**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to ensure the safety of one of one sampled resident (1) who fell, suffered head trauma, and required emergency room (ER) treatment when one of one certified nursing assistant (CNA) (B) failed to use a gait belt as directed in the resident's care plan while assisting the resident to the bathroom. Failure to use the gait belt potentially contributed to resident 1's fall which resulted in an injury that required treatment at the ER. This citation is considered past non-compliance based on review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's 1/10/25 SD DOH FRI regarding resident 1 revealed: *She was walking with her walker and certified nursing assistant (CNA) B to get dressed for the day. *She did not have a gait belt on. *She fell backward and hit her head on her end table, which caused a laceration to the back of her head. *She was transferred to the emergency room (ER) and her laceration was closed with eight staples. *On 1/10/25 following the above incident CNA B was provided immediate education regarding gait belt use. Resident 1 was out of the facility and not available for observation or interview at the time of the survey. Interview on 1/27/25 at 11:32 a.m. with director of nursing (DON) A revealed: *Resident 1 was impulsive and at times would not wait for CNAs to assist her before she started walking. *It was her expectation that staff were to use a gait belt when ambulating resident 1. *Education on gait belt use had been provided to all staff after the 1/10/25 incident. Interview on 1/27/25 at 12:15 p.m. with registered nurse (RN) C revealed: *Staff had been provided education on gait belt use that included: -When to use a gait belt. -When to put on and take off a gait belt. -The use of gait belts to transfer residents that had fallen. Review of resident 1's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her diagnoses included: dementia, Parkinson's disease with dyskinesia (involuntary muscle movements) with fluctuations, and abnormalities of gait and mobility. *On her 10/21/24 Fall Risk Evaluation she had a fall risk score of 17, which indicated she had a high risk for falls. *Review of resident 1's 1/27/25 care plan revealed: *She was identified to have a high risk for falls and had fallen multiple times. *She was able to ambulate with the use of a two-wheeled walker, gait belt, and stand-by staff assistance. *She required staff supervision for walking all distances while using her walker. Review of resident 1's ER notes revealed: *She was seen on 1/10/25 at 9:00 a.m. related to her fall. -She had a laceration to the right back side of her head. -She did not have a loss of consciousness. *She was discharged back to the facility on 1/10/25 at 9:45 a.m. with the following orders: -Staples to be removed in 7 days. -For the next 48 hours perform neuro check every 4 hours x4 [4 times] then every 8 hours along with monitoring vitals-if any changes in pupils, speech, vomiting, etc patient needs to be re-evaluated. Review of CNA B's employment and training records revealed: *She was hired on 7/21/21. *On 1/20/25 she had attended the provider's Team Meeting. Review of the provider's 1/20/25 Team Meeting information revealed: *A portion of that meeting addressed gait belt usage. *It indicated Always use a gait belt with resident transfers and ambulation. Do not take shortcuts! Review of the provider's 9/16/23 Fall and Fall Prevention policy revealed: *Residents who are High Risk [for falls] should utilize a gait belt with transfers and ambulation. -Apply gait belt securely around resident's waist. -One hand should be secured on gait belt with ambulation. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 1/27/25 after record review revealed: *DON A provided immediate education on 1/10/25 to CNA B after the fall regarding resident 1's need for a gait belt with transfers and ambulation. *Education was provided to all nursing care staff on 1/20/25 regarding gait belt use with transfers and ambulation as well as the need to follow residents' individualized care plans. *Staff interviews on 1/27/25 revealed the staff understood the education that had been provided. *Observations on 1/27/25 revealed staff were using gait belts with resident transfers and ambulation. *DON A audited to ensure staff were using gait belts with residents when walking them. *Resident falls and reportable incidents were reviewed through their Quality Assurance program. Based on the above information, non-compliance at F689 occurred on 1/10/25, and based on the provider's implemented corrective actions on 1/20/25 for the deficient practice confirmed on 1/27/25 the non-compliance is considered past non-compliance.

Based on interview, observation, and document review, the provider failed to protect one of one sampled resident's (4) right to be free from neglect by one of one certified nursing assistant (CNA) N who had not followed the resident's care plan related to transferring (moving from one place to another) which resulted in an open wound on her leg. This citation is considered past non-compliance based on review of the corrective actions the provider implemented immediately following the incident. Findings include: 1. Interview on 12/17/24 at 3:42 p.m. with resident 4 revealed: *She was talking about her recent dermatology appointment. *When asked if she had any sores or wounds, she pulled up her left pant leg. *She said she got that wound on her leg over a year ago. *She explained that CNA N helped her into bed and her left leg got caught on something. -She got a skin tear from that accident. -CNA N transferred her using the pivot technique rather than with the full-body mechanical lift. -She said that [CNA N] was in a hurry. *She did not blame the CNA for the accident and was very complimentary of the care he provided. 