Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI) review, record review, interview, and policy review, the provider failed to ensure one of one resident's incident to the SD DOH within the required time two-hour frame. The resident sustained serious bodily injury related to a fall from the whirlpool tub chair. Findings include: 1. Review of the provider's 3/31/25 SD DOH FRI regarding resident 1 revealed: *He had a Brief Interview for Mental Status (BIMS) assessment score of 10, which indicated he was moderately cognitively impaired. *On 3/30/25 at 6:40 p.m., resident 1 had fallen off the whirlpool tub's chairlift while being transferred out of the whirlpool by certified nursing assistant (CNA) D after his bath. -The CNA notified other staff and the resident was assessed by licensed nursing staff and had been unconscious and bleeding noted to the resident's forehead. -He was sent to the emergency room via ambulance for evaluation and treatment. -He had sustained two subarachnoid hemorrhages (a type of stroke caused by bleeding into the space between the brain and the tissue that covers it), a closed fracture (broken bone that does not penetrate the skin) of nasal bones, one laceration (skin cut or tear) on the right side of his forehead, and one laceration on his right lower extremity (leg). *Notes in the report indicated that: -Prior to the transfer the safety belt was secured within the tub-chairlift and fastened around resident 1's waist. *During the transfer resident 1 requested from CNA D that the safety belt be removed, and stated it was too tight. *The safety belt had been loosened by CNA D, but was not removed. *On 3/31/25 at 4:40 p.m. social worker C submitted an SD DOH FRI. 2. Interview on 7/1/25 at 11:15 a.m. with resident 1 in his room revealed: *He recalled when he fell off the whirlpool tub-chairlift on 3/30/25 at 6:40 p.m. *He denied he had removed the safety belt on the whirlpool tub chair. *He denied CNA D had removed the safety belt either. 3. Interview on 7/1/25 at 2:39 PM with social worker C revealed: *She had interviewed resident 1 at the hospital on 3/31/25 regarding his fall on 3/30/25. *She had submitted the initial FRI that involved resident 1 to the SD DOH. 4. Interview on 7/2/25 at 11:25 a.m. with administrator A and director of nursing B revealed: *They expected that a resident fall with a major injury to be reported by the nurse to the nurse leader who was to be on call at that time. *An email was to be sent out to the leadership staff to notify them of a resident fall with a major injury to notify them. * In accordance with the facility's policy, a report of a resident's fall with a major injury must be completed no later than two hours of the (incident or known major injury?) to the SD DOH. *Administrator A had indicated that the facility is not Very good about getting incidents with a major injury reported within the required time two-hour frame. 5. Review of the provider's 2/2025 Long Term Care Abuse, Neglect, Mistreatment and Misappropriation of Resident Property-System Standard Policy revealed: *All alleged violations of abuse, neglect, exploitation of residents, misappropriation of resident property, injuries of unknown origin, corporal punishment, and involuntary seclusion must also be reported by the facility to officials in accordance with State law, including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities. -Immediately, but no later than 2 hours if the alleged violation involves abuse or results in serious bodily injury.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one licensed practical nurse (LPN) (G) implemented a pain management intervention for one of one sampled resident (7) who complained of left foot pain before a dressing change. Findings include: 1. Observation and interview on 3/19/24 at 9:40 a.m. with resident 7 in his room revealed he: *Was seated in a recliner reviewing customer account information for his business. *Had a history of a fall that resulted in fractured back vertebrae. -Used a pain patch to manage his back pain. *Had left foot pain that was more bothersome to him than his back pain. -A blister on the top of that foot had popped and the bandage covering his foot was changed daily. Observation on 3/19/24 at 10:03 a.m. of licensed practical nurse (LPN) G completing resident 7's left foot dressing change revealed: *She asked the resident before starting the dressing change what number between zero and ten on a pain scale that rated his foot pain. -Zero was no pain and ten was the worst possible pain. *He rated his pain an 8. *Without offering him any pain relief options or interventions LPN G initiated and completed the resident's dressing change. *Pain medication was offered after the dressing change was completed. -LPN G gave medication options including tramadol or Tylenol for pain and the resident requested tramadol because Tylenol doesn't do anything for my discomfort. Interview and record review on 3/19/24 at 10:20 a.m. regarding resident 7's March 2024 Medication Administration Record with LPN G after leaving his room following the dressing change revealed: *I didn't know it [the dressing change] was going to be painful [to the resident]. I should have given him something prior to the treatment. *Tramadol was last administered at 12:53 a.m. on 3/19/24 and was able to have been administered every six hours as needed. Interview on 3/19/24 at 10:22 a.m. with resident 7 in his room while LPN G administered his tramadol revealed he: *Re-iterated his foot pain score was an 8. -Described his foot pain as jolting like electricity and felt like nerve pain. Review of resident 7's electronic medical record (EMR) revealed: *His diagnoses included: chronic peripheral venous insufficiency, chronic kidney disease, and chronic lower extremity edema. *Between 3/1/24 and 3/20/24 the resident was administered at least one tramadol dose daily except for five days. *Tylenol was last administered on 3/2/24. *His 1/25/24 care plan interventions related to pain revealed: -His pain was controlled with a Lidocaine patch, scheduled muscle relaxants, and as needed tramadol. -No non-pharmacological interventions for pain management were identified. -The resident will have an acceptable-to-resident 7-pain level during TCU [transitional care unit] stay. --There was no indication of what the resident considered to have been an acceptable pain level. 