Based on South Dakota Department of Health (SD DOH) complaint review, record review, interview, and policy review, the provider failed to follow their policy for reporting to the SD DOH and one of one sampled resident's (1) representative of the resident's injury of bruising to her left arm and hand with unknown cause (origin).Findings include:1 Review of a 7/16/25 SD DOH complaint intake revealed that during the weekend of 7/4/25, resident 1 was visited by her family. The resident's left hand and arm had shown no signs of injury at that time. The resident's family had returned a few days later to visit and noticed extreme bruising and swelling of her [the resident's] left hand and forearm. Digital photographs of resident 1's hand taken by the family during that visit showed the underside of the resident's hand had purple and black bruising of her fingers and palm that extended upwards to her forearm. The entire top of the resident's left hand was similarly bruised. The resident's family had not been notified that resident 1 had been injured.Interview on 9/4/25 at 9:00 a.m. and review of resident 1's electronic medical record (EMR) with infection preventionist (IP)/clinical care leader (CCL) B revealed the progress note she entered in resident 1's chart on 7/1/25 stated received and returned her [the resident's daughter] call to discuss the bruise noted on the resident's arm. Explained that according to PCC [EMR] notes, the mark was most likely caused by a recent lab draw on 7/7/25. IP/CCL B confirmed resident 1's 7/7/25 blood draw was taken from the resident's right arm. She confirmed the cause of resident 1's left hand and arm injury was not the result of a lab draw.IP/CCL B confirmed that resident 1's left hand and arm injury was first documented in her medical provider's 7/11/25 Nursing Home Attending Physician Visit note, which indicated there was no definitive cause that was found for resident 1's left hand and arm injury. A 7/11/25 nurse progress note completed by licensed practical nurse (LPN) E after the above visit: indicated [Medical provider's name] visited. The medical provider and a nurse wrapped resident 1's L [left] forearm, which is bruised and has a large hematoma [a raised bruised area] on the top of [her] L hand.IP/CCL B stated it was LPN E's responsibility to have notified resident 1's family of the left hand and arm injury. Because the cause of that injury was unknown, LPN E should also have notified a nurse supervisor or administrator A. Injuries of unknown origins were expected to have been documented, investigated, and reported to the SD DOH, but that had not occurred. Interview on 9/4/25 at 10:15 a.m. with administrator A confirmed the staff had not followed the provider's procedure for notifying families, and the SD DOH regarding resident injuries of unknown cause.Review of the provider's revised 4/7/25 Abuse and Neglect policy revealed:Procedure: 4.c. Designated agencies will be notified in accordance with state law, including the State Survey and Certification Agency [SD DOH].4.g. Notify the physician and family regarding the facts of the situation. If there is alleged or suspected abuse/neglect or in an injury of unknown origin, inform them that an investigation is in progress. That notification was expected to have been recorded.

Based on South Dakota Department of Health (SD DOH) complaint review, observation, record review, interview, and policy review, the provider failed to ensure an investigation was completed and documented for one of one sampled resident (1) with an injury of bruising to the resident's left arm and hand with unknown cause (origin).Findings include:1 Review of a 7/16/25 SD DOH complaint intake revealed that during the weekend of 7/4/25, resident 1 was visited by her family. The resident's left hand and arm had shown no signs of injury at that time. The resident's family had returned a few days later to visit and noticed extreme bruising and swelling of her [the resident's] left hand and forearm. Digital photographs of resident 1's hand taken during that visit showed the underside of the resident's hand had purple and black bruising of her fingers and palm that extended upwards to her forearm. The entire top of the resident's left hand was similarly bruised. Observations 9/3/25 at 10:10 a.m. of resident 1's room revealed there were bilateral 1/4 siderails on her bed, and it was positioned low towards the floor. She had a cylindrical-shaped call light with a red button at one end to alert staff for assistance.Continued observation on 9/3/25 at 10:15 a.m. of resident 1 in an activity room revealed she was participating in a game of Jeopardy with other residents. She sat in a wheelchair that tilted slightly back and had been customized with things like a left arm trough (a device attached to the wheelchair armrest for positioning comfort and posture support) that accommodated her left-sided weakness. Her hands had no visible bruising. Review of resident 1's electronic medical record (EMR) revealed that her admission date was 5/9/25. Her diagnoses included hemiplegia (muscle weakness or partial paralysis on one side of the body) due to a stroke affecting her left side, dysphagia (difficulty swallowing), congestive heart failure, anxiety, and insomnia. She had fallen multiple times after she had been admitted , but she had no documented falling incidents since the beginning of July 2025.Resident 1 had episodes of restlessness, anxiousness, and calling out. At times when staff had responded to her calling out, resident 1 was not able to identify what she had needed. Her ability to functionally use her call light was infrequent. Redirecting the resident was not always successful. Changes to her anti-depressant and anti-anxiety medications had been made by her medical provider in May 2025 and June 2025.Interview on 9/3/25 at 2:20 p.m. with physical therapist (PT) F revealed that resident 1 was receiving therapy services. PT F had seen resident 1's left hand and arm injury after the 4th of July weekend. It was black and blue and puffy. She stated that resident 1 was unable to provide any insight into the cause of her injury. PT F stated there was no known cause for the injury that she remembered, but she thought the resident's hand could have been injured when she was transferred. Staff had used an Easy Stand lift (a type of mechanical lift used for transferring from one position to another) for transferring her. PT F also stated that resident 1's previous wheelchair did not have a left arm trough that kept her weakened left arm stable and safely positioned, like her current customized wheelchair had. Resident 1 had started using that wheelchair in early August 2025.Resident 1's left hand and arm injury was first documented by the resident's medical provider in her 7/11/25 Nursing Home Attending Physician Visit note. This patient [resident] developed swelling and bruising of her left hand on July 7 or 8. Her family had visited on the weekend, and the [resident's] hand appeared normal, although she has left arm weakness because of a stroke. Yesterday they visited and found the left hand very swollen with bruising extending from the fingertips to up the forearm. [Resident 1] thinks she might have rolled out of bed (staff says that has not happened this week) or bumped it on a door [she] but does not really know how it happened. Staff thought it might have been related to a blood draw on July 7 but [resident 1] says the blood draw was from the other arm. [resident 1] is on aspirin and apixaban [anticoagulant] for history of stroke and DVT [deep vein thrombosis] with PE [pulmonary embolism].A 7/11/25 progress note completed by licensed practical nurse (LPN) E after the above medical provider's visit indicated [Medical provider] visited. We wrapped the L [left] forearm which is bruised and has a large hematoma [a raised bruised area] on the top of [her] L hand. There was no documentation to support that an investigation had been initiated to identify a cause for resident 1's injury, any factors that might have contributed to that injury occurring, or what actions had been implemented to decrease the likelihood of that injury reoccurring. Interview on 9/4/25 at 10:10 a.m. with LPN E revealed she stated, I don't recall knowing it [resident 1's left hand and arm injury] was there earlier that day [on 7/11/25 before the medical provider's visit]. LPN E stated the cause of that injury might have been related to the resident's 7/7/25 blood draw. LPN E had not known that a blood draw was taken from resident 1's right hand and not her left hand, so it could not have caused that injury.LPN E confirmed that after the left hand and arm bruise was identified on 7/11/25, she had not reported that injury of unknown cause to a nurse supervisor. As a result, an investigation was not initiated to identify the cause or possible cause for that injury. Without having identified a cause for resident 1's left arm and hand bruising, LPN E agreed that nothing different had been done to prevent a similar injury from recurring. Interview on 9/4/25 at 9:00 a.m. with infection preventionist (IP)/Clinical Care Leader (CCL) B revealed it was LPN E's responsibility to have notified a nurse supervisor or administrator A of resident 1's injury of unknown origin. Injuries of unknown origin were expected to have a thorough investigation completed and documented, but that had not occurred. Interview on 9/4/25 at 10:15 a.m. with administrator A confirmed that the staff had not followed the provider's procedure for documenting and investigating resident injuries of unknown cause. Review of the provider's revised 4/7/25 Abuse and Neglect policy revealed:Purpose: To ensure that all identified events of alleged or suspected abuse/neglect, including injuries of unknown origin, are promptly reported and investigated. To ensure a complete review by the investigation team to identify events, such as suspicious bruising of residents/clients, occurrences, patterns and trends that may constitute abuse to determine the direction of the investigation.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to follow nursing professional standards of practice for implementing and documenting neurological checks according to the provider's policy for one of one sampled resident (2) who had fallen and sustained a head injury. Findings include:1. Record review of resident 2's electronic health record (EHR) revealed:*She was admitted to the facility on [DATE].*Her diagnoses included blindness, cerebral infarction (stroke), hearing loss, rheumatoid arthritis (an auto-immune disease affecting small joints in the hands and feet, and can damage other body systems), repeated falls, major depressive disorder, dementia (a group of symptoms affecting memory, thinking, and social abilities) without behavioral, psychotic, and mood disturbance, anxiety disorder, and traumatic subdural hemorrhage (fall with head injury that caused bleeding inside the skull).*She had been taking Aspirin (an anticoagulant or blood thinner medication) since 2021.*Her fall risk assessments (an assessment of a resident's risk for falling) indicated her risk for falling was:-High (score of 20) after she fell on 2/21/25.-Low (score of 11) after she fell on 3/4/25 and 3/20/25.-Medium (score of 14) after she fell on 5/21/25 and 6/15/25.-High (score of 20) after she fell and sustained an injury on 7/22/25.*She had seven falls in the last six months (between April 2025 and September 2025).*She had a fall in her room on 7/22/25 and sustained a head injury with bleeding.-She was found lying on the floor, next to her bed at 6:52 a.m. in a pool of blood under her left face/head.-The pool of blood was partially coagulated (thickened) and was approximately 10 by 14 inches in diameter. *Resident 2 was talking and stated, I fell and hit my head and my hips hurt and Get me up.*A head-to-toe assessment had been completed and her vital signs (measurements of the body's basic functions, such as temperature, blood pressure, pulse, and respiration rate) were checked by registered nurse (RN) G.-RN G did not perform a neurological assessment (an evaluation of mental status, cranial nerve function, motor strength, reflexes, sensation, and coordination) of resident 2.*Resident 2 was transferred to the emergency room and admitted to the hospital for treatment of a subdural hemorrhage (a collection of blood between the brain and the inner layer of the skull).-Neurological assessments were not performed of resident 2 upon her return to the facility from the hospital. 2. Interview with administrator A on 9/4/25 at 1:50 p.m. revealed:*Nurses were expected to follow the fall prevention policy and protocols.*She verified that neurological exams should be completed for all residents who fell and hit their head during that fall.-She agreed that no neurological exam had been completed for resident 2 after she fell and hit her head on 7/22/25. 3. Review of the facility's 2/17/25 Neurological Evaluation Policy revealed:*The policy is used following:- a witnessed fall when a resident has hit his/her head.-an unwitnessed fall.-a resident event that results in known or suspected head injury.*The policy procedure includes:- After the completion of initial neurological evaluation with vital signs, continue with evaluations every 30 min [minutes] x4 [times four], then every eight hours [times three] days or as directed by the provider.-Notify responsible party of event, resident condition, and findings and document.-If after completing one or more Neurological Evaluations the resident goes to the hospital for a few hours or is admitted to the hospital and returns to the center, documentation should resume using the existing schedule. 4. Review of the provider's 4/8/25 Fall Prevention and Management Policy revealed:*The purpose of the policy is to give prompt treatment after a fall occurs and to provide guidance for documentation.*Procedure:-1. Do not move resident.-2. Remain calm and reassure and comfort the resident.-3. Stay with the resident and summon the licensed nurse or other help. If able, observe the fall scene.-5. For a fall WITH injury, do the following:--a. If the resident is bleeding, locate the injured area and apply continuous, form pressure to the area.--b. Do not remove any blood-soaked dressings or clothing but instead add more layers to absorb the blood.-6. A nurse must observe the resident and perform a full-body exam to determine if there may be suspected injury and direct whether to move the resident.--b. If the fall was not witnessed, neurological checks are required and must be documented in the medical record.