2. Review of resident 4's electronic medical record revealed: *Her care plan included a total of seven interventions that mentioned the use of a Hoyer lift (a band of full-body mechanical lift) and/or a total lift. -Staff are to use [Hoyer] lift with all transfers. Initiated on 12/17/21. Revised on 6/12/23. -DRESSING: .Resident needs assist with staff member and Hoyer lift for dressing abilities. Initiated on 10/23/17. Revised on 4/1/23. -TRANSFER: The resident is fully dependent on staff with [Hoyer] lift for all transfers with two staff at all times. Initiated on 10/23/17. Revised on 11/6/22. -TOILET USE: The resident utilizes a total lift with 2 staff for toileting needs. Initiated on 10/23/17. Revised on 11/6/22. -Resident utilizes Tena products [a brand of incontinence products] to promote ability to toilet with Hoyer lift. Initiated on 6/12/18. Revised on 11/6/22. -Resident uses [Hoyer] lift for transfers, however at times she refuses due to the amount of time it takes to hook up resident and transfer. Initiated on 6/26/19. Revised on 2/27/24. -Tena product utilized for [incontinence] and availability to change product while utilizing a [Hoyer] lift. Initiated on 10/23/17. Revised on 11/6/22. *Her 9/19/24 quarterly Minimum Data Set assessment indicated she had a Brief Interview for Mental Status score of 15, indicating she was cognitively intact. *There was a physician's order that read, Wound care to LEFT lower leg: clean w/ wound cleanser. Apply Bacitracin ointment [an antibiotic ointment]. Cover with collagen pad. Secure with bordered gauze. Change QOD [every other day]. [One] time a day on even days change after showering. *Progress note from 2/23/24 at 7:57 a.m. -Staff was transferring resident from her bed into her wheelchair using a pivot transfer, while transferring resident's left leg was cut open. A [four to five-inch] laceration noted to left lower extremity, gauze and paper tape applied to control bleeding. Assessed by wound care nurse, steri strips and mepilex applied. *She had a diagnosis of bullous pemphigoid, an autoimmune skin condition causing large, fluid-filled blisters. *At the time of the survey, the wound was still healing due to blisters forming in the wound area and continually opening per RN skin assessments. 3. Interview on 12/18/24 at 2:33 p.m. with registered nurse (RN) F about resident 4's skin revealed: *She remembered the accident where resident 4's skin on her left leg was torn due to an inappropriate transfer by a CNA. It happened on 2/23/24. *The resident's skin was very fragile due to a rare skin condition. -Her skin was a constant cycle of open and closed. -Resident 4 also had a habit of picking at her skin. *She confirmed that resident 4 was supposed to have been transferred using the full-body mechanical lift rather than with a pivot transfer according to her care plan. 4. Interview on 12/18/24 at 2:59 p.m. with CNA N about the accident with resident 4 revealed: *At the time of the accident, resident 4 was not able to use the toilet in her room. *He was planning on taking resident 4 to the shower room to use the toilet. *He cut corners and transferred her using the pivot technique. -He later admitted the transfer technique he used was not the pivot technique as resident 4 was not able to put her feet on the ground. -Instead, he explained that he assisted her to the edge of her bed, he wrapped his arms around her, lifted her up and transferred her to the wheelchair. *Resident 4's left lower leg got caught on either the bedframe or her wheelchair and caused a skin tear. *There was significant bleeding when that occurred. *Staff brought the resident to the neighboring clinic for treatment of the skin tear. *A large investigation was conducted after the accident. *He received verbal and written reprimands and education about following residents' care plans and how to properly transfer residents. *He knew what he did was wrong and that he should have transferred her according to her care plan. *All staff were reeducated on the importance of following residents' care plans at the February 2024 all-staff meeting. 5. Interview on 12/18/24 at 4:50 p.m. with director of nursing (DON) B revealed: *She confirmed that CNA N had not transferred resident 4 using the full-body mechanical lift on 2/23/24 which resulted in the skin tear to her left lower leg. *The wound was still healing. *Her skin condition made it hard for wounds to heal. *The investigation process included interviewing resident 4 and CNA N to get the whole story related to the accident. *They also interviewed other staff and residents to determine if anyone had concerns with the care that CNA N was providing. *CNA N was reeducated on safe resident transferring and the importance of communicating with coworkers and following residents' care plans. *DON B reeducated all staff at the monthly staff meeting in February 2024. -Those staff who were not in attendance were reeducated prior to their next working shift on accident hazards and following residents' care plans. 