2. Interview on 3/20/24 at 8:15 a.m. with resident 7 revealed: *His left foot dressing change was just completed. *His pain post-dressing change was a 7 or 8. -The onset of his pain occurred at the time the dressing was removed off the top of his foot and the bare skin was exposed to the air. Interview on 3/20/24 at 8:20 a.m. and again at 11:30 a.m. with registered nurse I revealed: *Tramadol was administered to the resident at 6:25 a.m. that morning for a reported left foot pain score of a 4. *She completed the resident's left foot dressing change at about 8:00 a.m. that morning. *The resident activated his call light at 8:30 a.m. after the dressing change and complained of back and foot pain. -It was too soon to administer an additional tramadol and non-pharmacological interventions including leg elevation and relaxation were encouraged. Interview on 3/21/24 at 11:30 a.m. with director of nursing B and administrator C revealed: *LPN G was expected to have addressed resident 7's pain complaint before initiating his dressing change. *The resident's pattern of tramadol use should have been reviewed to determine if he would have benefited from some type of scheduled pain relief plan. *Specific non-pharmacological pain management interventions were expected to have been identified on the resident's care plan. *A definition of what the resident considered to have been acceptable pain was expected to have been reflected in his care plan. Review of the December 2018 revised Pain Management policy revealed: *10. Management of pain: In collaboration with the physician/prescriber, the facility staff develops, implements, monitors and revises as necessary interventions to prevent or manage the individual resident's pain, beginning at admission. *13. Monitoring, reassessment, and care plan revision. Monitor the resident over time to determine the extent to which pain is being controlled. Revise plan if needed.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Disinfection of the rubber seal on one of one sampled resident's (31) insulin vial by one of one licensed practical nurse (LPN) (H) before inserting the syringe needle. *Proper glove use during one one of one sampled resident's (7) dressing change by one of one LPN G. Findings include: 1. Observation and interview on 3/19/24 at 8:20 a.m. with LPN H preparing resident 31's insulin administration revealed she: *Did not wipe the rubber seal on his Levemir insulin vial with an alcohol pad before piercing it with a syringe. -Was expected to have wiped the seal with an alcohol pad prior to piercing it. 2. Review of resident 7's electronic medical record revealed: *His diagnoses included chronic peripheral venous insufficiency, chronic kidney disease, and chronic lower extremity edema. *He developed an eight-centimeter by nine-centimeter blister on the top of his left foot that opened up on 2/28/24. -Dressing changes to that foot occurred twice daily and as needed. *Wound assessments described the top of his foot as pink and moist with scant to moderate clear drainage and no signs of wound infection. Observation on 3/19/24 at 10:03 a.m. of LPN G performing resident 7's left foot dressing change revealed: *The resident was seated in a recliner in his room. *LPN G performed hand hygiene, put on a gown, and a clean pair of gloves then: -Lifted a red metal box sitting on top of the chair in front of the resident's recliner and moved it. -Moved the chair the box sat on out of the way. -Lifted the resident's walker by its handles from in front of him and moved it. -Removed the resident's left sock. *Without changing her gloves, performing hand hygiene, and putting on a clean pair of gloves she removed the pad from the top of his foot. *After discarding the pad she removed her gloves, performed hand hygiene, put on a clean pair of gloves and completed the dressing change. Interview on 3/19/24 at 10:30 a.m. with LPN G after resident 7's dressing change was completed revealed she should have removed her gloves, performed hand hygiene, and put on a pair of clean gloves after handling high-touch items like the red box, the chair, the walker, and the sock before touching the Vaseline gauze pad on the resident's foot. Interview on 3/21/24 at 11:00 a.m. with director of nursing B and administrator C regarding the observations referred to above revealed: *Insulin preparation practices including disinfection of the rubber seal of the insulin vial were not followed according to the policy regarding safe injection practices. *Glove removal, hand hygiene, putting on a pair of clean gloves after handling high-touch surfaces and before removing resident 7's dressing was expected to mitigate the risk of exposing contaminants to the resident's opened skin on his foot. Review of the revised December 2023 Safe Injection Practices-Medication Injections policy revealed: *IV Frequently Asked Questions Regarding Safe Practices for Medical Injections: -A. 1. b. Proper hand hygiene should be performed before handling medications and the rubber septum should be disinfected with alcohol prior to piercing it. Review of the November 2023 revised [NAME] LTC (Long Term Care) Standard Precautions policy revealed: Gloves may need to be changed during the care of an individual patient [resident]. -Gloves should be changed after contact with a contaminated site and before contact with a clean site on the same resident.