Based on record review, observation, interview, and policy review, the provider failed to ensure: *The physician was notified of medications not administered due to unavailability as directed in the provider's policy for one of one sampled resident (20). *A physician's order to take vital signs every six hours was followed for one of one sampled resident (38) for an infection. Findings include: 1. Review of resident 20's medication administration record (MAR) revealed: *She had physician's order for Benefiber Oral Tablet Chewable (Wheat Dextrin) [fiber supplement] 1 tablet by mouth in the morning for constipation related to DRUG INDUCED CONSTIPATION. -In March 2025 resident 20's Benefiber was documented not available 13 times. --Unlicensed medication aide (UMA) L had documented all the medication not available in March 2025 for the Benefiber. *She had a physician's order for Citracal Plus Tablet (Multiple Minerals-Vitamins) [calcium with vitamin D supplement] 1 tablet by mouth one time a day related to VITAMIN D DEFICIENCY. -Resident 20's Citracal was documented as not available on 3/24/25 and 3/25/25 by two different UMAs. 2. Observation on 3/26/25 at 10:15 a.m. of the medication cart revealed: *There was a bubble-pack medication card with one Citracal tablet in a bubble, and one empty bubble. -The dispensed date on the Citracal card was 3/25/25. *There was a bottle of Benefiber powder with a dispensed date of 1/10/24 and was labeled with #4. -The bottle was unopened. *There was no medication card that contained Benefiber tablets. 3. Interview on 3/26/25 at 10:25 a.m. with UMA L revealed: *The monthly medication delivery for all medication carts was scheduled for 3/27/25. *The Citracal had been received from the pharmacy with 28 tablets in February, which left the facility two tablets short for the month. *UMA L had requested the Citracal from pharmacy on 3/23/25 and 3/25/25 and both times she had indicated on the medication request that the facility had no remaining tablets for administration. *UMA L stated that she had documented the Benefiber as unavailable because the medication order was for a tablet and the medication available in the medication cart was the powder. *She explained that resident 20 had previously been on the Benefiber tablets but per her daughter's request the order had been changed to the Benefiber powder. *When resident 20 was returned from a hospital admission the order was changed back to a tablet. *UMA L indicated she had alerted Minimum Data Set (MDS) nurse C and registered nurse (RN) F of the Benefiber order being for a tablet instead of the powder when resident 20 was readmitted to the facility from the hospital. 4. Review of pharmacy Medication Reorder Sheet revealed: *A 3/23/25 Medication Reorder Sheet which indicated Resident 20's Citracal had been reordered from the pharmacy by fax at 1:36 p.m. -The reorder form also indicated there were no tablets that remained for administration. *A 3/25/25 Medication Reorder Sheet which indicated Resident 20's Citracal had been reordered from the pharmacy by fax at 12:14 p.m. 5. Review of resident 20's electronic medical record (EMR) revealed: *Resident 20's 2/12/25 readmission orders indicated the Benefiber order as, wheat dextrin 3 gram/3.5 gram powder 1 dose by mouth daily. -The order was entered as Benefiber Oral Tablet Chewable (Wheat Dextrin) [fiber supplement] 1 tablet by mouth in the morning for constipation related to DRUG INDUCED CONSTIPATION. -The order was entered and cosigned by MDS C and RN S. *A 3/24/25 progress note indicated the Citracal Plus tablet was currently unavailable, pharmacy contacted and awaiting delivery. *There was no documentation that indicated the physician was notified regarding the Citracal or the Benefiber not having been given related to the medication not having been available. 6. Interview on 3/26/25 at 5:04 p.m. with MDS nurse C regarding medication orders revealed: *If a staff came to her with a medication question, she would help the staff figure out the order. *She would look at the original order and compare it to the MAR and the pharmacy label. *She was not previously aware of the Benefiber order being a tablet and the medication available in the medication cart was a powder. *She indicated that if the medication order was for a tablet and the facility had the medication as a powder, she would agree that the medication was not available for administration. *She expected the pharmacy to have been notified of the medication not being available and to request the form of the medication that was indicated on the order. -The pharmacy typically was able to provide the medications requested the same day the medication was ordered. *It was her expectation that the physician would have been notified the medication was not administered due to the medication not being available for administration. *She thought someone had entered the Benefiber order incorrectly when resident 20 was readmitted from the hospital. *The admission and readmission orders for residents were typically entered and verified by the nursing office staff. 7. Review of resident 38's EMR revealed: *She had a urine sample sent to her physician's office to be tested for an infection. *The physician was waiting for the urine culture and sensitivity [results to determine treatment]. *On 3/22/25 a physician's order to Monitor VS [vital signs] every 6 hours and notify on call [physician] of HR [heart rate] >[greater than]110 [beats per minute], SBP [systolic blood pressure] < [less than] 90, RR [respiratory rate] > 22 [breaths per minute], or Temp [temperature] >100.4 [degrees Fahrenheit] every 6 hours with an end date of -Resident 38's vital signs were being monitored to determine if there was a change in her vital signs which could indicate a worsening infection. --A variation from the indicated margins would require the facility to notify the resident's physician for immediate interventions. -The order entered into the EMR did not include the link to enter the vital signs within the order to have them documented into the EMR vital signs tab. *Review of resident 38's vital signs documentation revealed: -On 3/22/25 her vital signs were documented at midnight, 5:07 a.m., 11:42 a.m., 5:00 p.m., and 9:09 p.m. -On 3/23/25 her vital signs were documented at 3:09 p.m. and 9:41 p.m. -On 3/24/25 her vitals signs were documented at 5:56 a.m. and 12:52 a.m. -On 3/25/25 her vital signs were documented at 2:25 a.m., 6:03 a.m., 12:25 p.m., and 5:33 p.m. -On 3/26/25 her vital signs were documented at 5:15 a.m. and 9:13 p.m. 8. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *He indicated the physician orders often were received by fax. *Once an order was received, he would enter the order into the resident's EMR, fax the order to the pharmacy, and if there was a medication that needed to be administered immediately, he would obtain it from the emergency medication supply, otherwise he would wait for the medication to arrive from the pharmacy. *If a medication was not available for administration or was not given, he would notify the pharmacy immediately. *If the medication was unable to be obtained from the pharmacy or the facilities emergency medication supply, he would notify the physician. *He stated the nurses and CMAs completed and documented residents' vital signing the EMR. *Vital signs were charted into the EMR. *He verified there was no documentation that indicated resident 38's vital signs had been taken as ordered by the physician. *He was not aware there was a physician order for resident 38 to have her vital signs taken every 6 hours until he was told in shift report that morning (3/27/25) that the order was completed. 9. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *She expected that physician orders be followed. *The pharmacy delivered medications to the facility daily and medications typically arrived at the facility the same day it was ordered. *The process for new physician orders was for the nurse to read, sign, and enter the order into the resident's EMR. *The order process was to be completed by the nurse that was in charge of that resident's care and the order should be double-checked and cosigned that the order was entered into the EMR correctly. *She expected the physician to be notified if a medication was held or not administered for any reason. *She was aware the physician had not been notified for the medications that were documented as not administered due to medication not being available. Review of the provider's 3/4/25 Medications: Acquisition Receiving Dispensing and Storage policy revealed Licensed nursing employees are responsible for ordering from the pharmacy and checking all new orders of medications from the physician's orders. Review of the provider's 3/4/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *A provider's order for any medication is required and must include: diagnosis, name of medication, dose, route, frequency, and STOP order if indicated. *If a medication is not available for 24 hours, the provider must be notified that the medication is not available and must be given direction for how to proceed. *Follow the Six Rights: Right medication, right dose, right resident, right route, right time and right documentation. *Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and policy review, the provider failed to ensure residents who used assist/grab bars (bed rails) had: *A routine assessment, when a assist/grab bar was initiated and quarterly, was completed for four of eight sampled residents (6, 8, 33, and 38). *A signed consent for the use for the assist/grab bars for one of six sampled resident (6), with cognitive impairment, and a power of attorney (POA). *Received education on the risks of use versus benefits of the use of assist/grab bars for five of six sampled residents (6, 23, 26, 33, and 38). *Other attempted interventions were documented on five of eight sampled residents (6, 13, 23, 33, and 38). Findings include: 1. Observation on 3/24/25 at 2:14 p.m. of resident 33's room revealed she had bilateral (on both sides) assist/grab bars in the upright position near the head of her bed. Review of resident 33's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated she had moderate cognitive impairment. *Her 11/9/24 Physical Device and/or Restraint Evaluation and Review assessment revealed: -She consented for her own assist/grab bars with known cognitive impairment and a POA. -No barriers were documented related to Learning barriers related to education/educational material provided. -There were no documented attempted alternatives identified. *Her care plan revealed: -She has a focus area of has impaired cognitive function relating to vascular dementia e/b [evidence by] cognitive impairment, forgetfulness, decision making impairments. -Her POA had given prior consents via phone for resident 33 to receive liquor and to be photographed. 2. Observation on 3/24/25 at 2:24 p.m. of resident 26's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 26's EMR revealed: *She was admitted on [DATE]. *Her 2/17/25 BIMS assessment score was 12, which indicated she had moderate cognitive impairment. *Her 2/23/25 Physical Device and/or Restraint Evaluation and Review assessment revealed there was no documentation to reflect education had been provided related to the risk vs benefit of the use of resident 12's assist/grab bar. 3. Observation on 3/24/25 at 4:04 p.m. of resident 6's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *Her 2/21/25 BIMS assessment score was 15, which indicated she was cognitively intact. *There was no Physical Device and/or Restraint Evaluation and Review assessment completed. 4. Observation on 3/24/25 at 5:04 p.m. of resident 13's room revealed she had an assist/grab bar in the upright position near the head of her bed on the right side. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 2/4/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 2/10/25 Physical Device and/or Restraint Evaluation and Review assessment revealed: *There was no attempted alternative to the assist/grab bars documented. *Review of resident 13's 3/26/25 care plan did not identify that she had an assist/grab bar on her bed. 5. Observation on 3/25/25 at 11:29 a.m. of resident 8's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 8's EMR revealed: *She was admitted on [DATE]. *Her 2/12/25 BIMS assessment score was 8, which indicated she was moderately cognitively impaired. *Her 8/23/24 Physical Device and/or Restraint Evaluation and Review assessment indicated, Resident does not have grab bars on her bed since moving rooms. Resident has no difficulty without [the] use of them. 6. Observation on 3/25/25 at 11:30 a.m. of resident 23's room revealed she had an assist/grab bars in the upright position near the head of her bed on the left side. Review of resident 23's EMR revealed: *She was admitted on [DATE]. *Her 2/11/25 BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *Her 2/18/25 Physical Device and/or Restraint Evaluation and Review assessment revealed: -There was no attempted alternative to the assist/grab bars documented. -There was no education documented related to risk versus benefit of use, the resident's ability to use the assist/grab bars or the resident's understanding of use. 7. Observation on 3/25/25 at 11:32 p.m. of resident 38's room revealed she had bilateral assist/grab bars in the upright position near the head of her bed. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 2/20/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 8/19/24 Physical Device and/or Restraint Evaluation and Review assessment revealed: -There was no attempted alternative to the assist/grab bars documented. -There was no education documented related to risk versus benefit of use, the resident's ability to use the assist/grab bars or the resident's understanding of use. 8. Interview on 3/26/25 at 2:25 p.m. with Minimum Data Set (MDS) nurse C revealed: *She expected the Physical Device and/or Restraint Evaluation and Review assessments to be completed prior to the implementation of a resident's assist/grab bars. *She completed the Physical Device and/or Restraint Evaluation assessment for residents with assist/grab bars with the quarterly MDS. *She was unaware there was missing documentation within the assessments and there were assessments not completed upon initiation of the assist/grab bars and quarterly. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *It was her expectation the completion of the Physical Device and/or Restraint Evaluation assessments be completed by a licensed nurse prior to the application of assist/grab bars. *The Physical Device and/or Restraint Evaluation assessment would determine if an assist/grab bar was appropriate to be initiated for the evaluated resident. *Once the assist/grab bar was placed on the bed others would know that the assessment was completed. *It was the licensed nurse's responsibility to assess for the resident's risk for entrapment. *She indicated it was MDS nurse C's responsibility to complete the Physical Device and/or Restraint Evaluation and Review assessment with the quarterly MDS. Review of the provider's 10/29/24 Restraint policy revealed: *Anytime a device, material or equipment is attached or placed adjacent to the resident's body, a determination will be made by a licensed nurse as to whether it is or could be a restraint for the individual resident and a Physical Device and/or Restraint Evaluation and Review UDA is completed by a Licensed Nurse. *If the device, material or equipment is not a restraint, it must be reviewed quarterly and with significant change in condition in conjunction with the care plan to ensure that it continues to not be a restraint for the resident.

Based on observation, interview, record review, and job description review, the provider failed to assess, document, and implement interventions for one of one sampled resident (51) with a mood disorder. Findings include: 1. Observation and interview on 3/24/25 at 3:13 p.m. with resident 51 and his spouse revealed: *The resident's room was without any personal items from home. *He enjoyed music but had no way to listen to it. He was Lutheran and would not have objected to having clergy from that faith visit him. His spouse was working with a visually impaired service provider so the resident had access to books on tape. *He was admitted to the facility after back surgery after a complicated and extensive hospitalization. -His goal was to return home with his spouse after his rehabilitation stay at the facility. *His pain had improved since he was admitted to the facility. *The resident's affect was flat. *In early March 2025, the resident's physician had recommended he see a counselor for worsening depression. -The resident's spouse had asked that a male counselor see the resident. She was told there were no male counselors available to have met with the resident. No other counseling alternatives had been discussed or provided for the resident. Interviews on 3/25/25 at 2:00 p.m. and on 3/26/25 at 4:45 p.m. with resident 51 in his room revealed: *He had a history of depression and was taking anti-depressant medication. His depression had worsened his admission to the facility. -He felt he had lost weight because nothing tasted good. He had feelings of imprisonment, and a sense of loss of control of his body. He was a loner and remained in his room most of the time. *His spouse had visited him regularly and he had a few friends who had stopped by to see him occasionally. -It had felt good to unload how he was feeling with his friends. *Caregivers had been good about engaging with him during routine care. He would have liked to have someone who could sit down to talk with him each week about his loss of control. *At home the resident had enjoyed sitting in his own recliner and using his home computer. Having personal items that surrounded him at home brought him joy. Review of resident 51's electronic medical record (EMR) revealed: *His admission date was 2/10/25. *His 3/26/25 Brief Interview for Mental Status assessment score was 13 which indicated he had little or no cognitive impairment. *His 2/11/25 PHQ-9 (Patient Health Questionnaire - a self-report tool used to assess depression symptom severity) assessment score was 8 which indicated he had mild depression. *A 2/11/25 physician's history and physical progress note (PN): Psychiatric/Behavioral: Positive for confusion (now improved) and sleep disturbance. The patient is nervous/anxious (He is concerned about what the future may hold). *A 2/18/25 physician's PN: Staff and his [resident 51's] wife note that he is depressed. His wife would like his sertraline (anti-depressant medication) increased. A physician's order was written on that same date changing the sertraline dose from 50 mg (milligrams) daily to 100 mg daily. *A 2/20/25 interdisciplinary care conference PN had discussed the resident's weight loss, his improved pain management, and his current medications. -Social Services: [resident's spouse] would like home health at discharge and plan is to discharge home with wife. [Resident 51] is a full code, no concerns from social services at this time. *A 3/4/25 physician's 30-day post admission PN revealed resident 51's chief complaints had been a poor appetite and depression. -He [resident 51] admits to feeling depressed. He feels down at times and wishes his life were over. He has thought about suicide but did not verbalize a method. He feels worthless and not any good to his children or grandchildren. His energy level was poor and his concentration was decreased. -The resident had agreed that counseling was not a bad idea. A physician's order was written on that same date: [Counseling agency] may see for psychological counseling. *There was no nurse PN documented on 3/4/25 after the physician's visit that acknowledged any communication had occurred between the nursing staff and the physician. *SSD/CSW I's PN documentation between 2/20/25 and 3/20/25 regarding resident 51's mood state revealed: -On 3/5/25 the resident's spouse had asked SSD/CSW I if a male counselor was available to visit with resident 51. -On 3/6/25 SSD/CSW I had documented the counseling agency resident 51 had been referred to for counseling had no male counselor available to have met with the resident. -There was no documentation to support what other counseling alternatives had been investigated or offered to resident 51. *On 3/18/25 registered dietician (RD) R's PN: Resident has not been eating and has noted to state 'I'm going to starve myself' per IDT [interdisciplinary team] at QOL [quality of life] meeting - this was stated a few weeks ago. Review of the 2/11/25 through 3/25/25 weekly QOL/Nutrition meeting minutes revealed: *Resident 51's weight loss was discussed during those meetings. -There was no documentation in those minutes related to RD R's above documentation regarding resident 51's statement about starving himself. Interviews on 3/25/25 at 1:00 p.m. and again on 3/26/25 at 4:00 p.m. with SSD/CSW I and SSD/CSW J regarding resident 51's mood state revealed: *One of SSD/CSW I's responsibilities was monitoring and responding to the psychosocial well-being of the residents. *She was aware resident 51's depression symptoms had worsened since his admission and his anti-depressant medication was increased on 2/19/25. In response, she had not but could have: -Initiated one-to-one visits with the resident and identified, and implemented other interventions to have addressed his mood state. -Collaborated with the activities department to have followed-up on those things above that the resident had identified that had enhanced his quality of life. -Confirmed a daily mood symptom monitoring task had been initiated to assess if the resident's mood state continued to worsen or had improved. -Readministered a PHQ-9 assessment for comparison with the last completed PHQ-9. *SSD/CSW I had only spoken with resident 51's wife and not the resident regarding the above physician-ordered counseling services so she had not known the resident's preference for a male versus a female counselor. She had not informed the resident of her inability to find a male counselor or discussed with him any other alternatives to assist him with the management of his depression. *SSD/CSW I had not known about the above statements made by resident 51 to his physician during their 3/4/25 visit. Interview on 3/27/25 at 8:00 a.m. with administrator A regarding resident 51's mood state decline revealed: *Psychological services could have been arranged for resident 51 through a telehealth service provider the facility had access to. *The QOL/Nutrition meeting was an interdisciplinary team whose focus was discussing residents who had weight loss and were at risk for or had factors that affected their well-being. -She stated weight loss had mostly been discussed during those meetings, but her goal was for the inclusion of residents' QOL issues. It just hasn't happened yet. Interview on 3/28/25 at 9:45 a.m. with administrator A and director of nursing (DON) B regarding the physician's on-site resident visits revealed: *The physicians had a list of residents they were expected see during their on-site resident visits. -Nursing staff had discussed with the physician pertinent non-emergent changes or developments related to the residents on the physician's visit list as well as residents not on the list. *Nursing staff received a hand-off report from the physician after the physician's visits had been completed. That report included a review of new physician's orders and resident recommendations. *It was the responsibility of that nursing staff to ensure information from that hand-off communication was relayed to the appropriate interdisciplinary team members -That usually occurred during weekday interdisciplinary stand-up meetings. If the matter was more urgent, a personal conversation or telephone call was expected to have occurred. *The nursing staff who had received hand-off communication from the physician was expected to have made a progress note entry regarding that communication. *Administrator A and DON B had not known: -SSD/CSW I was not notified of the comments made by resident 51 during his 3/4/25 physician visit. -There was no documentation to support if nursing staff had received a physician's hand-off report after resident 51's 3/4/25 physician visit. A Mood/Behavior policy was requested from administrator A on 3/28/25 at 9:00 a.m. A Behavioral Causes and Interventions policy was provided which had not addressed the provider's process for managing resident's mood disorders. Review of the revised 3/19/25 Social Services job description revealed: *It was SSD/CSW I's responsibility to: -Provide leadership for the delivery of medical Social Services, expertise and/or consultation and acts as a liaison by representing at the local, regional, and state levels. -Develop and review service plans in consultation with clients and perform follow-ups assessing the quantity and quality of services provided.