6. Random interviews with residents during the survey on 12/17/24, 12/18/24, and 12/19/24 revealed no other residents voiced concerns regarding potential neglect. 7. Observations and interviews during the survey on 12/17/24, 12/18/24, and 12/19/24 with nursing staff throughout the survey revealed appropriate resident transfers according to residents' care plans. 8. Review of staff training records revealed staff were educated about the above resident's accident and re-educated about following residents' care plans on 2/26/24 and 2/28/24. 9. The provider's implemented systemic actions to ensure the deficient practice does not reoccur was confirmed on 12/19/24 after record review revealed the facility had followed their quality assurance process, education was provided to all staff about accident prevention and following resident care plans, and observations and interviews revealed staff understood the education provided regarding those topics. Based on the above information, non-compliance at F600 occurred on 2/23/24, and based on the provider's implemented corrective actions for the deficient practice confirmed on 12/19/24, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, interview, and policy review, the provider failed to adequately treat pressure injuries for one of one sampled resident (11) by not following wound care nurse recommendations, and not notifying the resident's physician, resulting in a non-healing pressure injury. Findings include: 1. Review of resident 11's electronic medical record (EMR) revealed: *He had decreased feeling in his lower legs due to paraplegia (the inability to voluntarily move the lower extremities) from a previous spinal cord injury. *He also had diagnoses of congestive heart failure and dementia. *He had a pressure related injury to his left lateral ankle diagnosed on [DATE]. *His wound care was being managed by wound care registered nurse (RN) G. *RN G assessed his wound once weekly and placed orders for how to care for the pressure injury. 2. Review of resident 11's care plan revealed: *The resident has an ADL [activities of daily living] self-care performance deficit r/t [related to] paraplegia. *BATHING/SHOWERING: The resident requires extensive assist with 1 to 2 staff with bed bath 2x [two times] weekly and as necessary. *BED MOBILITY: The resident is able to assist with turning in bed with use of grab bars. Staff assist of 1-2 needed for position changes. *Resident transferred with staff assist of 2 and hoyer lift [mechanical lift that uses a sling] when getting out of bed or obtaining weights. *The resident has potential for pressure ulcers r/t immobility and paraplegia. -Assess/record/monitor wound healing q [every] Week. Measure length, width, depth where possible. Assess and document status of wound perimeter, wound bed and healing progress. Report improvements and declines to the MD [physician]. Revision on: 12/31/2020. -Follow facility policies/protocols for the prevention/treatment of skin breakdown. Date Initiated: 12/28/2020. -Wash feet daily with warm soap and water, pat dry. Apply silicone cream. Ensure heels and LEFT lateral ankle is floated at all times. Date Initiated: 04/05/2021. Revision on 03/02/2023. -Wound care nurse to assess on Wednesdays. Date Initiated: 07/13/2023. -Heel protectors on while in bed and in wheelchair. Nurse to check skin and placement every shift. Date Initiated: 10/23/2023. -Ensure LEFT lateral ankle is floated [elevated to avoid pressure] with pillow support whenever in bed. Date Initiated: 12/17/2024. 3. Observation on 12/17/24 at 3:16 p.m. of resident 11 revealed the resident laying in his bed with his left ankle not floated, laying directly on a pillow without support under his calf. 4. Observation on 12/18/24 at 2:15 p.m. RN G performing a dressing change on resident 11's left ankle pressure injury revealed: *The dressing was removed, there was a small amount of blood-tinged drainage to the dressing. *A small circular wound to his left outer ankle. *RN G measured the wound, measurements were 0.8 cm (centimeters) x (by) 0.5 cm. *The wound was cleansed with wound cleaner. *New dressing was applied. *Resident 11 did not have complaints of pain. 5. Observation on 12/18/24 at 2:45 p.m. revealed a sign on resident 11's closet door that read, Float Left Outer Ankle. Remove heel protector and use it and a pillow under the calf area. This should float the heel as well, preventing pressure injury to it. Thank you! [RN G]. 6. Observations on 12/18/24 at 5:00 p.m. and 6:23 p.m. revealed the resident laying in his bed with his left ankle not floated, laying directly on a pillow without support under his calf. 7. Observation and interview on 12/19/24 at 11:43 a.m. with RN F of resident 11 in his room revealed: *RN F reported that the wound care RN would see the resident weekly on Wednesdays. -She reported that care instructions would frequently change after the wound care nurse visit, and those instructions usually were not verbalized to nursing staff, but were updated in the resident's care plan. *The resident was sitting up in his wheelchair. *His left ankle was resting on a pillow with no pillow support under his calf to float it. *RN F's definition of floating the resident's ankle would be by placing main support under the resident's calf to avoid pressure on the resident's ankle. -When the surveyor asked if the resident's ankle was floated, RN F replied No. -She agreed that a lack of circulation to the resident's wound could delay wound healing. 