Based on observation, interview, and policy review, the provider failed to: *Maintain the following in one of one service kitchen in a clean and sanitary manner: -Two of three silverware holders on one of one dish drying rack. -One of one plastic wrap dispenser. -One of one beverage dispenser station. -One of one stack of uncovered kitchen towels. -One of one plastic bag of to go food containers. Findings include: 1. Observation and interview with nutrition and food service employee E on 3/19/24 at 11:15 a.m. during the initial kitchen tour revealed: *Attached to the dish drying rack next to the three-compartment sink were three plastic silverware holders. -Inside one of the two white plastic holders were several utensils pointed downward inside of the holder and touching the bottom of it. --The bottom of that holder was rust-colored in appearance. -The second plastic holder was empty and the bottom of that holder was rust and black-colored in appearance. *On the counter next to the steam table was a plastic wrap dispenser. -The top of the dispenser had clear-colored build-up on it and the device that slid across the plastic wrap to cut it had several brown stains on it. 2. Observation on 3/19/24 at 11:25 a.m. of the dining room beverage station revealed: *The stainless-steel station was located next to the kitchen serving window. *Between the coffee and juice machines was a folded white towel. -The side of the towel closest to the coffee machine was stained brown. *Beneath the coffee machine was an open storage area. -On the bottom shelf there were two separate rows of coffee cups. --Between those two rows near the front of that shelf were several coffee-stained areas. -On the top shelf there were two separate rows of coffee cups and coffee carafes. --Between those two rows near the front of that shelf were several coffee-stained areas. 3. Continued observation and interview on 3/19/24 between 11:30 a.m. and 11:40 a.m. with nutrition and food service employee E in the service kitchen revealed: *Inside the hallway door entrance was a tall, opened cardboard box. -An opened plastic bag inside of that box held disposable to-go food storage containers stacked as high as the opening of the box. --The containers were used by residents to transport food items. *Behind the door that opened into the kitchen from the dining room was a garbage can with a lid able to be flipped. -Directly behind that garbage can were uncovered, stacked kitchen towels on a cart. --Those towels were used to wipe off wet meal trays or to cover food items during transport. 4. Observation and interview on 3/20/24 at 8:00 a.m. with nutrition and food service employee E regarding kitchen and dining area cleaning revealed: *The areas in the service kitchen and at the beverage station referred to above remained unchanged from the observations made on 3/19/24. *There was a cleaning checklist completed daily by food service staff who worked the evening shift. -Those staff consisted of mostly high school students. *There was no cleaning checklist form food service staff to complete during the day. -Those staff were long-time employees and knew what was expected to have been completed. 5. Interview on 3/20/24 at 11:50 a.m. with nutrition and food services manager F regarding the kitchen and beverage station observations referred to above revealed: *The areas described above in the kitchen and dining areas were not maintained in a sanitary manner. *There was currently no process for auditing the completed evening cleaning checklists to ensure compliancy. -The cleaning checklist might need re-evaluation and a day time cleaning checklist might need to be initiated. 6. Review of the revised March 2024 LTC (Long Term Care) Food Safety and Sanitation-System Standard policy revealed: Maintaining high standards of sanitation and prevention infection in Nutrition Services Department require health personnel, properly maintained equipment, uncontaminated supplies and an ongoing awareness, practice, and monitoring of proper sanitation and hygiene.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to develop comprehensive person-centered plans of care for two of two sampled residents (17 and 27). Findings include: 1. Observation and interview on 3/14/23 at 3:31 p.m. with resident 17 revealed: *He was seated in his wheelchair watching the television in his room. *He stated he had been living in the facility for many years. *When asked if he participated in the activities offered by the provider he stated not really, but he enjoyed visiting with a few of the other male residents and he goes out to eat every once in a while with family. Review of resident 17's medical record revealed: *He was admitted on [DATE]. *His diagnoses included cerebrovascular accident, diabetes mellitus type II, pain, and depression. *His most recent brief interview for mental status (BIMS) indicated he was cognitively intact. *His most recent score on the mood assessment indicated minimal depression. *He was taking an antidepressant medication daily. *His 2/24/23 care conference progress note included the resident requested a men's group every week or so . Review of resident 17's 3/15/23 care plan regarding activities, diabetes, and mood revealed: -No intervention was listed for his insulin injection. -No intervention addressed his antidepressant medication. -No intervention addressed his preference and request for socializing with other male residents. Interview on 03/15/23 02:59 PM with activity coordinator (AC) F revealed: *She had just started a men's group last month on 2/28/23 at 2:00 p.m. and resident 17 attended. *She stated she completed the assessments on the residents but is not involved in developing or revising the activity care plan. -She stated MDS nurse coordinator D developed the resident care plan from the assessments she completed. 