Based on observation, interview, record review and policy review, the provider failed to Follow proper infection control practices and precaution interventions related to: *The use of personal protective equipment (PPE) to help prevent the transmission of infections for three of three sampled residents (1, 31, and 24). *Maintaining the cleanliness of four of four handwashing sinks used by staff (Charting Station 1, Charting Station 2, Charting Area 151, and Charting Area 174) in two of two residential living units (North and South). Findings include: 1. Observation of resident 1's room on 3/24/25 at 3:10 p.m. revealed: *There was a magnet on the door frame of her room that indicated she was on transmission based precautions (TBP). -There were gowns outside of her room for staff to don (put on). Interview on 3/24/25 at 3:12 p.m. with resident 1 revealed: *Resident indicated that she is on EBP because It tells people who are sick to not come into my room. - She verified they wear gloves when caring for her, but they do not wear gowns. Review of resident 1's electronic medical record (EMR) revealed: *Her 1/7/25 Brief Interview for Mental Status (BIMS) assessment score was 15, indicating she had no cognitive impairment. *Her 3/26/25 revised care plan indicated that she was on enhanced contact precautions (CP) requiring the use of gown and gloves on every entry into her room, regardless of the level of care being provided to the resident. -She had extended spectrum beta-lactamase (ESBL) (bacterial infection that is resistant to many antibiotics and highly contagious). -Wear gowns when changing contaminated linens and brief. - Provide private room and use contact precautions. -She required enhanced barrier precautions (EBP) that required staff to wear gowns and gloves during resident care and activities due to her ESBL. -Staff were to Don gowns and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. -Physical therapy (PT) and occupational therapy (OT) are to use EBP in common areas when therapy activities have risk for repeated contact. -Educate resident and /or family regarding the importance of good hand hygiene and the need for and duration of EBP. 2. Observation on 3/24/25 at 3:11 p.m. of resident 31's room revealed: *On the door frame outside of resident 31's room there was a magnet that indicated she was on TBP. -Inside of resident 31's room there were gowns and gloves for staff to don. Interview on 03/24/25 at 3:52 p.m. with resident 31 revealed staff do not wear gowns when doing cares with her, but they do wear gloves. Observation on 3/26/25 at 2:07 p.m. of resident 31's room revealed: *Certified nurse assistant (CNA) N and unlicensed medication assistant (UMA) L had exited resident 31's room after providing care for her, both only wearing gloves. *There now was a magnet on the door frame of her room that indicated resident 31 was on EBP. Interview on 03/26/25 at 2:20 p.m. with CNA N revealed: *She verified that only gloves were worn when she provided cares for resident 31. -She had indicated typically gloves, gown, and a face shield is worn if working with bodily fluids, but stated I have a tendency to forget. Observation and interview on 3/27/25 at 8:27 a.m. with CNA M revealed: *She had provided cares for resident 31 with glove use only. -She had verified that the resident is on EBP because She has something in her urine. -She had indicated that they only transferred the resident out of bed to her chair, they were not doing anything with her urine or changing her brief. Review of resident 31's EMR revealed: *Her most recent care plan indicated that she was on EBP related to MDRO (multidrug-resistant organism) colonization. -Interventions on her care plan had indicated to Don gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. -Doff (remove) gown and gloves inside resident's room. Perform hand hygiene. -Educate resident and /or family regarding the importance of good hand hygiene and the need for and duration of EBP. *Her 9/26/24, BIMS assessment score was 15, indicating she had no cognitive impairment. 3. Observation of resident 24's room on 3/24/25 at 3:12 p.m. revealed: *There was a magnet on the door frame of her room that indicated she was on TBP. -There were gowns outside of her room for staff to don. Interview on 03/25/25 at 10:55 a.m. with resident 24 revealed staff do not wear gowns when doing cares with her, but they do wear gloves. Review of resident 24's EMR revealed: *Her 7/24/24 BIMS assessment score was 15, indicating she had no cognitive impairment. *Her most recent care plan indicated that she requires to be on EBP related leg wound. -Interventions on her care plan had indicated to Don gown and gloves when performing high contact care activities including dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care and/or use, and wound care. -Educate resident and /or family regarding the importance of good hand hygiene and the need for and duration of EBP. Interview on 3/24/25 at 5:19 p.m. with clinical care leader (CCL)/infection preventionist (IP) D revealed: *While providing cares to a resident who is on EBP she would do the following: -She had indicated that she would apply her PPE before caring for a resident who is on EBP whenever she is having close contact with them such as working with the resident's linen, changing their clothes or assisting them with their activities of daily living (ADL)'s, or repositioning them. -She would finish by doffing her PPE prior to leaving their room and then wash or sanitize her hands. 4. Interview on 3/26/25 at 2:50 p.m. with administrator A revealed: *She stated, she would expect staff to Follow the Policy and do exactly what the sign says on the door. -When asking Administrator A what the facility's policy is for EBP, she had indicated, gloves, gowns, and masks and whatever the signs tell them to be doing. 5. Interview with clinical care leader (CCL) E on 3/27/25 at 1:04 p.m. revealed: *Her expectation of staff would be for them to follow the precautionary measures by wearing the appropriate PPE according to the EBP policy when caring for the residents. *They have done a performance improvement plan (PIP) within the last year over EBP and had provided education for all staff. 6. Observation on 3/24/25 at 2:00 p.m. of the North Unit Charting Station 2 handwashing sink revealed: -There was a white build-up around the perimeter of the handwashing sink that was removed with a fingernail. That white build-up smelled like soap. -The faucet spout had a white lime build-up around it. Additional lime splashes and stains were observed throughout the inside of the sink basin, at the base of both hand controls, and at the base of the faucet spout. -There was an unidentified brown substance around the sink drain perimeter that was removable with a fingernail. *There was a container of disinfectant wipes near that sink. 7. Observations on 3/24/25 at 2:30 p.m. and on 3/26/25 at 1:15 p.m. of the North Unit Charting Station 1 handwashing sink revealed the same observed findings described above for the Charting Station 2 handwashing sink. Observation and interview on 3/26/25 at 8:32 a.m. with RN G revealed: *After exiting an unidentified resident's room, RN G had used the Charting Station 2 handwashing sink to wash her hands. -The handwashing sink remained in the same uncleaned condition that it was observed to have been in on 3/24/25. *RN G did not know who was responsible for cleaning that sink or how frequently that sink was cleaned. She agreed the sink was unclean. 8. Observation on 3/26/25 at 1:15 p.m. of the South Unit Charting Area 151 handwashing sink revealed: *The faucet was dripping. -The faucet spout had white lime build-up around it. Additional lime splashes and stains were observed throughout the inside of the sink basin, at the base of the hand controls, and at the base of the faucet spout. -There was an unidentified brown substance around the sink drain perimeter that was removable with a fingernail. *There was no container of disinfectant wipes near that sink. 9. Continued observation of the South Unit Charting Area 174 handwashing sink and interview with certified nurse aide (CNA) M revealed: -The faucet spout had white lime build-up around it. Additional lime splashes and stains were observed throughout the inside of the sink basin, at the base of the hand controls, and at the base of the faucet spout. -There was an unidentified brown substance around the sink drain perimeter that was removed with a fingernail. *There was a container of disinfectant wipes near that sink. *CNA M had thought the handwashing sink was cleaned daily by a housekeeper. She agreed that sink was unclean. 10. Interview on 3/27/25 at 8:05 a.m. with administrator A and environmental services supervisor Q regarding the cleaning of the above four handwashing sinks revealed: *Those handwashing sinks were expected to have been cleaned daily by housekeeping staff. -Disinfecting and cleaning those sinks and countertops was included on a daily cleaning checklist that housekeeping staff was expected to have followed. Review of the provider's undated SNF [skilled nursing facility] Checklist for Cleaning Public Areas checklist revealed disinfecting and cleaning the above handwashing sinks was listed as a task to have been completed daily.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to support residents' right to choose and receive the frequency and type of shower or bath consistent with their preferences for 7 of 17 sampled residents (20, 13, 38, 18, 15, 42, and 306). Findings include: 1. Interview on 3/24/25 at 3:30 p.m. with resident 20's daughter/power of attorney (POA) revealed: *Resident 20 was scheduled for a bath weekly. *She previously was bathed twice weekly but resident 20's daughter/POA was told she no longer received twice weekly baths because there was not enough staff to accommodate that. Review of resident 20's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/17/25 Brief Interview of Mental Status (BIMS) assessment score was 6, which indicated she had severe cognitive impairment. *She was documented to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Resident 20's 3/26/25 care plan did not address her preference to receive two or more baths per week. 2. Interview on 3/24/25 at 5:04 p.m. with resident 13 revealed: *She was bathed once weekly. *She had notified facility management that she would like to bathe more than once weekly but was told she could not because there was not enough staff. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 2/4/25 BIMS assessment score was 15, which indicated she was cognitively intact. *She was documented to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Resident 13's 3/26/25 care plan did not address her preference to receive two or more baths per week. 3. Interview on 3/25/25 at 11:32 a.m. with resident 38 revealed: *She usually received her bath weekly. *She had not received a bath in the past week. *She had not refused her bath for a long time. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 2/20/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *There was no documentation that indicated she had been bathed since 3/15/25. -She had not received a bath within the last 10 days. 4. Interview on 3/24/24 at 2:28 p.m. with resident 306 and his daughter in his room revealed: *Resident 306 stated he always had to ask for a bath. *He was told by staff, I'll be right back to give you a shower and three hours later he still hadn't had one. *He stated, They always say we're short-staffed. *He stated he wanted a shower but they talked me into a bath. *His daughter stated she would like for him to get on a bath schedule. Review of resident 306's EMR revealed: *He was admitted on [DATE]. *His 2/12/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact. *His 2/11/25 Sit-Stand-Walk Data Collection Tool assessment indicated he preferred two or more baths per week. *His 2/11/25 care plan did not address his preferences for type or frequency of bathing. *From 2/23/25 to 3/25/25 he had documented bathing on 3/3/25, 3/5/25, 3/10/25, and 3/20/25. A follow-up interview on 3/26/25 at 4:13 p.m. with resident 306 and his wife in his room revealed: *His wife stated, One bath a week is not enough. *He stated he had previously shared his concerns about not getting a shower with the social worker. 5. Interview on 3/24/25 at 3:02 p.m. with resident 15 in her room revealed: *She stated, I didn't get a bath last week, and they're working on getting one for this week. *She stated, It does not feel like there's enough help here. Review of resident 15's EMR revealed: *She was admitted on [DATE]. *Her 1/21/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 1/20/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *From 2/23/25 to 3/25/25 she had a bed bath documented on 2/27/25, 3/6/25, and 3/13/25. *It was documented that she refused a bath on 3/20/25. *There was no documentation that indicated she had been bathed since 3/13/25, 12 days prior. A follow-up interview on 3/26/25 at 4:36 p.m. with resident 15 in her room revealed: *She did not refuse a bath last week. *She would prefer two or three baths per week. 6. Interview on 3/24/25 at 3:26 p.m. with resident 18 in her room revealed: *She was supposed to get a bath that day but did not. *She was told by staff that they would try to get her a bath tonight. Review of resident 18's EMR revealed: *She was admitted on [DATE]. *Her 9/13/24 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her 2/27/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *She had documented baths on 3/3/25, 3/10/25, 3/19/25, and 3/24/25, all at 2:14 p.m. -The bath that was documented on 3/24/25 at 2:14 p.m. was the same day she said that she was supposed to get a bath but did not and was told by staff that they would try to get her a bath that night. A follow-up interview on 3/26/25 at 4:42 p.m. with resident 18 regarding her preferences revealed she would like to have a bath every day if possible. 7. Interview on 3/24/25 at 4:14 p.m. with resident 42 in her room revealed: *She stated, We only get a bath once a week because they're short on help. *She would prefer more frequent baths. Review of resident 42's EMR revealed: *She was admitted on [DATE]. *Her 2/18/25 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her 2/17/25 Sit-Stand-Walk Data Collection Tool assessment indicated she would like two or more baths per week. *She had a 2/24/25 physician order for two baths per week. *From 2/23/25 to 3/25/25 she had baths documented on 3/4/25, 3/10/25, and 3/17/25. 8. Review of the provider's grievances from 1/16/24 through 2/26/25 revealed: *There were five grievances filed on behalf of four separate residents related to not receiving baths consistent with their preferences. *Documented resolutions to those grievances included the provider: -Indicated what days baths were scheduled. -Educated staff on following the bath schedule. -Followed up with the resident in writing that they would try to accommodate a preference for two baths per week but did not schedule the resident for two baths. -Followed up with family and indicated the resident is getting baths. -Followed up with family and indicated the resident remains on a bathing schedule. 9. Interview on 3/26/25 at 1:45 p.m. with Clinical care leader (CCL)/infection preventionist (IP) D regarding resident bathing revealed if no bath aide was available the certified nursing assistant (CNA) that was working on the floor providing resident cares would be responsible to provide the resident's bathing according to the bath schedule. 10. Interview on 3/26/25 at 2:25 p.m. with Minimum Data Set (MDS) nurse C revealed: *The resident preferences related to bathing was documented in the Sit-Stand-Walk Data Collection Tool assessment in the EMR. -MDS nurse C completed this assessment quarterly. *CCL/IP D maintained the resident bath schedule and MDS nurse C believed she went by the preferences documented on the Sit-Stand-Walk Data Collection Tool assessment to make the bath schedule. *It was her expectation that the preferences documented in the Sit-Stand-Walk Data Collection Tool assessment be followed when scheduling the resident's bathing. 11. Interview on 3/27/25 at 8:01 a.m. with CNA M revealed: *She was usually scheduled as a bath aide when she worked. *If a resident refused a bath, the bath aide was to ask again later that day. If the resident refused again, the bath aide was to ask another staff member to approach the resident for a bath or the evening staff was to attempt to give that resident a bath. *She rarely had a resident refuse their scheduled bathing. *Residents usually received one bath per week. *There were times the bath aide was reassigned to work as a CNA on the floor to provide resident cares. *If the bath aide was reassigned to the floor each CNA would be responsible to complete the resident's bathing according to the bathing schedule. *She thought the bath aide was reassigned to work the floor at least one day per week. *If a resident requested more than one bath per week, staff were to attempt to accommodate the request, and the bathing schedule and the resident's care plan were to be updated to reflect the request. 12. Interview on 3/27/25 at 8:22 a.m. with CNA P regarding resident bathing revealed: *There was a resident bathing schedule located in the nurses' station. *The residents' baths were to be completed by the CNA assigned to provide resident bathing for that shift. *There were times when a bath aide was not scheduled to work. *There were times the bath aide was reassigned to work on the floor to provide resident care. *If there was no bath aide scheduled the float CNA would usually complete the resident baths. *If there was no float or a bath aide the CNAs assigned to work on the floor were to complete the baths scheduled for that day. *In the last three weeks, on the days he had worked, there had been three or four times when no bath aide was available to complete the assigned residents' baths and the CNA that was providing direct care was responsible to provide the resident on their assignment with their bath. 13. Interview on 3/27/25 at 10:16 a.m. with CCL/IP D regarding resident bathing revealed: *She maintained the resident bathing schedule. *The resident baths were scheduled on the treatment administration record (TAR) and in the tasks in the EMR. *The bathing schedule may change according to resident requests. *She indicated the residents were interviewed regarding their bath preferences. *She was not aware who completed the interview, when the interviews were to be completed, or where to locate the information obtained during the interview. *Residents could discuss their concerns and preferences with staff or during care conferences. 