8. Interview on 12/19/24 at 11:55 a.m. with resident 11 revealed: *He was unsure of how long he had resided at the facility. *He reported he received good care from the staff. *He was unsure of how long he had the pressure injury to his left ankle. *He had some sensation in his lower extremities, but the pressure injury did not hurt. 9. Interview on 12/19/24 at 10:15 a.m. with director of nursing (DON) B and clinical care coordinator (CCC) C revealed: *Resident 11 could be difficult to provide care for due to his decreased sensation in his lower extremities and his inability to convey his feeling of discomfort to staff. *DON B followed the wound care of resident 11. *DON B expected her staff to follow the orders of the wound care nurse. *DON B reported that it was her impression that resident 11 should only have had his left heel floated when he was in bed. *DON B did not always agree with the care recommendations of the wound care nurse. *When asked if there had been any attempt to consult a physician when the DON was not in agreement with the wound care nurse, she responded that it was difficult to step on toes. 10. Review of resident 11's progress notes documented by wound care RN G related to the left ankle pressure injury revealed: *10/23/24 Skin/Wound note, Outcome: Not progressing-LEFT lateral not floated upon arrival 10/23. *11/20/24 Skin/Wound note, Resident resting in bed upon arrival. Agrees to wound assessment and cares. Ankle not floated upon arrival. Staff education needed. Float instructions hanging above bed., Wound Healing % -166.67. *11/27/24 Skin/Wound note, Wound Healing % 0. *12/4/24 Skin/Wound note, Wound Healing % 0. *12/11/24 Skin/Wound note, Wound is stagnant with little to no progress., Wound Healing % 0. *12/18/24 Skin/Wound note, Wound Healing % -33.33. *There was no documentation that the resident's physician was notified of the lack of healing for the left ankle pressure injury. 11. Review of the providers 12/2019 Pressure Ulcers policy revealed: *10. Pressure ulcers will be treated as ordered by the physician and/or wound care RN and documented in the medical record. *11. No change or deterioration in a pressure ulcer over a 2-4 week period of time will warrant physician notification for evaluation of the current treatment plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the South Dakota Department of Health (SD DOH) complaint online report, interview, and policy review, the provider failed to protect one of one sampled resident (20) from mistreatment while receiving care from staff. Findings include: 1. Review of the SD DOH complaint online report revealed the following: *On 2/8/24 at 12:30 p.m. certified nursing assistant (CNA) C reported to registered nurse (RN) B that while providing care in the morning for resident 20, resident 20 had grabbed the back of CNA D's arm and twisted it. -That caused three open abrasions and redness on CNA D's arm. -CNA D had put resident 20's hands between her legs and put her weight on top of resident 20. -Resident 20 began yelling, You're going to break my arm. -CNA D stated, You're going to get dressed, and you're not going to hit me anymore. -CNA C told CNA D to ease up [on resident 20], and called out for help from other staff members. -CNA E came into the room and saw that CNA D to be straddling on top of resident 20 with the resident's arms crossed and the resident yelling get off me, you're going to break my arms. -CNA E then had assisted in helping resident 20 stand up and walk to the dining room. -RN F came to the room as CNA E was walking the resident out of the room. Observation on 3/6/24 at 10:27 a.m. of resident 20 in her room revealed she was in her bed, laying on her left side, with her eyes closed. Observation on 3/6/24 at 11:30 a.m. of resident 20 in the dining room revealed: *Her noon meal was served on a red plate. -She had pushed that plate into the middle of the table. *When asked open-ended questions, she had shaken her head no to each one of those questions with no other response. Review of resident 20's medical record revealed: *She was admitted on [DATE]. *Her 12/7/23 Brief Interview of Mental Status score was a 99 indicating she was unable to be interviewed. *Her diagnoses included dementia with behavioral disturbances and visual loss. *Her 3/6/24 care plan included the following: -Allow sufficient time for dressing and undressing. -She requires substantial assistance by 1 [one] staff [member] to dress. -At times will refuse morning cares due to preference of sleeping in. -She was resistive to care. --Give clear explanation of care activities prior to an as they occur during each contact. --If resident resists with ADL's [activities of daily living], reassure resident, leave and return 5-10 minutes later and try again. --The resident is verbally aggressive with staff. --The resident has impaired visual function r/t visual loss. Confidential interview with an employee who wished to remain anonymous regarding the above incident revealed: *She heard a staff call for help from resident 20's room. *She went to resident 20's room, and heard yelling that was