2. Observation and interview on 3/14/23 at 11: 24 a.m. with resident 27 revealed she: *Was laying in bed with her bed clothes on with the television on and crossword puzzle books were on her overbed table next to her bed. *Had lived in the facility almost one year. *Stated she did not care to attend the group activity programs but preferred to watch television and do crossword puzzles in her room. Further interview with resident 27 on 3/14/23 at 1:28 p.m. revealed: *She was concerned with putting on weight, stated she has gained 30 pounds since being here, and that she mentioned she would like to lose weight to the nurses. Review of resident 27's medical record revealed: *She admitted on [DATE]. *Her diagnoses included arthritis and frequent pain. *Her most recent BIMS coded her as cognitively intact. *Her 7/8/22 nutrition evaluation documented a three pound weight gain in the last 30 days and 11 pounds, 9.6 ounces weight gain since her admission. Review of resident 27's 3/16/23 care plan regarding activities and nutrition revealed: -No intervention addressed her preference to watch television and do crosswords in her room. -No intervention addressed her concern with gaining weight. Interview on 3/15/23 at 3:25 p.m. with MDS nurse coordinator D regarding care planning revealed she: *Developed and revised the care plans for the most part. *Agreed resident 17's care plan was not individualized for his: -Diabetes problem which had not included an intervention for his insulin injections he received daily. -Mood state which had not included an intervention for his antidepressant medication he received daily. *Agreed resident 27's care plan had not addressed the resident's concern with gaining weight. -She agreed with the 30 pounds of weight gain since her admission. -She was not aware of the resident's weight concerns. *Agreed there could be more collaboration with activities staff in the activity care plan. *Agreed the care plans needed to be more individualized. 3. Interview on 3/16/23 at 8:33 a.m. with food service manager G regarding care planning revealed he attended the care conferences but the dietary department did not formulate the care plan. Interview on 3/16/23 at 9:00 a.m. with social services associate E revealed: *She completed the social service assessments. *She did not develop care plans for social service concerns, but relied on MDS nurse coordinator D to develop and revise individual care plans from the computerized assessments she completed. Interview on 3/16/23 at 9:58 a.m. with MDS coordinator C revealed she agreed the care plans could be more individualized. Interview on 3/16/23 at 11:17 a.m. with DON B revealed she: *Agreed the care plans are generic. *Stated their computer system made it easy to be generic and that it took effort to individualize the care plans. 4. Review of the provider's 8/2020 Care Planning policy revealed: *Policy: The interdisciplinary team will develop a baseline and comprehensive care plan for each resident, based on the admission assessments, assessment tools and the MDS assessment to provide effective and person-centered care of the resident that meet professional standards of quality care and to attain or maintain the resident's highest practicable, physical, mental and psychosocial well-being. *Definitions: -'Person-centered care' - to focus on the resident as the focus of control and support the resident in making their own choices and having control over their daily lives. Person-centered care includes making an effort to understand what each resident is communicating, verbally and nonverbally, identifying what is important to each resident with regard to daily routines and preferred activities, and having an understanding of the resident's life before coming to reside in the nursing home.

Based on observation, interview, and document review, the provider failed to prevent one of one sampled resident (46) mattress from shifting diagonally on the bed frame, thereby creating a potential area for injury or entrapment between the mattress and the bed frame. Findings include: 1. Observation and interview on 3/14/23 at 9:31 a.m. with resident 46 in her room revealed: *She had a cane-like grab bar on her bed frame in the up position. *Her mattress was positioned diagonally on the bed frame. -There was approximately a five- to six-inch gap between the mattress and the edge of the bed frame. -The metal springs of the bed frame were exposed. *She had not wanted to injure her skin on the metal springs or get stuck between the mattress and the grab bar, so she put one of her pillows in between the mattress and the grab bar. *Staff would at times readjust the mattress to be in line with the bed frame. *The mattress had been positioned diagonally for a couple of days. 2. Observation on 3/14/23 at 4:47 p.m. of resident 46's bed revealed the mattress was still positioned diagonally on the bed frame. 3. Observation and interview on 3/15/23 at 11:14 a.m. with resident 46 in her room revealed: *Her mattress was in line with the bed frame. *She expressed that she was glad someone had fixed it. -She stated someone must have adjusted the mattress when her bed was made that morning. 4. Interview on 3/15/23 at 3:36 p.m. with administrator A and resident 46 about the resident's bed revealed: *Administrator A had been assisting the maintenance department with bed frame safety checks. -She had checked resident 46's bed frame on 2/17/23 and found that everything was in order. *Resident 46 said, it was ridiculous, in reference to the sizable gap between the mattress and the edge of the bed frame. *Administrator A agreed that the mattress shifting around on the bed frame was a hazard. 5. Review of the provider's undated Procedure Detail Report for Bedrail Safety Inspections revealed: *Inspect and [check] the [mattresses] and bedrails for areas of possible entrapment. *Mattress should not have a gap wide enough to entrap a resident's head or body (4 ¾ [inches]). *Check rails quarterly to ensure installed correctly and ensure rail has not shifted and loosened over time.