14. Interview on 3/27/25 at 10:37 a.m. with administrator A regarding resident choices revealed it was her expectation that staff do their best to accommodate resident choices. 15. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B regarding resident bathing revealed she expected staff to follow the bathing schedule. 16. Review of the provider's 2016 Resident's Rights for Skilled Nursing Facilities revealed: *The resident has the right to be informed of, and participate in, the development and implementation of his or her person-centered plan of care, including, but not limited to: -The right to participate in establishing the expected goals and outcomes of care, the type, amount, frequency and duration of care and any other factors related to the effectiveness of the plan of care. *The resident has the right to be treated with dignity including: -The right to reside and receive services in the facility with reasonable accommodation of individual needs and preferences, except when to do so would endanger the health or safety of the resident or other residents. *The resident has the right to and the facility must promote and facilitate resident self-determination through support of resident choice. -The resident has a right to choose activities, schedules (including sleeping and waking times), healthcare and providers of healthcare services consistent with his or her interests, assessments and plans of care. -The resident has a right to make choices about aspects of his or her life in the facility that are significant to the resident. *Services included in Medicare or Medicaid payment. -Routine personal hygiene items and services as required to meet the needs of residents, including, but not limited to, .hair and nail hygiene services, bathing assistance, . 17. Review of the provider's 12/02/2024 Grievances, Suggestions, or Concerns- Rehab/Skilled policy revealed: *Purpose -To document concerns, investigative findings and plans of correction. -To develop a systematic approach in resolving grievances as a tool to ensure continuous quality of care. *Policy -A resident has the right to voice grievances orally, in writing and anonymously without discrimination or reprisal. Such grievances, complaints or concerns include those with respect to treatment that has been furnished, as well as those that have not been furnished. -Grievances, suggestions and concerns are to be deemed high priority customer satisfaction issues. Facility staff will make prompt efforts to resolve a grievance and keep the resident/resident representative apprised of progress toward resolution.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure two of eight sampled residents' (1 and 51) care plans were revised to reflect their current status and care needs. Findings include: 1. Observation and interview on 3/24/25 at 3:13 p.m. with resident 51 and his spouse revealed: *The resident's room was without any personal items from home. *He was admitted to the facility after back surgery. He had a complicated and extensive hospitalization. *His goal was to return home with his spouse after his rehabilitation stay at the facility. *His pain had improved since he was admitted to the facility. *The resident's affect was flat. *In early March 2025, the resident's medical provider had recommended he see a counselor for his worsening depression. -The resident's spouse had asked that a male counselor see the resident. She was told there were no male counselors available to have met with the resident. No other counseling alternatives had been discussed with her or the resident. Interviews on 3/25/25 at 2:00 p.m. and on 3/26/25 at 4:45 p.m. with resident 51 in his room revealed: *He had a history of depression and was taking an anti-depressant medication. He had increased depressive symptoms since he was admitted to the facility. -He had lost weight because nothing tasted good. He had feelings of imprisonment, and a sense of loss of control of his body. He was a loner and remained in his room most of the time. *His spouse had visited him regularly and a few friends had also visited him. -It had felt good to unload how he was feeling with his friends. *At home, the resident had enjoyed sitting in his own recliner and using his home computer. Having personal items that surrounded him at home brought him joy. Review of resident 51's electronic medical record (EMR) revealed: *He was admitted on [DATE]. *His 3/26/25 Brief Interview for Mental Status assessment score was 13 which indicated he had little or no cognitive impairment. *His 2/11/25 PHQ-9 (Patient Health Questionnaire - a self-report tool used to assess depression symptom severity) assessment score was 8 which indicated he had mild depression. *His anti-depressant medication was increased on 2/19/25. Review of resident 51's care plan revealed: *Interventions related to the resident's risk for an alteration in his mood and psychosocial well-being were initiated on 2/10/25 and included: -Adjust environment to promote comfort i.e. room temperature, furniture arrangement, lighting, personal belongings. -CSW [certified social worker] to initiate referrals as needed/indicated. -Depressive symptoms: Encourage positive conversation during cares and interactions, offer praise and encouragement, empathize with feelings and concerns. -Provide opportunities for resident to engage in meaningful conversation and activities with others. -Staff to monitor and provide ongoing conversation regarding routine and preferences. *No revisions were made to those interventions since they were initiated. *Interventions related to the resident's depression diagnosis initiated on 2/25/25 and revised on 3/3/25 included: -Consult with pharmacy, healthcare provider, etc. to consider dosage reduction when clinically appropriate. -Depression: attempt non-pharmacological interventions such as one-one [one on one] visits, offer counseling if agrees, monitor for adverse effects of medications and effectiveness of medications. *Interventions related to the resident's use of anti-depressant medication were initiated on 2/10/25 and included Monitor resident condition based on clinical practice guidelines or clinical standards of practice r/t [related to] use of Sertraline [anti-depressant medication]. Interview on 3/28/25 at 9:10 a.m. with social service directors (SSD)/CSW I and J revealed: *SSD/CSW J had documented the above care plan interventions related to resident 51's risk for a decline in his mood and psychosocial well-being. *She stated those interventions were generic. -She was expected to have revised the interventions to ensure they had been person-centered and individualized to have reflected the current and ongoing needs of resident 51 during his nursing home stay. *Her care plan had not reflected: -What individualized accommodations were to have been offered or made to improve the resident's environmental comfort. -If any counseling service referrals had been made or services provided. -How staff were to attempt to engage the resident in meaningful conversation and activities. -SSD/CSW J stated the one-on-one visits with the resident would have been her responsibility to have implemented and documented. She had not known about that intervention so there had been no follow-up. *Care plan interventions related to resident 51's anti-depressant medication monitoring and depression diagnosis had been documented by minimum data set (MDS) nurse C. Interview on 3/28/25 at 1:10 p.m. with MDS nurse C regarding resident 51's care plan revealed she: *Had documented the interventions on his care plan related to depression and anti-depressant medication use monitoring. *No monitoring tool had been implemented to measure the type and frequency of resident 51's depression symptoms. -Should have identified the staff person responsible for implementing that intervention on the care plan and communicated that responsibility to them. *Agreed the intervention related to a medication dose reduction should have been updated to reflect the resident had an increase in his anti-depressant medication. A dose reduction was currently contra-indicated. *Had not known if the one-on-one visits she had referred to in her interventions were implemented. -Should have identified the staff person responsible for implementing that intervention on the care plan and communicated that responsibility to them. 2. Observation and interview on 3/24/25 at 4:04 p.m. with resident 6 in her room revealed: *There was a cushion in her wheelchair. *She reported she had a sore on her buttocks that staff was applying cream to. *There was no PPE in her room or outside the door to her room. Interview on 3/24/25 at 5:19 p.m. with registered nurse (RN) F regarding resident 6's skin revealed: *She previously had a pressure ulcer to her right heel that was healed. *She had some excoriation (skin was scraped off) on her buttocks that the CNAs were applying a cream to. Review of resident 6's 3/26/25 care plan revealed: *A focus area of The resident has respiratory infection: Covid 19. -A intervention for the focus area was, DROPLET and CONTACT PRECAUTIONS: Wear gowns, gloves, N95 masks (if available), and eye protection when changing contaminated linens. Bag linens and close bag tightly before taking to laundry. Isolation x10 days dx [diagnosis]. *A focus area of The resident requires Enhanced Barrier Precautions R/T [related to] wounds. -An intervention for the focus area was, Don [put on] gown and gloves when performing high contact care activities including: dressing, bathing, transferring, providing hygiene such as shaving or brushing teeth, changing linens, repositioning, checking and changing, device care, and/or use, and wound care. 3. Interview on 3/26/25 at 10:37 a.m. with RN S regarding resident 6 revealed: *Her right heel wound had resolved almost three weeks ago, and she was no longer on EBP for this. *She had COVID over a month ago and was no longer on transmission-based precautions. 4. Interview on 3/36/25 at 8:22 a.m. with Minimum Data Set (MDS) nurse C regarding care plans revealed: *She was responsible for updating resident care plans with each resident's MDS assessment. *Anyone on the interdisciplinary team could update resident care plans. *Clinical care leader (CCL)/infection preventionist (IP) D was responsible for updating resident care plans that addressed resident wounds or infections. *It was her expectation that care plan updating be an ongoing process and occur any time there was a change in resident condition or care. *Resident 6's care plan had not been updated after the resolution of her right heel wound and after she was taken off transmission-based precautions for COVID. 5. Interview on 3/26/25 at 1:58 p.m. with CNA O revealed: *She was a travel CNA and had recently been assigned to this facility. *She indicated she referenced a resident's care plan or Kardex (a report of residents' care needs and interventions) to determine what cares were to be provided for a resident and how to provide the cares. 6. Interview on 3/27/25 at 10:16 a.m. with CCL/IP D regarding care plans revealed: *She was responsible for updating residents' care plans related to infections, wounds, transmission and enhanced barrier precautions. *Care plan updating was a working interdisciplinary team collaboration. *Care plans should be updated anytime there was a change in resident condition or care needs in addition to quarterly. *She agreed resident 6's care plan was not up to date and should have been. 7. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B regarding care plans revealed: *It was the responsibility of the nurses, clinical team, and herself to update resident care plans. *She expected resident care plans to be updated anytime there was a change in the residents' plan of care. Review of the provider's 12/2/24 Care Plan policy revealed: *Each resident will have an individualized, person-centered, comprehensive plan of care that will include measurable goals and timetables directed toward achieving and maintaining the resident's optimal medical, nursing, physical, functional, spiritual, emotional, psychosocial, and educational needs. Any problems, needs and concerns identified will be addressed through use of departmental assessments, the Resident Assessment Instrument (RAI) and review of the physician's orders. *The plan of care will be modified to reflect the care currently required/provided for the resident. Review of the provider's 4/2/24 standard and transmission based precautions policy and procedure revealed that the use of EBPs was indicated for residents with: *Chronic wounds (pressure ulcers, diabetic foot ulcers, unhealed surgical wounds, and venous statis ulcers) and residents with indwelling medical devices,)central lines, hemodialysis catheters, indwelling urinary catheters, feeding tubes, and tracheostomies). *EBP are also needed for residents with centers for disease control and prevention (CDC) targeted and epidemiologically important (facility discretion) MDRO infection and colonization, when contact precautions do not apply. multi-drug-resistant organisms (MDRO) when contact precautions do not otherwise apply. *High contact resident care activities include transfers, dressings, assisting during bathing, providing hygiene, changing briefs or assisting with toileting, working with resident in therapy gym, specifically when anticipating close physician contact while assisting with transfers and mobility, changing linens, device care or use. Review of the provider's 10/30/24 infection, prevention and control program policy and procedure revealed: *Purpose -To establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. *Infection prevention and control program is a program that prevents, identifies, reports, investigates, and controls infections and communicable diseases for all residents, staff, and visitors, following nationally accepted standards and guidelines.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, grievance review, and facility assessment review, the provider failed to have enough sufficient staff available to promote resident's rights, physical, mental, and psychosocial well-being for: *Eleven of fifteen sampled residents (7, 13, 14, 15, 18, 20, 26, 33, 38, 42, and 306) who were dependent on the staff to assist them with grooming, bathing, and toileting. *Five of five additional residents (22, 36, 45, 54, and 55) who had filed grievances on bathing and extended call light response time. Findings include: 1. Observation and interview on 3/24/25 at 2:14 p.m. with resident 33's in her room revealed, she: *Had multiple long gray facial hairs extending from her chin. *Reported that there were times when it took staff a long time to answer her call light. *Had waited longer to have her call light answered at night. Review of resident 33's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview of Mental Status (BIMS) assessment score was 11, which indicated she had moderate cognitive impairment. *Her care plan indicated she required assist of one staff member for dressing, grooming, and bathing. 2. Interview on 3/24/25 at 3:21 p.m. with resident 7 revealed, she: *Was told her physician ordered her two baths per week, but she had been receiving one bath weekly. *Had expressed her desire for more than one bath weekly with the CNAs, but no one else had come to talk to her about it and nothing had changed. *Expressed concerns about her call light not being answered promptly. -Staff told her that her call light was not working but it was now. Review of resident 7's EMR revealed, she: *Was admitted on [DATE]. *Had a BIMS assessment score of 15, which indicated she was cognitively intact. *She required assistance of for bed mobility, transfers, dressing, toilet use, and personal hygiene. Review of resident 7's 2/2/25 grievance revealed: *She indicated she was placed on a bedpan at 3:00 a.m. and the staff member told her, I will be back. -The staff member had not returned, she fell asleep, woke up feeling the bed pain, and started to feel pain. -She turned on her call light and thought she felt someone touch her shoulder and leave. -She again turned on her call light and thought someone came in and left again. -She then started yelling, but nobody came. -She knew it was about the time of a staff shift change because she looked at her cell phone and it was morning. -Someone entered her room, removed the bedpan from under her, and assisted her with her care needs. -She indicated by that time her bedding was soaked [with urine]. *The CNA that placed resident 7 on the bedpan stated she did so sometime between 3:30 a.m. and 4:30 a.m. -She indicated she had forgotten to remove the bedpan and forgot to tell the oncoming shift. 3. Interview on 3/24/25 at 3:30 p.m. with resident 20's daughter/power of attorney (POA) revealed: *She indicated she visited her mother daily. *Her mother was hard of hearing and legally blind. *She indicated she felt the facility was short-staffed. *She felt the staff rushed the residents when providing their care. *There were times when staff did not apply her mother's compression socks or put in her hearing aids before taking her to breakfast. *When resident 20 was in the dining room, staff often did not take the time to explain to her where her food was on her plate or assist her with eating meals. *Her mother has had multiple falls. *Resident 20 was scheduled for a bath weekly. *She previously was bathed twice weekly but resident 20's daughter/POA was told she no longer received twice weekly baths because there was not enough staff to accommodate that. Review of resident 20's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her 2/17/25 Brief Interview of Mental Status (BIMS) assessment score was 6, which indicated she had severe cognitive impairment. *She was scheduled to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Her care plan revealed she required assist of one staff member for bathing, dressing, personal hygiene, and toilet use. *She required set up assistance and cueing for eating. 