F regarding the above-referenced report revealed: *Her employment began in March, 2023, and she: -Had transferred from a sister facility. -Had worked as the RA for about three months. -Had previously worked for the provider for a a year or two a few years ago. *She had started placing warm packs on residents' necks before completing the restorative nursing care to help loosen the residents' neck muscles. -She had no training in the use of warm packs. -She had no guidance from a nurse or physical therapist in the use of warm packs. -Warm packs were heated up in the microwave for 30 seconds. *On 1/20/24 she had heated three warm packs in the microwave and she: -Took two of the warm packs and placed them on resident 21 and resident 22's necks. -Thought the third warm pack had cooled. -Then placed the third warm pack back in the microwave and warmed it for another 30 seconds. --That warm pack she wrapped in a Chux with the plastic side out, and placed on the back of resident 20's neck, was not on for 20 minutes. -She had not thought it would get that hot (to cause a burn). Interview on 1/30/24 at 12:38 p.m. with certified nursing assistant (CNA) G regarding the use of warm packs revealed: *CNAs did not use warm packs. *RA F and nurses had used them for resident care. Observation and interview on 1/30/24 at 12:45 p.m. of resident 20 with registered nurse (RN) D revealed: *The mid-back of resident 20's neck had an area of eschar (a collection of dead tissue within the wound of the skin) approximately the size of a quarter, and on the right side of the back of his neck were two areas of eschar the approximate size of dimes. *RN D stated those eschar areas were caused from a warm pack burn on 1/20/24. -CNAs and RA F were able use warm packs on residents that were cognitively aware and could tell them if the warm pack was too hot. -She was not certain who would have trained CNAs and RAs in the use of warm packs. -She thought the RA F would have known how to use them, as she had been trained in restorative. Interview on 1/30/24 at 12:56 p.m. with RN C regarding the use of warm packs for residents revealed: *On 1/20/24 she observed resident 20's neck after staff notified her of a possible burn. -The back of his neck was red, was not raised, or blistered. --She placed a cool pack on it and called his medical provider. *She stated the area had not become open and had some eschar tissue on the area where the warm pack had been placed. *Warm packs were only used on residents who were cognitively aware and could say if the warm packs were too warm. *She was not certain who had trained CNAs and RAs in the use of warm packs. Interview on 1/30/24 at 1:06 p.m. with administrator A regarding the use of warm packs and restorative nursing care revealed: *There was not a restorative nursing care training program for staff. -CNAs were trained, during their CNA certification course, and how to complete basic restorative care. *There was no documented restorative nursing care training for RA F. *A RA job description was requested from administrator A and was not provided by the end of the survey period. -She thought RA F had not signed a RA job description, as she had started her employment as a CNA. *Thought RA F had RA training during her previous employment with a sister facility. -There was no documentation to support that the training had occurred. Interview on 1/30/24 at 3:25 p.m. with administrator A and clinical care coordinator (CCC) E regarding the use of warm packs revealed: *RA F was also a CNA. *RA F was not provided initial training in restorative nursing care as: -She previously worked at this facility. -Her employment was transferred from a sister facility. *CCC E stated nurses may have known RA F was using warm packs for resident 20's neck but she was not certain. *Administrator A stated the process for warm packs had been changed on 1/24/24. -The process now included not using warm packs on cognitively impaired residents. -Training for the nursing employees regarding the new process was completed on 1/24/24. DON B was not available for an interview during the survey period. Review of the provider's September 2023 facility assessment revealed: *One RA was scheduled for five days per week. *Staff competency was to have been assessed annually. Review of the provider's November 2023 Restorative Nursing Care Program policy revealed: *The Restorative Nursing Care Program, coordinated by the Director of Physical Therapy, provides exercises for patients based on their individualized needs. A physical therapist evaluates and designs the exercise program for each patient. The patient care staff is instructed by the physical therapist on how to carry out that exercise program. Review of the provider's undated Warm Packs policy revealed: *Warm Packs -Moisten wash cloth or towel with warm water from the faucet. Wring cloth or towel out, place in microwave no more than 30 seconds, then place in a plastic bag and [NAME] with a dry cloth. Apply to affected area. Check every 15-30 minutes and reheat/reapply as needed. Do NOT place wet cloth/towel in microwave more than 30 seconds .Check area where warm pack is applied every 15-30 [minutes]. -This policy was developed as a guide for the delivery of health services and is not intended to define the standard of care. *The policy did not include who was able to apply warm packs to residents. Review of the provider's revised August 2020 Abuse, Neglect, Mistreatment and Misappropriation of Resident Property policy revealed: *Definitions of Abuse and Neglect -f. Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. *Abuse policy -Additionally, residents will be protected from abuse, neglect, and harm while they are residing at the facility. -The facility will strive to educate staff and other applicable individuals in techniques to protect all parties.