Based on observation, interview, and policy review, the provider failed to prevent potential cross-contamination when checking the temperatures of the food by nutrition and food service (NFS) staff H during one of one meal service observation. Findings include: 1. Observation on 3/15/23 at 4:53 p.m. of NFS H in the dining room service kitchen revealed: *After preforming hand hygiene, he retrieved two thermometers off of a shelf. *Without cleaning or sanitizing the first thermometer he: -Put the probe of the thermometer into the vegetable soup. -Without cleaning or sanitizing the probe he then placed the probe into the mashed potatoes and then the gravy. *Without cleaning or sanitizing the second thermometer he: -Put the probe of the thermometer into the corn. -Without cleaning or sanitizing the probe he then placed the probe into the breaded pork cutlet and then the pureed port cutlet. *When he had completed taking the food temperatures, he cleansed the probes with an alcohol-based thermometer wipe and placed the thermometers back on the shelf. 2. Interview on 3/15/23 at 5:59 p.m. with NFS H about his process for checking food temperatures for the meal service revealed: *Before starting the food service, he would have washed his hands. *He would poke a hole in the plastic and/or aluminum foil covering over each food item. *He would wait until the temperature reading on the thermometer slowed down and he would record the food temperature on the temperature sheet. *He would repeat the process until all the food temperatures had been checked. *To justify not cleaning or sanitizing the thermometer probe in between each food item, NFS H stated he would temp the foods with the highest amount of potential allergens last so as not to contaminate the other foods with allergens. 3. Interview on 03/16/23 at 8:50 a.m. with food service manager G about the above observation and interview with NFS H revealed he: *Was not aware NFS H was not sanitizing the thermometer probes between each food temperature check. *Expected NFS H to perform appropriate food temperature checks due to his extensive food service experience. *NFS staff needed more training on food safety and preventing cross-contamination. 4. Review of the provider's February 2021 Food Preparation policy revealed: *Under the PROCEDURE section: -11. Wipe post of thermometer with disposable alcohol swab - wait 30 seconds to insert post into food. Wipe post between all items to prevent possible cross contamination.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 11/16/21 at 10:01 a.m. of resident 28's room revealed a bedside pole next to his bed that extends from the floor to the ceiling. Interview on 11/17/21 at 11:22 a.m. with resident 28 revealed: *He does use the positioning pole to get in and out of bed. *He does not recall getting any education on the risks and benefits of side rail use. Review of resident 28's medical record revealed: *He had been admitted on [DATE] *His BIMS score was 11 and indicated moderate cognitive impairment. *His last revised care plan stated he may use grab bar on bed for bed mobility. *No documentation that education for risks and benefits of side rail use had taken place. *No signed informed consent from the resident or representative for side rail use. 6. Observation on 11/16/21 at 3:06 p.m. of resident 37's bed revealed a single side rail near the head of the bed in the upright position. Review of resident 37's medical record revealed: *He had admitted on [DATE]. *His BIMS score was 10 and indicated moderate cognitive impairment. *An 8/10/21 physician order for a side rail to aid with bed mobility. *A 10/18/21 restraint evaluation stated: -The device was used to assist the resident to stand up. -The question, Can the individual easily remove the device? was answered not applicable it is on the bed, not the resident; he uses it to improve his independence. Interview and observation on 11/17/21 at 10:46 a.m. with resident 37 revealed: *He had not recalled getting any education on side rails. *He relied on staff to put the side rail up and down. 7. Interview on 11/17/21 at 9:30 a.m. with registered nurse (RN)/minimum data set (MDS) coordinator assistant H revealed: *They had not: -Provided education to the residents or their representatives on the risks and benefits of side rails. -Requested informed consent from the resident or their representative. -Performed regular safety assessments for the proper installation of side rails. Interview on 11/17/21 at 10:06 a.m. with MDS Coordinator L revealed: *They had not provided education to the resident or their representative on risks and benefits of side rails or obtained a signed informed consent form. *They received a request from the therapy department or from the resident themselves for side rails. *If the resident was cognitively appropriate they got a physicians order for side rail use. Surveyor 41088: Interview on 11/18/21 at 11:19 a.m. with administrator A and director of nursing (DON) B revealed: *Side rail assessments for residents were completed with the quarterly minimum data set assessments. *Were not aware of a side rail policy in place. *They confirmed: -Education to residents or their families had not taken place regarding the risks and benefits of side rail use. -Consent forms had not been received from residents or their families for use of the side rails. -They had not put the side rails on a schedule to be checked for safety and proper placement. On 11/18/21 at 11:42 a.m. DON B gave surveyor a copy of their facility policy for side rails. *She confirmed they had not followed their policy. 8. Review of the provider's revised September 2016 Safety Policy revealed: Patient beds are equipped with: 1. Side rails only after the following criteria have been met: a. Upon the resident's admission or as the need is identified, staff assessment will determine if a bed equipped with side rails is necessary for mobility, and whether it is safe for that individual. b. The resident's care plan must document the need/use for side rails if the side rails are implemented. 