4. Interview on 3/24/25 at 5:04 p.m. with resident 13 revealed: *She had at times waited for her bathroom call light to be answered for a half hour. *She thought she had waited as long as an hour and ten minutes for her bathroom call light to be answered. *She was bathed once weekly. *She had notified facility management that she would like to bathe more than once weekly but was told she could not because there was not enough staff to accommodate that. Review of resident 13's EMR revealed: *She was admitted on [DATE]. *Her 2/4/25 BIMS assessment score was 15, which indicated she was cognitively intact. *She was documented to have been bathed weekly. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred two or more baths per week. *Her care plan revealed she required assistance from one staff for toilet use, and transfers. -She required set up assistance for dressing, grooming, eating, wheelchair mobility, and oral care. Review of resident 13's 2/20/25 grievance revealed: *During 2/19/25 care conferences resident 13 and her daughter expressed concerns regarding: -Her bathroom her call light response time was often 30 to 60 minutes. -She did not know week to week if she was going to receive a bath. -She had gone 15 days between baths previously. -Her preference for bathing was twice weekly and always on Fridays. -She would have liked to receive more assistance from staff with clothing mgt [management]. *Investigation stated, Unable to view call light response time. *Response to resident 13's grievance included: -Staff was educated on call light response time; review Call light Policy at daily huddles. -Whirlpool completed on 01/31; 02/07; 02/14; 02/21 and 02/28. Preference is twice a week and will strive to accommodate twice weekly. Care plan updated regarding clothing management. 5. Interview on 3/25/25 at 8:53 a.m. with resident 26 in her room revealed: *She indicated she was assisted to bed last night by a male staff member and he did not put her into her pajamas. *When she woke up in the morning, she was in the same clothes she had worn the day before and the morning staff member helped her change her clothing. *She felt staff took a long time to answer her call light. -It often took between 10 to 15 minutes but was longer at times when she was in the bathroom. *She indicated she usually got a bath on Sundays but recently she has had to fuss in order to get a bath. *She stated she felt, they don't have time for me. Review of resident 26's EMR revealed: *She was admitted on [DATE]. *Her 2/17/25 BIMS assessment score was 12, which indicated she had moderate cognitive impairment. *Her care plan revealed she required assistance of one staff member for bating bed mobility, dressing, toilet use, and transfers. -She required set up assistance by a staff member for eating, oral care, and personal hygiene. 6. Interview on 3/25/25 at 11:32 a.m. with resident 38 revealed: *She usually received her bath weekly. *She had not received a bath in the past week. *She thought the facility was short-staffed but felt the staff was doing the best they could. *Staff had told her they were short-staffed. *She did not feel there was a specific time of day that the call light response times were longer than other times. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her 2/20/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *There was no documentation to support she had been bathed since 3/15/25, 10 days prior. 7. Resident group interview on 3/25/25 at 1:59 p.m. revealed: *One resident stated she would like more baths, especially when it was hot out. *Another resident stated she had gone 12 days without a bath, she began to cry and then stated they [staff] told her they were too busy to give her a bath and that made her upset. She then stated, I have to suffer because the staff are too busy to give me a bath. *Another resident stated she didn't receive help soon enough. She expanded to state she waited an hour and ten minutes last week for staff to respond to her call light. Usually, the call light response time was 20 minutes, and she then stated the wait time kills me. *Another resident stated that call light response wait times varied from a few minutes to an hour. 8. Interview on 3/24/24 at 2:28 p.m. with resident 306 and his daughter in his room revealed: *Resident 306 was admitted for rehabilitation after a hospitalization *He stated he hadn't been able to regain his strength after his cancer diagnosis and treatment *He stated he always had to ask for a bath and never knew when or if he was going to get one. *He was told by staff, I'll be right back to give you a shower, and three hours later, he still hadn't had one. *He stated, They always say we're short-staffed. *He stated he wanted a shower but they talked me into a bath. *His daughter stated she would like for him to get on a bath schedule. Review of resident 306's EMR revealed: *He was admitted on [DATE]. *His 2/12/25 Brief Interview for Mental Status (BIMS) assessment score was 15, which indicated he was cognitively intact. *His diagnoses included personal history of malignant neoplasm of prostate (prostate cancer), weakness, difficulty in walking, not elsewhere classified, and unsteadiness on feet. *His 2/11/25 Sit-Stand-Walk Data Collection Tool assessment indicated he preferred two or more baths per week. *His 2/11/25 care plan contained an intervention that indicated he needed staff assistance for transfers. *From 2/23/25 to 3/25/25 he had documented bathing on 3/3/25, 3/5/25, 3/10/25, and 3/20/25. A follow-up interview on 3/26/25 at 4:13 p.m. with resident 306 and his wife in his room revealed: *His wife stated, One bath a week is not enough. *He stated he had previously shared his concerns about not getting a shower with the social worker. 9. Interview on 3/24/25 at 3:02 p.m. with resident 15 in her room revealed: *She stated, I didn't get a bath last week, and they're working on getting one for this week. *She stated, It does not feel like there's enough help here. Review of resident 15's EMR revealed: *She was admitted on [DATE]. *Her 1/21/25 BIMS assessment score was 15, which indicated she was cognitively intact. *Her 1/20/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *From 2/23/25 to 3/25/25 she had a bed bath documented on 2/27/25, 3/6/25, and 3/13/25. *It was documented that she refused a bath on 3/20/25. *There was no documentation that indicated she had been bathed since 3/13/25, 12 days prior. A follow-up interview on 3/26/25 at 4:36 p.m. with resident 15 in her room revealed: *She did not refuse a bath last week. *She would prefer two or three baths per week. 10. Interview on 3/24/25 at 3:26 p.m. with resident 18 in her room revealed: *She was supposed to get a bath that day but did not. *She was told by staff that they would try to get her a bath tonight. Review of resident 18's EMR revealed: *She was admitted on [DATE]. *Her 9/13/24 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her diagnoses included difficulty in walking, unsteadiness on feet, repeated falls, and muscle wasting and atrophy (decrease in size). *Her 2/27/25 Sit-Stand-Walk Data Collection Tool assessment indicated she preferred one bath per week. *She had documented baths on 3/3/25, 3/10/25, 3/19/25, and 3/24/25, all at 2:14 p.m. -The bath that was documented on 3/24/25 at 2:14 p.m. was the same day she said that she was supposed to get a bath but did not and was told by staff that they would try to get her a bath that night. A follow-up interview on 3/26/25 at 4:42 p.m. with resident 18 regarding her preferences revealed she would like to have a bath every day if possible. 11. Interview on 3/24/25 at 4:14 p.m. with resident 42 in her room revealed: *She stated, We only get a bath once a week because they're short on help. *She would prefer more frequent baths. Review of resident 42's EMR revealed: *She was admitted on [DATE]. *Her 2/18/25 BIMS assessment score was 12, which indicated she was moderately cognitively impaired. *Her diagnoses included weakness, muscle wasting and atrophy, difficulty in walking, not elsewhere classified, and unsteadiness on feet. *Her 2/17/25 Sit-Stand-Walk Data Collection Tool assessment indicated she would like two or more baths per week. *She had a 2/24/25 physician order for two baths per week. *From 2/23/25 to 3/25/25 she had baths documented on 3/4/25, 3/10/25, and 3/17/25. 12. Interview on 3/24/25 at 5:05 p.m. with resident 14 in her room revealed: *She no longer waited for the staff to answer her call light when she needed to use the bathroom. *She used to wait for assistance to the bathroom but had incontinent episodes because she had to wait too long. *She stated, Sometimes I don't see anyone from 8:00 in the morning until 8:00 at night, except the person who brings in my room [meal] tray. They don't have enough help. Review of resident 14's EMR revealed: *She was admitted on [DATE]. *Her 1/29/25 BIMS assessment score was 15, which indicated she was cognitively intact. Review of the 2/6/25 grievance filed by resident 14 revealed: *She had concerns about not getting her bedtime medications on time. *She did not get her medications until midnight. *She had concerns about medications being left at her bedside. *The provider's investigation documentation of medication pass times included nothing [no medications] administered after midnight. *The provider's resolution included: -Reassured res [resident] that meds [were] to be passed per schedule. 13. Review of the provider's grievances from the previous year revealed: A 1/16/24 grievance filed on behalf of resident 54 by family indicated: *Resident 54 was not getting a bath since he was admitted . *Extended call light staff response times. *The provider's investigation documentation included: -When [the] resident was admitted , bathing was added but not finalized to show on tasks. Completed on 1/18/24. -Call light audit from 1/11/14 through 1/16/24 revealed: --Three call light response times over 10 minutes. --One call light response time over 15 minutes. --Two call light response times over 20 minutes. --Two call light response times over 30 minutes. *The provider's follow-up included: Will educate nurses about call light response time. A 7/30/24 grievance filed by resident 55 for her call light being on for an hour indicated: *A call light audit confirmed the resident's call light was on for 56 minutes. *Resolution documentation included: Education provided to CNA/nurse that all call lights are to be answered promptly. An 8/13/24 grievance filed on behalf of resident 22 for not getting a bath indicated: *The provider's audit of Tasks documentation revealed resident 22 had a: -Bed bath on 8/2/24 at 9:59 p.m. -Whirlpool bath on 8/5/24 at 12:01 p.m. -Bed bath on 8/9/24 at 10:14 p.m. -Bath documented as refused on 8/12/24 at 1:22 p.m. A 2/6/25 grievance filed on behalf of resident 45 with concerns about her bathing schedule indicated: *The provider's investigation documentation included: bathing schedule reviewed and resident is getting her bathing completed. -No audit was included. A 2/18/25 grievance filed by resident 36 regarding extended call light response time indicated: *Resident 36 reported that the shampoo machine was so loud that nobody heard anything. *A call light audit revealed a response time of 29 minutes and 26 seconds. *T provider's follow-up comments included: Education to staff: be extremely cognizant of loud equipment used, i.e.; shampoo machine; conduct an additional and intention rounding to ensure residents needs are addressed. An additional 2/26/25 grievance filed on behalf of resident 45 regarding bathing and call light response time indicated: *A family member reported that resident 45 had only received three baths since arriving at the facility. *The resident's call light was on for an hour. *The provider's follow-up comments included: -Education to staff on following bathing schedule. -Call light response time; strive for timely manner to answer. *No audits were included. Interview on 3/26/25 at 1:45 p.m. with Clinical care leader (CCL)/infection preventionist (IP) D regarding resident bathing revealed if no bath aide was available the certified nursing assistant (CNA) that was working on the floor providing resident cares would be responsible to provide the resident's bathing according to the bath schedule. Interview on 3/26/25 at 2:25 p.m. with Minimum Data Set (MDS) nurse C revealed: *The resident preferences related to bathing was documented in the Sit-Stand-Walk Data Collection Tool assessment in the EMR. -MDS nurse C completed this assessment quarterly. *CCL/IP D maintained the resident bath schedule and MDS nurse C believed she went by the preferences documented on the Sit-Stand-Walk Data Collection Tool assessment to make the bath schedule. *It was her expectation that the preferences documented in the Sit-Stand-Walk Data Collection Tool assessment be followed when scheduling the resident's bathing. Interview on 3/27/25 at 8:01 a.m. with CNA M revealed: *Residents usually received one bath per week. *There were times the bath aide was reassigned to work as a CNA on the floor to provide resident cares. *If the bath aide was reassigned to the floor each CNA would be responsible to complete the resident's bathing according to the bathing schedule. *She thought the bath aide was reassigned to work the floor at least one day per week. Interview on 3/27/25 at 8:22 a.m. with CNA P revealed: *There was a resident bathing schedule located in the nurses' station. *The residents' baths were to be completed by the CNA assigned to provide resident bathing for that shift. *There were times when a bath aide was not scheduled to work. *There were times the bath aide was reassigned to work on the floor to provide resident care. *If there was no bath aide scheduled the float CNA would usually complete the resident baths. *If there was no float or a bath aide the CNAs assigned to work on the floor were to complete the baths scheduled for that day. *In the last three weeks, on the days he had worked, there had been three or four times when no bath aide was available to complete the assigned residents' baths. *It was his expectation that call lights be answered as soon as possible. *He answered the bathroom call lights first. *He indicated that nurses and CNAs were responsible for answering the call lights. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *He expected residents' call lights to be answered by around five minutes. *He indicated it was everyone's responsibility to respond to call lights. Interview on 3/27/25 at 10:16 a.m. with CCL/IP D revealed: *She indicated the residents were interviewed regarding their bath preferences. *She was not aware who completed the interview, when the interviews were to be completed, or where to locate the information obtained during the interview. *Residents could discuss their concerns and preferences with staff or during care conferences. *It was her expectation that anyone could answer a call light. Interview on 3/27/25 at 10:37 a.m. with administrator A revealed: *That she expected staff do their best to accommodate resident choices. *Regarding grievances, she expected staff to follow policy, complete a thorough investigation, and complete periodic reevaluations after the initial grievance resolution. *She stated that anyone could answer a resident's call light. *She referred to the facility assessment when the staffing policy was requested. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *She expected staff to follow the bathing schedule. *She indicated it was everyone's responsibility to answer call lights. *She expected call light response times would be what the policy stated. *Call light response audits were periodically completed on a case-by-case basis. -The north call lights were able to be audited through the call light system. -The south call lights were audited by a leadership member by activating a call light and then waiting in the room and timing the response of the staff member to respond to the call light. Interview on 3/27/25 at 1:04 p.m. with CCL E regarding call light response times revealed: *She was responsible for the coordination of QAPI (quality assurance and performance improvement) for the facility. *The facility had identified call light response times as an area that needed improvement. -A performance improvement plan (PIP) was initiated regarding staff response times to resident call lights. --A trend was identified during this PIP of call light response times being the longest between 7:00 a.m. and 9:00 a.m. --The PIP was completed on 12/9/24. Review of the provider's 8/12/24 Facility Assessment revealed: *The assessment indicated: -The provider had appropriate staffing to meet the needs of the residents. -The acquity [acuity] & [and] needs of [the] residents were met by [The provider] monitors the acuity level and the PPDs [per patient day hours] of the facility. We ensure we have the appropriate staffing levels based on national and state averages. We ensure that if we have a high acuity level[,] we adjust staffing to meet the needs of the residents. -[Provider] utilizes an interdisciplinary approach to meet the needs of our population and its individuals across all shift[s] including nights and weekends, using data from MDS, case mix index, and considering care planned interventions . As the needs of the population change as indicated by the number of residents served, acuity levels, MDS results and care plans the staffing pattern is adjusted to meet those needs. We consider variability in care needs across day, evening and night shifts, including weekends and holidays, and adjust as necessary. We confirm needs are met by engaging in frequent communication with residents, their families and representatives with regular care conferences, rounding, quality assurance audits, resident group meetings, availability of suggestion/concern forms and email surveys. -The following is measured and monitored to ensure proper ongoing care and service meet resident needs. --Care plans, Care conferences/Family conversations, Medicare Meeting, continuous staff meetings, QAPI meetings, Quarterly and annual MDS assessments, resident council meetings, concern forms, and quality of life meeting. -Coordination and continuity of care is measured and monitored by Scheduling will be done. We will monitor through resident council and other means as well to ensure coordination and continuity of care is being done. Refer to F561.