not unusual, knocked and entered the room. *She heard CNA D state, She is not going to [profanity] hit me again. *CNA C had looked at her and stated quietly to her, I don't know what to do. *Resident 20 was on the bed lying on her side. -CNA D was lying over the top of resident 20. -Resident 20's arms were crossed and underneath of her. -CNA D stated, You are not getting up, she isn't going to hit me again. -The anonymous employee, during the interview, that the tone of resident 20's voice stating, Don't hurt me made her ill. -CNA C and the anonymous employee intervened and assisted resident 20 to stand up. -CNA D left the room. -RN F came into the room, looked around, and then left the room. *As resident 20 walked down the hallway, she stated Where is the ghost? -The employee asked resident 20 who the ghost was and resident 20 responded, That is what I am going to call that mean lady, a ghost. *On 2/8/24 after the above incident there was an emergency staff meeting held for all staff regarding abuse and neglect, proper restraining of residents, and how to handle residents with behaviors. Confidential interview with a second employee who wished to remain anonymous regarding the above incident revealed the following: *She heard a call for assistance in resident 20's room. -When she went into the room, CNAs C and D were assisting resident 20 to stand up, and assisting her pulling up her pants. *Regarding CNA D the anonymous employee stated that CNA D had a short fuse. Interview on 3/6/24 at 11:54 with RN B regarding the above incident revealed: *The incident happened at around 10:00 a.m. while staff were assisting resident 20 in getting up for the day. *She was notified of the incident around noon time from CNA C. *She contacted director of nursing (DON) A, who was not in the facility at that time. *The investigation was started. -CNA D was suspended on 2/8/24 at 1:16 p.m. -The investigation was completed and was substantiated that abuse had occurred. -CNA D's employment was terminated on 2/14/24. *Education regarding abuse and neglect, retaliation, and dementia care was provided to every staff member after the incident on 2/8/24 and before their next working shift. -Additional education for those same topics was provided to all staff members on February 28, 2024. Interview on 3/6/24 at 12:06 p.m. with DON A regarding the above incident revealed: *She was notified on 2/8/24 of the above incident. -She came to the facility and started educating staff members on abuse and neglect. -Education was provided to staff members in their monthly meeting. *Events that were reportable to the SD DOH were included in the monthly Quality Assurance Process Improvement (QAPI) meeting for review. Review of the provider's revised February 2024 Abuse policy revealed: *Subject: Freedom from abuse, neglect and exploitation & [and] reporting *Purpose: To ensure the facility has followed all the required stops for recognizing and for appropriate reporting and follow up in cases of suspected resident/patient abuse. *Policy: Each resident/patient has the right to be free from abuse, neglect, misappropriation of resident/patient property .Residents/Patients must not be subjected to abuse by anyone, including, but not limited to, facility staff ,other residents/patients, consultants or volunteers, staff or other agencies serving the resident/patient, family members or legal guardians, friends, or other individuals. -C. To assist our facility's staff members in recognizing incidents of abuse, the following definitions are provided: -Physical Abuse includes but is not limited to hitting, pinching, slapping, punching, biting, and kicking. It also includes controlling behavior through corporal punishment. -Mistreatment means inappropriate treatment or exploitation of resident/patient -Person Centered Care is care that is individualized by being talored [tailored] to all relevant considerations for that individual, including physical, functional and psychosocial aspects. -Physical restraint as [is] any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria: --is attached or adjacent to the resident's/patient's body --can not be removed easily by the resident/patient. --restricts the residents/patients freedom of movement or normal access to his/her body. *Subject: Prevention *Purpose: to prevent abuse by providing residents/patients, families, and staff information and education on how and to whom to report concerns, incidents and grievances without the fear of reprisal or retribution. The leadership will assess the needs of the residents/patients in the facility to be able to identify concerns in order to prevent potential abuse. *Subject: Abuse/Neglect Inservice Training *Purpose: To provide periodic inservice [in-service] training for employees/volunteers on resident/patient rights and our facility's abuse/neglect prevention program. *Procedure: -5. Dementia training is offered throughout the year via [computerized training system] and staff meeting education, which addresses behavioral issues and approaches. Substantial compliance was confirmed on 2/14/24, after: *Staff member interviews confirmed education regarding dementia, abuse and neglect had occurred. *Review of documented dementia, abuse and neglect education for all staff members. *Termination of CNA D's employment. *SD DOH reports were reviewed during the QAPI meetings.