2. Removable head boards [headboards]. 3. Mattresses and side rails are assessed so gap is no more than 4.75 inches. 4. Locking device to attain a secure stationary position. 5. Mechanism for adjustable positions. 3. Observation and interview on 11/17/21 at 12:05 p.m. with certified nursing assistant (CNA) K while making resident 48's bed revealed: *A bed rail, in upright position, on the left side of the bed. *CNA K stated the resident used the side rail to reposition and get in and out of the bed. Review of resident 48's medical record revealed: *He was admitted on [DATE]. *His BIMS was 5, indicating his cognition was moderately impaired. *His diagnosis included: acute head injury, dementia with behavioral disturbance, multiple falls, and major depression. *He had a restraint assessment completed on 8/23/21 that indicated the side rail was used for bed mobility. *No documentation that education for risks and benefits of side rail use. *No signed consent from the resident or representative for side rail use. 4. Observation and interview on 11/17/21 at 12:03 p.m. with CNA J regarding resident 27 revealed she: *Had a side rail on the upper part of her bed which was in the upright potion, resident not in bed. *CNA J stated, she used it for repositioning. Review of residents 27 medical record revealed: *She had been admitted on [DATE]. *She was rarely understood, and BIMS could not be completed. *Her diagnosis included: unspecified dementia with behavioral disturbances, anxiety disorder, and weakness. *No documentation that education for risks and benefits of side rail use. *No signed consent from the resident or representative for side rail use. Based on observation, interview, record review, and policy review, the provider failed to ensure six of twelve sampled residents (15, 27, 28, 29, 37 and 48) had: *Received risks versus benefits education for side rail use. *Obtained signed informed consent forms for side rail use. *Performed regular safety checks for the proper installation of side rails. Findings include: 1. Observation and interview on 11/17/21 at 3:37 p.m. with resident 15 revealed she: *Had a side rail on the upper part of her bed which was in the upright position. *Used it to reposition or roll over in bed. *Stated the staff put the side rail up and down for her as she could not. *Could not remember staff educating her on the risks or benefits of the side rails or signing a consent form for their use. *Thought the side rails had always been on her bed. Review of resident 15's medical record revealed: *She had admitted on [DATE]. *Her brief interview for mental status (BIMS) was 15 and indicated her cognition was intact. *She had a 6/23/21 physician order for a side rail to the upper outside of her bed to assist with bed mobility. *No documentation that education for risks and benefits of side rail use had taken place. *No signed informed consent from the resident or representative for side rail use. 2. Observation and interview on 11/17/21 at 3:41 p.m. with resident 29 revealed: *He had bilateral side rails on the upper portion of his bed. *The outside rail was in the upright position. *The side rails assisted him to get in and out of bed. *The staff put the rails up and down for him because he could not move them. *He could not remember the staff educating him on the use of the side rails or signing an informed consent form for their use. *He was unsure when the side rails were put in place. Review of resident 29's medical record revealed: *He had admitted on [DATE]. *His BIMS was 15 and indicated his cognition was intact. *His diagnosis of Parkinson's disease and Lewy body dementia. *He had a 9/13/21 physician order for side rails. *No documentation that education for risks and benefits of side rail use had taken place. *No signed informed consent from the resident or representative for side rail use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to ensure medication disposal for one of two sampled residents closed record (47) had been completed by a registered nurse (RN) and a witness. Findings include: 1. Closed record review of resident 47's record revealed: *He had died on [DATE]. *There was no documentation of what had been done with his medications. Interview on [DATE] at 10:58 a.m. with director of nursing (DON) B regarding medication destruction for deceased residents revealed their process was to: *Destroy controlled substance medications with one licensed nurse and the DON. *All other medications were sent back to the pharmacy for destruction. -This was to be documented in the resident's electronic medical record [EMR]. -She could not find any documentation of the destruction of medications for resident 47. -She stated the pharmacy did not keep a record of what had been sent to them for destruction. Interview on [DATE] at 11:38 a.m. with assistant director of nursing E revealed she: *Had been unable to find any documentation of the destruction of medications for resident 47. -Stated their policy required this to be completed and they had not been doing it. Review of provider's 8/22 Medication Administration policy revealed: *Purpose: 1. To ensure safe medication administration, and proper control, storage and accountability of medications within the facility. *Policy -XX. Disposition of Outdated or Discontinued Medications. --c. Outdated or discontinued medications (including medications that are left when a resident expires) are to be returned to [NAME] pharmacy by placing them in a return to pharmacy tote in the 2nd floor/TCU (Transitional Care Unit) med [medication] room. --e. The nurse will document in the progress notes the name and dose of each medication followed by the number returned to the pharmacy. Review of provider's 3/20 Checklist for Nurses at time of Death of a Resident/Patient revealed: *Medications need to be returned to pharmacy. A medication reconciliation progress note listing the medications returned should be placed in Meditech [EMR].