Based on observation, interview, record review and policy review, the provider failed to ensure: *Two nurses had signed for the receipt of controlled medications (medications at risk for abuse and addiction) on the controlled drug record for five of five residents (6, 15, 21, 24, and 31) who were prescribed controlled medications *One prescribed controlled liquid medication concentration was documented on the Controlled Drug Record for one of one resident (31). *The destruction of fentanyl patches for one of one sampled resident (6) was accurately documented appropriately by individuals authorized to destroy controlled medications. Findings include: 1. Observation on 3/24/25 at 2:30 p.m. of the controlled substance binders on the south medication carts revealed: *A handwritten Controlled Drug Record identified as resident 15's for 24 lorazepam (a controlled anti-anxiety medication) 0.5 milligrams (mg) tablets did not indicate when the medication was received or who verified the receipt of the medication. *A Controlled Drug Record identified as resident 6's for 60 pregabalin (a controlled medication for nerve pain) 75 mg tablets delivered on 3/8/25 did not contain a pharmacy representative signature that documented the delivery of the controlled medication nor a nurse's signature that verified the receipt of the medication. 2. Observation on 3/26/25 at 11:30 a.m. of the controlled substance binders on the north medication carts revealed: *A handwritten Controlled Drug Record identified as resident 31's for 15 ml (milliliters) of morphine sulfate (a controlled pain medication) with no identified medication concentration, did not indicate when the medication was received or a signature of who verified the receipt of the medication. *A Controlled Drug Record identified as resident 24's for 60 tramadol (a controlled pain medication) 50 mg (milligrams) tablets delivered on 3/7/25 did not contain the signature of the nurse who verified the receipt of the medication. *A handwritten Controlled Drug Record identified as resident 24's for 4 patches of buprenorphine (a controlled medication to treat pain and opioid use disorder) 7.5 mcg (micrograms)/hr (hour) that did not indicate when the medication was received or a signature of who verified the receipt of the medication. *A Controlled Drug Record identified as resident 21's for 15 ml of morphine sulfate 100 mg/ml that did not contain the signature of the nurse to document the receipt of the medication. 3. Interview and review of the above controlled drug records on 3/24/25 at 2:48 p.m. with registered nurse (RN) G revealed she confirmed there were areas of documentation that had not been completed including signatures of receipt, dates of receipt, and a medication concentration. 4. Interview on 3/26/25 at 11:03 a.m. with RN S revealed: *Medications arrived from the pharmacy at about 6:00 p.m. *The night nurse was responsible for checking the medications in when received from the pharmacy transport person. *When the nurse received the medication from pharmacy transport person the nurse was to sign a form that was retained by the pharmacy and the Controlled Drug Record for that medication was then to be placed in the controlled substance binders on the medication carts. 5. Observation on 3/24/25 at 2:30 p.m. of the controlled substance binders on the south medication carts revealed: *Resident 6's Controlled Drug Record indicated she was to receive fentanyl 25 mcg/hr (controlled pain medication) topical patches every three days. *There was no documentation in the Controlled Substance Binder of the disposal of the fentanyl patches that were removed from the resident when another patch was applied. 6. Interview on 3/26/25 at 10:33 a.m. with RN S and unlicensed medication aide (UMA) L regarding used fentanyl patch destruction revealed: *Resident 6's fentanyl patch was scheduled for removal every three days on her medication administration record (MAR). *When the fentanyl patch was removed from the resident, it was to be destroyed by two people and documented in a nurse's note within the scheduled removal area in the MAR. *RN S stated resident 6's fentanyl patch had been removed that morning and she had witnessed its disposal in the medication destroyer product container in the medication cart. *RN S reviewed resident 6's nurse's notes and confirmed there was no documentation the fentanyl patch was destroyed. *RN S stated the process she had described was her practice to cover myself from suspicion of drug diversion. *She clarified two nurses did not sign the removal and destruction of the fentanyl patch, but rather the nurse that was charting in the MAR would indicate who witnessed the destruction. 7. Review of resident 6's electronic medical record (EMR) revealed: *She had a physician's order for fentanyl Transdermal [through the skin] Patch 72 Hour 25 MCG/HR (Fentanyl) Apply 1 patch transdermally one time a day every 3 day(s) related to OTHER LOW BACK PAIN. *Resident 6's MAR included and area for documentation of the application and removal of the fentanyl patch at 10:00 a.m. every third day. *Review of resident 6's March 2025 nurses notes revealed: -On 3/17/25 a nurse's note included, removed patch from RUQ [right upper quadrant] [of the abdomen], lead social service coordinator T in SWS [social work services] witnessed waste [destruction]of patch. -On 3/23/25 a nurse's note included, CMA UMA L witnessed this nurse placing previous [fentanyl]patch in liquid waste container, --Per Administrative Rules of South Dakota (ARSD) the destruction or disposal of controlled medications were witnessed by two persons, both of whom must be a nurse or pharmacist. -There was no documentation to support the fentanyl patch was destroyed or there was a witness to the destruction on 3/2, 3/5, 3/8, 3/11, 3/14, or 3/20. 8. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *A fentanyl patch should be destroyed by two nurses. *He was unable to identify where the destruction by two nurses was to be documented. 9. Interview on 3/27/25 at 9:41 a.m. with social service director (SSD)/certified social worker (CSW) I and SSD/CSW J revealed that lead social service coordinator T was not a licensed nurse. 10. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *She expected when a controlled substance arrived from the pharmacy, the pharmacy form and the Controlled Drug Record were to be signed by the pharmacy courier and the nurse that received the medication after the medication and count were verified as accurate. *She expected the fentanyl patches to be destroyed according to the provider's policy. 11. Review of the provider's 3/4/25 Medications: Acquisition and Receiving Dispensing and Storage policy revealed: *An employee will be responsible for signing for receipt of medication and obtaining the signature of the delivery person. It is preferred that a licensed nurse receive and verify the medications . Licensed nurses and medications aides (when allowed by state law) are responsible for reconciling medications received. *These medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed. Review of the provider's 6/27/24 Medications: Controlled policy revealed: *Reconciliation: refers to a system of recordkeeping that ensures an accurate inventory of medications by accounting for controlled medications that have been received, dispensed, administered and/or, including the process for disposition. *The location will along with their consultant pharmacist will establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation that determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled and meets all state and federal requirements for controlled medications. *When a new controlled medication is delivered, the nurse in the skilled nursing facility will be responsible for counting the medication, Schedule II medications require an Individual Resident's Narcotic Record . or in the Controlled Substance Bound Book. *Disposal of any medication will be carried out under local, state and federal guidelines or in consultation of the pharmacist for the appropriate disposal procedure. Documentation of medication disposal will be made using the [providers' form] or Controlled Substance Bound Book and will include the resident's name, medication name, prescription number (as applicable), quantity disposed, date and method of disposition and the involved nurse (s), consultant or other applicable individuals per state regulations. Review of the provider's 9/3/24 Medication: Disposition (Disposal) policy revealed: *Disposal of any medication will be carried out under local, state and federal guidelines or in consultation of the pharmacist in the appropriate disposal procedure. Documentation will include the resident's name, medication name, prescription number (as applicable), quantity, date of disposition and the involved staff member, consultant or other applicable individuals. *For Controlled substances, two nurses or a nurse and a med [medication] aide must witness the destruction, document on the Individual Resident's Narcotic Record [provider's form number], or in the Controlled Substance Bound Book, to ensure accuracy of the count. Document in [the] medical record the reason for the destruction.

Based on observation, interview, record review, policy review, and manufacturer's recommendations review, the provider failed to ensure a medication error rate of less than 5 percent related to: *A topical pain medication was not applied according to the manufacturer's recommendations for two of two sampled residents (18 and 42) by one of one observed registered nurse (RN) (S). *An oral medication was given to one of one sampled resident (42) without a physician's order by one of one observed RN (S). Those observations created a medication error rate of 10.71%. Findings include: 1. Observation and interview on 3/26/25 from 7:42 a.m. through 8:28 a.m. of registered nurse (RN) S during medication (med) administration revealed: *She dispensed an unknown amount of diclofenac sodium external gel 1% (for arthritis pain and inflammation) into a med cup and administered the gel to resident 18's right lower chest. -The order on resident 18's medication administration record (MAR) indicated she was to receive two grams of the gel. *She dispensed an unknown amount of diclofenac sodium external gel 1% into a med cup and administered the gel to resident 42's left elbow, right knee, and both wrists. -The order on resident 42's MAR indicated she was to receive two grams of the gel to her hands and knees two times a day. *When asked how she knew she was administering the correct dose she stated she thought two grams was about 2.5 cc's [cubic centimeters]. -She read the box for the diclofenac sodium gel and said, Maybe that's just a guess. *She administered vitamin C 1,000 milligrams by mouth to resident 42. -There was no order on resident 42's MAR for the vitamin C. -She indicated the administration of the vitamin C without an order was a medication error. 2. Interview on 3/27/25 at 8:44 a.m. with licensed practical nurse (LPN) K revealed: *The measuring device that was included in the box with the diclofenac sodium 1% gel was to be used to determine the dose of the gel to be administered. *He agreed the measurement device remained secured to the diclofenac sodium 1% gel box that was stored in the medication cart. *He agreed the tube in that box was partially empty. *He indicated that some staff members do not use the device when they administered the medication. 3. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed it was her expectation: *That the measurement device in the diclofenac sodium 1% gel be used to determine the dose of the medication prior to administration to a resident. *That the correct dose of medication was to be administered. *That staff follow the Six Rights of medication administration and follow their policy. 4. Review of the manufacturers' 10/22 recommendations for the diclofenac sodium 1% gel revealed: *User Guide -Remove the dosing card from the inside of the carton. You should always use the dosing card to measure out the correct dose of diclofenac sodium topical gel. 5. Review of the provider's 3/4/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *Procedure -Review the MAR for medications due. -Follow the Six Rights: Right medication, right dose, right resident, right route, right time, and right documentation. -Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication.

Based on observation, interview, and record review, the provider failed to ensure: *Medications for two of two residents (28 and 12) were properly labeled. *Medications for four of four residents (28, 50, 6, 12) were dated when opened. *Temperatures for two of two medication rooms (north and south) were monitored for acceptable medication storage temperatures according to the provider's policy. *Expired nutritional supplements and supplies were removed from two of two medication rooms (north and south). Findings include: 1. Observation and interview on 3/24/25 at 2:40 p.m. of a south medication cart with registered nurse (RN) G revealed: *There was a plastic bag with resident 28's identifying information on the outside of the plastic bag. -In the plastic bag was a Levemir (long-acting) insulin pen. --The Levemir pen did not have a resident's name on the label. --It was marked as opened on 2/11/24. *RN G verified the date the Levemir was opened was marked 2/11/24 and there was no resident name on the insulin pen. *She indicated a medication should be labeled with a resident's name to determine who the medication belonged to. *She indicated resident 28 no longer received Levemir. *Resident 28's Latanoprost eye drops (medicated eye drops for glaucoma) had a label on the box that instructed to discard 42 days after opening. -There was no date documented to indicate when the Latanoprost was opened. *Resident 50's Latanoprost eye drops did not indicate a date when it was opened. *Resident 6's Breo Ellipta inhaler (used to treat asthma and chronic breathing issues) had a label on the box that instructed to discard 42 days after opening. -The location on the label for the date the medication did not indicate a date when it was opened. *Resident 12's Breo Ellipta inhaler did not indicate a date when it was opened. *RN G verified resident 28's and 50's Latanoprost eye drops did not contain documentation to indicate when the eye drops were opened. *RN G verified resident 6's and 12's Breo Ellipta inhalers did not indicate when the inhalers were opened. *RN G stated she was aware of some medications that had shortened expiration dates after the medication was opened or removed from the refrigerator. *She verified she would not be able to determine when the expiration on the medications with the shortened expiration dates expired if there was no date documented on the medications. 2. Observation on 3/26/25 at 10:47 a.m. of the South medication room with RN S revealed: *Temperature logs for two refrigerators that were complete. *There was no thermometer in the South medication room. -There was no temperature log to record the temperatures of the medication room. *A lock box for controlled substances in a refrigerator where food was stored. *Five bottles of Pro-Stat (a protein supplement drink) with an expiration date of 11/14/24. *A bottle of hydrogen peroxide labeled as opened on 4/24/24 with an expiration date of 10/24. *Two bottles of Prosource (a protein supplement drink) with an expiration date of 12/5/24. *Two 14 Fr (French) (measurement of the diameter of catheters and other medical tubes) urinary catheter (a flexible tube inserted into the bladder to drain urine) with an expiration date of 1/31/25. *A partial box of 10cc syringes with an expiration date of 12/1/24. 3. Observation and interview on 3/26/25 at 11:17 a.m. of a South medication cart with unlicensed medication aide (UMA) L revealed: *A Voltaren gel (a topical medication for arthritis pain and inflammation) box that had [a resident's first name] #1 handwritten on it. -There was no pharmacy label with the medication's dosage, instructions, or the resident's identification. -There was no date documented on the medication to indicate when it was opened. *UMA L stated that the Voltaren gel belonged to resident 12. -She stated the resident's family provided the medication. 4. Observation and interview on 3/26/25 at 11:38 a.m. with clinical care leader (CCL)/infection preventionist (IP) D in the north medication room revealed: *Temperature logs for two refrigerators that were complete. -There was no temperature log to record the temperatures of the medication room. *A bin of 60cc syringes with an expiration date of 12/2014. *Nurses and medication aides were assigned to check for outdated supplies and medications in the medication rooms and the medication carts once a month. *There was no formal process for the staff assignment or completion of that task. *She verified the temperatures were not monitored or documented in the north or south medication rooms. 5. Interview on 3/27/25 at 8:45 a.m. with licensed practical nurse (LPN) K revealed: *If a medication was brought from home by a resident or a resident's family, staff would encourage the medication to be taken back home with the resident's family. *When he administered medications, he expected the medication to have a pharmacy label that contained the medication name, administration information, and the dispensing pharmacy. *He verified that he would not be able to compare the administration information on the medication with the medication administration record (MAR) on resident 12's unlabeled Voltaren gel. 6. Interview on 3/27/25 at 12:18 p.m. with director of nursing (DON) B revealed: *Medications brought in by residents' families was generally discouraged but is addressed on a case-by-case basis. *If a medication was brought in by a resident's family and the medication must be used by the facility the pharmacist would work with the facility to reconcile the medication. *It was her expectation that those medications be labeled with resident and medication information in order to complete the six rights of medication administration and the three checks during administration. *It was her expectation that medications be dated when opened. *She had not been aware the temperatures of the medication rooms needed to be monitored for safe storage conditions per the facility policy. 7. Review of the provider's 3/4/25 Medications: Acquisition Receiving Dispensing and Storage policy revealed: *The resident may secure prescriptions from the pharmacy of his/her choice when not receiving Medicare A services. *Licensed nursing employees are responsible for ordering from the pharmacy (except Schedule II medications) and checking all new orders of medications from the physician's orders. *An employee will be responsible for signing for receipt of medication and obtaining the signature of the delivery person. It is preferred that a licensed nurse receive and verify the medications . Licensed nurses and medications aides (when allowed by state law) are responsible for reconciling medications received. *The location will routinely check for expired medications and necessary disposal will be done in accordance with state/pharmacy regulations. *Refrigerators holding medications (such as insulin, etc) will be kept between 36 [degrees] F [Fahrenheit] and 46 [degrees] F. Medication rooms will be kept between 59 [degrees] F and 86 [degrees] F. Check refrigerator temperatures once in the morning and once in the evening. *Although it is not recommended to store medications with food, if this is done, medications should be kept in closed, labeled containers or compartments with internal and external medication separated; and separate from fruit juices, applesauce and other foods. *Controlled drugs (Schedule II) and other drugs subject to possible abuse will be stored in separate, locked, permanently fixed compartments, except when a single unit package drug distribution is used. If the medication requires a refrigerator, these need to be locked in a separate container. These drugs will be reconciled at least daily through an appropriate system of records of receipt and disposition established by the licensed pharmacist. *These medications must be labeled according to state pharmacy regulations. Cautionary and accessory instructions, as well as the expiration date, will be included. New labels will be applied by the pharmacist or the pharmacist's agent as needed. *If a medication is not available, please document discussion per #6 of the Local Pharmacy Medication Ordering - R/S, LTC procedure with the physician in the PN-Communication/Visit with Physician/EMR. If a medication is not available from the pharmacy when the order is received, contact the prescriber to determine if a different medication is needed or to determine the time frame acceptable to wait for the medication. 8. Review of the provider's 3/4/25 Medication: Administration Including Scheduling and Medication Aides policy revealed: *Procedure -Review the MAR for medications due. -Follow the Six Rights: Right medication, right dose, right resident, right route, right time, and right documentation. -Perform three checks: Read the label on the medication container and compare with the MAR when removing the container from the supply drawer, when placing the medication in an administration cup/syringe and just before administering the medication.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the South Dakota (SD) Department of Health (DOH) facility reported incident (FRI), observation, interview, record review, and policy review, the provider failed to ensure a secure environment by silencing alarms on 2 of 8 egress doors located on the north and south units. Findings include: 1. Review of the SD DOH FRI on 2/21/24 at 8:30 a.m. revealed: *A physical environment complaint resulting in an elopement of a resident. *A resident eloped from an alarmed door, but the alarm was silenced when the door closed. *The resident was outside the facility for 6 minutes. *The temperature at the time of the incident was in the 40s and the resident was wearing a light jacket. *The resident was found by a nurse going to lunch. *The resident had no history of elopement. 2. Observation on 2/21/24 at 8:50 a.m. of the east egress door on the south unit revealed: *A camera was located above the door on the ceiling. *An alarm sounds sign was painted on the top part of the glass door. *A keypad required a numerical code on the wall next to the door when exiting the facility. -A push bar located on that same door that activated the opening of the door. *A second keypad with the addition of a push button was on the opposite side of that door and was located on the wall. *A short 4-to-5 foot passthrough led to another door that led to the outside of the facility. 3. Observation on 2/21/24 at 9:00 a.m. of the north egress door on the north unit revealed the same set up as the south unit's east egress door. 4. Observation and interview on 2/21/24 at 9:20 a.m. with resident 1 revealed she: *Was sitting up in her bed eating her breakfast. *Had a WanderGuard [a device used to monitor the movement of residents that were an elopement risk; the device i was worn on the wrist like a bracelet or on the ankle] placed on her right wrist. *The WanderGuard was placed a couple of weeks ago. -Was attempting to take a shortcut to the activities room to play Bingo. -Went through the wrong door and ended up outside. *Remembered hearing the alarms going off, but she kept going through the door. *Realized she took a wrong turn when she ended up outside. -Stated it was chilly outside, but was wearing a light [NAME] jacket. *Was escorted back inside by an employee. -Understood why he thought she was trying to run away, but she just wanted to get to bingo. -Bingo was her favorite game and because of her mistake, she had to wear that stupid bracelet. 5. Interview on 2/21/24 at 9:50 a.m. with ancillary manager C revealed: *Door checks were done on a weekly basis in a system he used called TELS. -The application was downloaded to his cell phone for easy use. *A WanderuGard was used to check the alarms and locking mechanisms on the doors. *He demonstrated how to perform a door check in the TELS system. *It was the responsibility of the nursing staff to check the individual resident's WanderGuard function. 6. Observation and interview on 2/21/24 at 10:16 a.m. with administrator A and ancillary manager C regarding the double doors on the south unit that led to the independent living side of the building revealed: *An alarm sounds sign was posted on the metal doors. *A keypad required a numerical code on the wall next to the door when exiting the facility into a corridor that led to the independent living center. *A keypad with the addition of a push button was located on the opposite side of the double doors that was located on the wall. *A push bar was used to activate the opening of those doors. *If the keypad was not used before opening the doors, the push bar would have to be activated for 15 seconds before the door lock mechanism would release allowing the doors to open. -The door alarms would sound during that time and could only be silenced by entering the code on the keypad. *Administrator A purposely activated the alarm. *A timer was started to observe how long it would have taken staff to respond to the alarm. *Administrator A's expectation was for staff to respond to the alarm immediately. *Ten minutes passed before ancillary manager C arrived to disarm the alarm. *He did not hear the alarm until he begun rounding the corner to the location which was approximately 87 feet from the double doors. -He had some hearing damage to one of his ears from previous trauma have which might have affected the hearing of the alarm. *Ancillary manager C silenced the alarms with the keypad. *Administrator A and ancillary manager C both agreed the volume on the door alarm should have been louder. -Ancillary manager C confirmed the same volume was set on both the east egress door on the south unit and the north egress door on the north unit. *Ancillary manager C confirmed the volume on the alarm system was adjustable. 7. Observation and interview on 2/21/24 at 10:45 a.m. with administrator A and ancillary manager C regarding the east egress door on the south unit revealed: *When the push bar on the door was activated, there was no delay in opening the door. *The alarm sounded when the door was opened without using the keypad located on the wall. -The alarm did not sound if the keypad was used. *The alarm was silenced when the door closed. *A second keypad with an addition of a push button was on the opposite side of that door and it was located on the wall. -That keypad and push button were used to operate the door if an individual was entering the facility from the outside. *A short 4-to-5 foot passthrough that led to another door that led to the outside of the facility. -That door was not secured by a lock or a keypad and opened freely. *If the numerical keypad code was not used prior to opening the door, the alarm would sound and would silence once the door closed between the hours of 7:30 a.m. to 4:00 p.m. Monday through Friday. -The only time the door alarm would continue to sound during that adjusted setting time frame would have been if the individual was wearing a WanderGuard. *Ancillary manager C tested the door alarm with a WanderGuard. *The door alarm sounded when he did not use the numerical keypad code prior to opening the door. -When he did not use the numerical keypad code prior to pushing the door open, the door alarm sounded. *The adjusted setting was implemented for family or visitors that came through the door without using the numerical keypad code. *It was becoming a nuisance to have to silence the alarm manually each time someone did not use the numerical keypad code. -The adjusted setting was used as a convenience. *The north egress door on the north unit was set up to function the same way. *Resident 1 exited the facility during the adjusted setting on 2/9/24 at 12:50 p.m. -She was outside for 6 minutes when a staff member saw her outside of the window while going to lunch. *At that time, resident 1 was not wearing a WanderGuard. *It was administrator A's expectation that staff would still check if a resident exited the facility even though the alarm silenced once the door was closed during the adjusted time frame. *The charge nurse should have performed a headcount of the residents and followed the process on the elopement checklist if a resident was missing. *Administrator A confirmed that when resident 1 exited the facility, staff had not followed the elopement checklist. 8. Interview with administrator A on 2/21/24 at 11:45 a.m. revealed: *She provided an example of the elopement checklist. *Staff were educated on the checklist during various training opportunities and it was located in a binder at the 2 nurses' stations. *She was unable to provide documentation of that education as she had given verbal education on the topic. 9. Interview with administrator A on 2/21/24 at 11:52 a.m. revealed: *She provided documentation of staff education that was performed on 2/15/24. *The agenda showed 8 items listed. *There was a separate sheet that was not included on the agenda that listed elopement policy and procedure and had a handwritten addition listing checklist binder. *She had not finished the education as that was an ongoing process. *Staff that were unable to attend the staff meeting were shown the education on the days when they arrived to work and signed the signature sheet at that time. 10. Interview with activities supervisor E on 2/21/24 at 1:06 p.m. revealed: *On Bingo days, she usually went to get resident 1. -Sometimes the resident would meet her halfway to the activities room. *On 2/9/24 around 1:00 p.m. resident 1 decided to make her way to bingo on her own. *Bingo was held in the activities room and scheduled to begin at 2:00 p.m. *Resident 1 was embarrassed after the incident and was making jokes about her new bracelet. 11. Interview on 2/21/24 at 2:30 p.m. with administrator A, director of nursing (DON) B, ancillary manager C, and administrator F revealed: *Administrator F would be filling in for administrator A when she goes on vacation for the next 2 weeks. *The doors that have the adjusted setting time frame went back to it's regular setting at 4:00 p.m. on weekdays and was not implemented on the weekends. *Ancillary manager C has a meeting tomorrow with the door alarm system project manager to re-evaluate the adjusted setting. *They agreed the volume of the door alarms were not loud enough for staff to hear if they were on the opposite side of the unit. *They would be addressing the volume of the door alarms with the door alarm system project manager. *The adjusted settings time frame was more convenient for resident family members to enter the facility without having to use the front entrance. *They would be looking into a solution that would accommodate both the families of the residents and for resident safety. Review of the provider's 8/22/23 Alarms: Bed, Chair, and Door Rehabilitation/Skilled Care policy revealed Procedure: 3. All staff will be responsible for physically checking on the resident when an alarm goes off.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (112) had a documented diagnosis and was assessed for the removal of her Foley catheter. Findings include: 1. Observation and interview on 10/31/23 at 12:15 p.m. with resident 112 revealed she: *admitted after a fall in the community which required orthopedic surgery. *Was non-weight bearing (NWB) on her right leg. *Participated in physical therapy and was making progress with her physical mobility. *Had a Foley catheter bag attached to her wheelchair. -Had not required the use of a catheter before her surgery. Observation on 11/01/23 at 4:50 p.m. of resident 112 revealed she: *Was seated in a wheelchair in the doorway between her bathroom and her room. *Had activated her bathroom call light for staff to help her pull up her pants after she had used the toilet. *Had not waited for staff assistance before she transferred herself from the toilet to her wheelchair independently. *Her catheter bag hung to the side of her wheelchair and contained amber-colored urine. Interview on 11/1/23 at 4:51 p.m. with licensed practical nurse F regarding resident 112 revealed: *Staff had assisted her onto the toilet a few minutes before she activated her bathroom call light for staff assistance to get off the toilet. -She had not waited for staff to return to help her after she activated her call light before she transferred herself from the toilet to her wheelchair. *LPN F thought resident 112 had a Foley catheter because she had urinary retention and because she was at risk for urinary tract infections (UTIs). Review of resident 112's care plan last revised on 10/30/23 revealed no indication she had a Foley catheter. Review of resident 112's electronic medical record revealed: *A 10/25/23 surgical hospital Discharge Summary: -The resident had an open reduction and internal fixation (ORIF) of her right knee joint on 10/19/23. -She was NWB on her right leg. - .Keep Foley [catheter] as unable to get OOB (out of bed) yet at this time. Good Foley care and likely be able to dc [discontinue] in next few days. -A physician's order to continue taking an oral antibiotic for the treatment of a UTI. *A 10/25/23 Nursing Home History and Physical completed by her primary care provider revealed: -In addition to the UTI referred to above resident 112 had vaginitis [an inflammation of the vagina] which was being treated with a second antibiotic medication and an antifungal medication. *Review of Systems: Genitourinary: Positive for vaginal discharge. Had occasional incontinence at home. Foley catheter was placed for immobility. *A 10/25/23 physician's order summary: Foley Catheter Cares each shift. ALLERGIC to LATEX. Interview on 11/2/23 at 10:10 a.m. with clinical care coordinator C revealed: *She was an admission nurse and the Infection Preventionist. -She assisted with resident 112's nursing home admission on [DATE] and was aware the resident had a Foley catheter. *A Catheter Diagnosis Request was expected to have been completed and sent to the resident's primary care provider (PCP) the day of her admission or the day after admission. -The purpose of that request was for the PCP to have identified the medical diagnosis(es) which had required resident 112 to have had a Foley catheter. *No completed Catheter Diagnosis Request was found for resident 112. *Immobility referenced in the 10/25/23 History and Physical referred to above was not an appropriate diagnosis for the use of a catheter. *If there had been no appropriate medical diagnosis for the use of the resident's catheter a plan for the removal of that catheter was expected to have been discussed with the PCP) *Anytime we have the ability to discontinue a catheter we should. Catheters cause a lot of UTI's. We don't want it [the catheter] for too long. -Eight days had been too long for resident 112 to have had her Foley catheter without having initiated a plan for its removal. Review of the 11/28/22 Urinary Catheter policy revealed: *Insertion: 1. An order and indication is required for an indwelling foley insertion. *Removal: 1. Remove Foley catheter when no longer indicated.