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 4. Observation and interview on 11/16/21 at 4:34 p.m. with CNA C and PT D while assisting resident 14 revealed: *Resident was assisted onto the toilet with the mechanical lift. *CNA reported the facility did not have enough slings for every resident to have their own. *Staff shared cloth slings between the residents. *CNA explained staff had been wiping the harnesses down with sanitizer wipes. -She demonstrated cleaning the mechanical lift and harness by wiping them down with Kimtech Wettask System wipes. *CNA reported residents on transmission based precautions had their own harness. Interview on 11/18/21 at 10:00 a.m. with DON B revealed: *A new mechanical lift with additional harnesses had been ordered. *There had been conversations regarding if residents should each have their own harness. *Residents on transmission based precautions had their own harness. *Cleaning with the Kimtech Wettask System wipes would not disinfect the harness as they are cloth. *Harnesses had been shared amongst residents, the facility did not have enough harnesses for each resident to have their own. *She agreed harnesses should not have been shared amongst residents. Review of the EZ Way, Inc. manufacturer instructions for washable slings and harnesses revealed: *Washable EZ Sling and Harness Laundering instructions -To get the longest life out of your product: --1. Do not bleach --2. To prevent stains from setting, rinse 5 min. in 80-100 degree F. Stains will set when temp is over 105 degrees F. --3. Wash temp 160 degrees F. max. --4. RINSE THOROUGHLY in 100 degree F. If high alkaline detergent (with pH greater than 11.0) is used, rinse twice. --5. Tumble dry, temp. 110 degrees F. max. high heat will weaken the fabric. --6. If applicable, snap the buckle together before washing and drying. this will prevent any damage to the plastic buckle. --7. If available, use a laundry bag to wash and dry the sling or harness. *Manufacturer instructions did not include the use of disinfectant wipes. 5. Review of the provider's July 2021 [NAME] LTC - Disinfection of Non-Critical Patient Care Equipment policy revealed: *I. PURPOSE -A. Cleaning, disinfecting and storing equipment and supplies is important in preventing the transmission of potential pathogens within the long-term care facility. -B. In order to more easily control quality, cleaning, disinfection, and sterilization of re-usable patient care equipment, whenever possible, critical and semicritical disinfection will be completed by a facility in which sterilization practices are provided. Processes for handling and transport of equipment are designated by the receiving site. Sterile single use equipment will be utilized when appropriate. -C. For the safety and comfort of residents, all reusable(non-critical) resident care items will be cleaned, disinfected, and maintained in a safe manner between resident uses. *II. INFORMATION -A. Reusable resident care equipment/items fall into 3 different classification categories for disinfection and sterilization: non-critical, semi-critical, and critical. --1. Non-Critical items are those that come into contact with intact skin but not mucous membranes. these are divided into resident care items and environmental surfaces. ---a. Non-critical resident care items (Examples include blood pressure cuffs, stethoscopes, wheelchairs, therapy equipment) are cleaned between/after each resident use. They require Low level disinfection by cleaning following manufacturer instructions with an EPA-registered disinfectant, detergent, or germicide that is approved for healthcare settings. ---3. Critical items (Examples include needles, intravenous catheters, indwelling urinary catheter) enter sterile tissue or the vascular system. These items or equipment must be sterile when used, based on one of several accepted sterilization procedures. Most items in this category for LTC [long term care] are purchased sterile. -D. Non-critical items rarely, if ever, transmit disease but could contribute to secondary transmission by contaminating HCW (health care worker) hands or by contact with medical equipment that will subsequently come in contact with patients. Consequently, cleaning with a facility approved disinfectant is sufficient. *III. POLICY -A. Community/facility items removed from a resident's room need to be disinfected prior to use by a different resident. -E. All reusable resident care equipment removed from a resident room/procedure room is disinfected before use on another resident. -K. Disinfection recommendations- 1. Reusable resident care equipment: All applicable label instructions on EPA-registered [Environmental Protection Agency] disinfectant products must be followed. (Examples are use-dilution, shelf life, storage, material compatibility, safe use and disposal.) -a. Between each resident use and when soiled -e. Glucometer or re-useable point of care testing labeled for multiple resident[.] 2. Observation on 11/17/21 at 10:00 a.m. of RN I during medication pass revealed she had missed two out of ten opportunities to perform hand hygiene between residents. Interview on 11/18/21 at 9:21 a.m. with director of nursing (DON) B regarding the above observations revealed she had expected all staff to perform hand hygiene after administering medications to a resident and before moving on to the next resident. Review of the provider's revised October 2021 Hand Hygiene policy revealed: *Hand hygiene (HH) continues to be the primary means of preventing the transmission of infection. *A. HH, either with soap and water or with alcohol-based hand rub (ABHR)[.] -1. Immediately before touching a resident[.] -4. After touching a resident or the resident's immediate environment[.] 3. Observation on 11/17/21 at 12:50 p.m. revealed a Stat Strip (blood glucose monitoring machine): *Had been laying on paper towel, on canister of disinfectant wipes, in the hall by resident 42s room: *There had been a strip of paper taped on the top of the machine that stated, clean after each use (3 min wet time). -This strip of taped paper was peeled back approximately one inch from left edge of the glucometer. --This peeled taped had exposed paper underneath, making it an uncleanable surface. Interview on 11/17/21 at 1:08 p.m. with RN G revealed: *She had used the glucometer to test the blood sugar of resident 42, who was on transmission based precautions. -She had attempted to clean the glucometer by using a disinfectant wipe. *She had placed the glucometer on a docking station at the nurses desk. *The glucometer was shared with residents, needing their blood sugar checked, on the same wing as resident 42. Interview and observation on 11/17/21 at 4:21 p.m. with DON B regarding glucometer cleaning revealed: *They had utilized hospital grade glucometers. -The glucometers were placed on a docking station after use. --The information from the glucometer would be downloaded from the docking station into the resident's electronic medical record. -Each floor had one glucometer. *Glucometers had been shared between residents. -They had been disinfected between residents using them. -They had provided training to staff. Observation on 11/17/21 at 4:26 p.m. with DON B and RN F revealed: *The glucometer had been on the medication cart. *DON B and RN F agreed there was taped paper that had been peeling off the glucometer on one side. -DON B agreed this had made the glucometer a non-cleanable surface. -RN F removed the peeling taped paper. --She had not realized it had been on the glucometer. ---Agreed it should not have been on the glucometer. Based on observation, interview, manufacturer instructions, and policy review, the provider failed to ensure appropriate infection control precautions had been followed for: *One of one observation of housekeeper (M) while cleaning one of one resident (23) room. *One of one registered nurse (RN) (I) hand hygiene in two out of ten opportunities during medication pass. *One of one observation of glucometer use by registered nurse (RN) G with a resident (42) on transmission based precautions. *One of one observation of certified nursing assistant (CNA) C and physical therapist (PT) D during transfer of one of one resident (14) during personal care. Findings include: 1. Observation and interview on 11/17/21 from 10:48 a.m. to 10:55 a.m. with housekeeper M cleaning resident 23's room revealed she: *Placed cleanser from a bottle into the bathroom sink using gloved hands. *Took a sponge out of her cleaning caddy, scrubbed the sink and rinsed it out. *Placed the sponge back into the caddy. *Placed liquid disinfectant solution onto the freestanding toilet riser and into the toilet bowl. *Continued cleaning with disinfectant wipes and wiped down the area above the sink, mirror and grab bar beside the toilet. *Took the toilet brush in both hands and squeezed out the excess liquid. *Leaned onto the sink with her left gloved hand while she cleaned the toilet and toilet riser. *Finished cleaning the toilet and toilet riser, and placed the toilet brush back into the caddy. *She confirmed: -She had not disinfected the sink after she touched it with her gloved hand. -Was not sure how long the wait time was for the disinfectant used. -Had not timed the wait time for the disinfectant. -She cleaned other things until she thought it had been long enough time to disinfect. -She should know the wait time of the chemical used. -She had been trained to use one sponge to clean all resident sinks and then toss it at the end of the shift. -At the start of the shift a new sponge is placed on her cart to use for the day. -Agreed it would be a better practice to use a clean cloth or sponge for each resident sink instead. Interview on 11/18/21 at 8:21 a.m. with housekeeping supervisor N revealed: *The sponges had a scrubbing surface on the other side for getting soap scum buildup off the sinks and that is why they were used. *She was aware the housekeepers used a clean sponge at the beginning of their shift and threw it away at the end of the day. *The sponge would be reused for all resident rooms for the day unless the resident was on contact precautions. *The housekeepers did not go into the resident rooms with COVID. -The nurses and CNAs cleaned those rooms unless a request was made for a more thorough cleaning by a housekeeper to avoid exposure. -If requested, the housekeepers used full protective personal equipment to go into those rooms. *She agreed reusing sponges between residents rooms could be an infection control concern and source of cross contamination. Review of the provider's revised July 2021 Environmental Services Cleaning Policy revealed: *Carefully adhere to environmental cleaning guidelines. *Use and [sic] approved health care disinfectant, in concentrations established by housekeeping policies. *Strip room of linen items- take to the place where linen department collects items. *Provide special attention to decontamination of frequently-touched surfaces [e.g. over-bed tables, bed-rails, remote control, call buttons, telephones, lavatory surfaces, commodes, ventilators, over-bed bars, etc.]. *Disinfectant solutions for rags/mops should be discarded after use. *Mops and rags may be routinely laundered, using the health care facility's laundry. *Keep the environment around the patient free of unnecessary supplies and equipment to minimize contamination. *Infection control will advise staff of additional or different protocol.