5. Observation on 11/1/23 at 12:10 p.m. during the noon meal with food service assistant G revealed: *Without sanitizing her hands she: -Touched the paper menu. -Grasped the top of the plate with her hand to serve food. -Touched the inside of a bowl with her thump, and then served the soup. Interview on 11/1/23 at 12:15 p.m. after food service with lead cook I revealed: *The food service process was for the server to pick up menus to view resident's preferences and then serve the food. *They do not sanitize between menus and flatware. *Servers were not to touch the eating surface of flatware or bowl when serving resident's food. Interview on 11/1/23 at 2:00 p.m. with nutrition and food service supervisor E revealed: *Touching the eatable surface of flatware or bowls during resident food service was not acceptable. *They have no process in place for sanitizing employees hands after touching the resident's menus and then touching the serving dishes. Review of revised July 21, 2023 Dining Service Standards-Food and Nutrition Services policy revealed: *Procedure: -Follow procedures for prevention of foodborne illness when serving meals (e.g., never touching ready-to-eat foods with bare hands; never touch the eating surface of utensils and dishware). 4. Observation and interview on 11/01/23 at 9:27 a.m. with LPN F during glucometer use and a medication administration observation for resident (20) revealed: *The glucometer was in a black cloth zipper case and was taken from the medication cart into the resident's room and placed on her dresser. *The glucometer was removed from its cloth case and placed on a barrier. *After the glucometer use was completed, it was taken out of the resident's room wrapped in the used barrier and placed on top of the medication cart along with its cloth case. *The glucometer was cleaned and placed back into its cloth case and placed back into the medication cart. *The eye drop bottle was taken out of its box, placed in his scrub top pocket, and taken into the resident's room. *He used hand sanitizer, placed a pair of gloves on his hands, and then removed the eye drop bottle from his scrub top pocket then administered the resident's eye drops. *After the eye drop administration, he returned the eye drop bottle into his scrub top pocket and returned to the medication cart. *The eye drop bottle was returned to its box and placed into the med cart. *He agreed he should not have taken the cloth glucometer case into the resident's room, or he should have placed it onto the barrier as it was a non-wipeable surface. *The nurse agreed his scrub top pocket was not a clean surface and he should not have transported the resident's eye drop bottle in his scrub top pocket and removed the eye drop bottle from his scrub top pocket after he performed hand hygiene and placed gloves before he administered the resident's eye drops. Interview on 11/02/23 at 10:07 a.m. with CCC C revealed: *She was the infection preventionist. *She agreed that LPN F should not have taken the glucometer case that was cloth and a non-wipeable surface into a resident's room placed it on the dresser without a barrier and then returned it to the medication cart. It was a breach of infection control. *She agreed that transporting an eye drop bottle in a scrub top pocket into a resident's room and removing it from the scrub top pocket was a breach of infection control. *She reported she planned to remove the glucometers from their cloth cases, place the glucometers in zip lock bags that were changed out weekly, and provide staff education that the glucometers were to have been removed from the baggies while at the medication cart and not taken into the resident rooms. Review of the provider's 9/22/2023 Blood Glucose Monitoring, Disinfecting and Cleaning policy revealed: *Purpose -To provide proper cleaning methods for glucose meters and to avoid cross-contamination issues. --2. Cleaning and disinfecting can be completed by using a commercially available EPA-registered disinfectant or germicide wipe. Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for the following: *Appropriate glove use by one of one licensed practical nurse (LPN) (F) during skincare treatments for two of two sampled residents (36) and (44). *A water management program (WMP). *Appropriate handling of a glucometer in a cloth case by one of one LPN (F) during a blood sugar check for one of one sampled residents (20). *Appropriate handling of an eye drop bottle by one of two LPN (F) during medication administration for one of two sampled residents (20). *Appropriate handling of plated food during food service. Findings include: 1. Observation on 10/31/23 at 12:40 p.m. in resident 44's room revealed: *Certified nurse aide (CNA) L and occupational therapist M assisted the resident to sit at the edge of her bed to prepare her for a wheelchair transfer. -CNA L noticed blood on the resident's back which the resident stated had been caused by scratching her back. -The back of the resident's shirt had small tears which appeared to have been caused by her nails. *LPN F was called into the resident's room and: -With gloved hands he cleansed the open areas on her back and patted them dry with a gauze pad. -The gauze pad was light red in color from the blood on her back. -Without changing his gloves, or performing hand hygiene, and putting on a new pair of gloves he applied a clean bandage to the resident's back. 2. Observation and interview on 10/31/23 at 3:46 p.m. with LPN F in resident 36's room revealed he: *Performed hand hygiene, put on a new pair of gloves, and cleansed opened areas on the inner aspect of her left ankle, her left lower leg, and her right breast. -He had not changed his gloves, or performed hand hygiene, and put on a new pair of gloves after he had cleansed each of the skin areas referred to above but agreed he should have. -The same practice should have been observed during the skin care observation referred to above with resident 44. Interview on 11/1/23 at 12:30 p.m. with clinical care coordinator (CCC) C regarding the skin treatments performed by LPN F referred to above revealed she: *Was the infection preventionist. *Expected LPN F to have removed his gloves, performed hand hygiene, and put on a clean pair of gloves after cleansing resident 44's back and before applying a new bandage. *Expected LPN F to have removed his gloves, performed hand hygiene, and put on a clean pair of gloves: -After he cleansed resident 36's foot and before he cleansed her left leg. -After he cleansed her leg and before he cleansed her right breast. *Changing gloves after cleansing the skin and before applying a clean dressing reduced the risk of an infection occurring. Review of the 3/29/22 Hand Hygiene policy revealed: *Glove use: -Change gloves when moving from a dirty to a clean or sterile activity performing hand hygiene in between changing gloves. 3. Interview on 11/2/23 at 11:45 a.m. with maintenance director D regarding the WMP revealed: *He had been in his current position for six weeks. *The provider used a computer-based program called TELS which included a WMP prevention program. -That program had not been implemented by the previous maintenance director. *Maintenance director D had not yet implemented that system either but was aware he needed to. Interview on 11/2/23 at 12:05 p.m. with senior director A regarding the WMP revealed she had: *Expected the TELS system to have been used as the provider's WMP. -Not been aware the previous maintenance director had not followed that expectation. -Trusted that process was occurring but had not ensured it was implemented. Review of the undated Water Management Plan Process Summary revealed: *The Good Samaritan Society has moved from a reactive WMP to a prevention [controlled] WMP that included scheduled review, monitoring, and/or maintenance of the following: -Domestic water temperatures. -Cold water main temperatures and chlorine residual testing. -Commercial water temperatures. -Flushing of water systems in unoccupied rooms. -Ice machines. -An annual site WMP.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview on 11/1/22 at 3:47 p.m. with resident 36 revealed he: *Was alert, hard of hearing, and able to understand and answer simple questions. *Denied any concerns and stated he did not want to talk long because he was going to an activity. *Was sitting in a wheelchair and wearing a shirt, basketball shorts, and slip on shoes. -Had white compression stockings on both legs that went from his feet extending to his upper thighs. -There was a moderate amount of edema to both lower legs from his feet to above his knees. *Became short of breath while talking with this surveyor causing him to pause for air. Review of resident 36's medical record included the diagnoses of: generalized edema, cardiac murmur, bradycardia, atrial flutter, persistent atrial fibrillation, hypertension, endocarditis, hypo-osmolality (low electrolytes, protien, and nutrients) and hyponatremia (low blood sodium), abnormal weight loss, vascular dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Review of resident 36's Order Summary Report included: *A 9/24/20 order, Daily weights-edema to lower legs-UNTIL stabilizes-in the morning for monitoring. *A 3/4/22 order, Thigh High compression stockings ON in AM; OFF at HS (hour of sleep) in the morning and bedtime for edema prevention. *A 1/10/22 order, Lasix 20 milligrams by mouth one time a day every Monday, Wednesday, and Friday for diuretic related to generalized edema. Review of resident 36's revised 10/6/22 care plan revealed: *Focus: -The resident has potential fluid volume overload E/B [as evidenced by] generalized edema. *Goal: -Resident will remain free of s/s [signs and symptoms] of fluid overload through review date, as evidenced by no pitting edema, weight WNL [within normal limits] as prescribed by doctor. --There were no normal limits of weight identified and when to notify the doctor of weight gains. *Interventions: -Weigh: daily -SUPPORT STOCKINGS: Apply and/or remove AM and HS-requires assistance from staff Review of resident 36's 9/2/22 through 11/2/22 Daily Weights and Vitals Summary revealed: *Daily weights had not been recorded on nine days: 9/4, 9/5, 9/6, 9/11, 10/8, 10/12, 10/14, 10/15, and 10/16/22. *His weights had fluctuated between a low of 183.6 on 9/21/22 and a high of 196.0 on 11/2/22. -This was a 12.4 pound weight gain in two month's time. Review of resident 36's nursing progress notes from 9/2/22 through 11/2/22 revealed there was no documentation the provider had been notified of his weight fluctuations or to seek clarification of his normal weight limits. Interview on 11/3/22 at 1:50 p.m. with licensed practical nurse's (LPN's) H and I regarding resident 36's daily weights revealed: *They had been unable to clarify if it was his weight or his edema that was being monitored. *There had been no clarification on when to notify the provider. -LPN H stated she would normally monitor a resident's weight and notify the provider if there was a weight gain. *They were unable to recall if a provider had been notified about clarifying his weight orders. Interview on 11/3/22 at 4:47 p.m. with DON B regarding resident 36's daily weights revealed: *She would have expected the nurse to reach the provider to get guidelines on weight limits. -There should be a weight parameter set by the provider. *We need to streamline a better process. 3. Review of the revised 12/02/21 Physician/Practitioner Orders policy revealed: *Purpose: To provide a procedure that facilitates the timely and accurate processing of physician/practitioner orders. Review of the revised 4/26/22 Notification of Change policy revealed: *Policy: A facility must immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative(s) when there is: -3. A need to alter treatment significantly-a need to discontinue or change an existing form of treatment or to commence a new form of treatment. Refer to F692. Based on observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident's (45) physician order (PO) for daily weight monitoring and physician notification of weight gains greater than two pounds (lbs.) in a 48-hour timeframe had been followed. *One of one sampled resident's (36) PO for weight monitoring had been clarified for weight parameters and physician notification by nursing staff. Findings include: 1. Observation and interview on 11/1/22 at 10:30 a.m. and on 11/2/22 at 3:20 p.m. with resident 45 and his spouse revealed: *He was admitted on [DATE] from a local hospital following treatment for congestive heart failure (CHF). *They had not known if any specific interventions such as fluid restriction or weight monitoring had been implemented relating to his CHF diagnosis. Review of resident 45's medical record revealed his diagnoses included: heart failure, chronic obstructive pulmonary disease, Parkinson's disease, ischemic cardiomyopathy, and arteriosclerotic heart disease. Review of resident 45's 11/2/22 Order Summary Report revealed: *The following POs had started on 9/28/22: -Weights and Vitals: Assess lung sounds, peripheral edema, respiratory effort, and weight daily. -Call CHF Clinic provider/practitioner for weight gain greater than two lbs. in 48 hours or if five lbs. over admission weight every day shift. Review of resident 45's 9/28/22 through 11/2/22 Weights and Vitals Summary report revealed: *Daily weights had not been recorded on 10 days: 9/30/22, 10/10/22, 10/16/22, 10/17/22, 10/20/22, 10/22/22, 10/23/22, 10/29/22, 10/31/22, and 11/1/22. *Weight gains of greater than two lbs in a 48-hour timeframe were documented between: -10/1/22 (144 lbs) and 10/3/22 (151.8 lbs), a gain of 7.8 lbs. -10/4/22 (148.6 lbs) and 10/6/22 (150.8 lbs), a gain of 2.2 lbs. -10/15/22 (150.3 lbs) and 10/18/22 (152.4 lbs), a gain of 2.1 lbs. --No weight had been recorded on 10/17/22. -10/19/22 (152.4 lbs) and 10/21/22 (155 lbs), a gain of 2.6 lbs Review of resident 45's nurse progress notes between 9/28/22 and 11/2/22 revealed no documentation the CHF Clinic provider/practitioner had been called regarding the weight gains referred to above. Interview on 11/3/22 at 1:45 p.m. with registered nurse J regarding resident 45's weight monitoring revealed: *His weights were expected to be recorded daily by a licensed nurse. *She used his previous day's weight to compare to the current day's weight to identify weight changes that might require physician notification. -She had not monitored his weight according to the physician's order, but should have been. Interview and review on 11/3/22 at 4:40 p.m. of the 9/28/22 through 11/2/22 Weights and Vitals Summary report for resident 45 with director of nursing B revealed: *There were 10 days his weight had not been documented per the PO. *There were four times he had weight gains greater than two lbs in a 48-hour timeframe without documentation to support a nurse had called the CHF Clinic provider/practitioner. *His weight had not been monitored per the PO, but should have been. -That had been the responsibility of the licensed nursing staff.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation and interview on 11/1/22 at 3:47 p.m. with resident 36 revealed he: *Was alert, hard of hearing, and able to understand and answer simple questions. *Denied any concerns and stated he did not want to talk long because he was going to an activity. *Was sitting in a wheelchair and wearing a shirt, basketball shorts, and slip on shoes. *Had white bilateral compression stockings on both legs that went from his feet extending to his upper thighs. *Had a moderate amount of edema to both lower legs from his feet to above his knees. *Became short of breath while talking with this surveyor causing him to pause for air. *Had not known if he was on any type of restricted fluids. Review of resident 36's medical record included diagnoses of: generalized edema, cardiac murmur, bradycardia, atrial flutter, persistent atrial fibrillation, hypertension, endocarditis, hypo-osmolality (low electrolytes, protien, and nutrients) and hyponatremia (low blood sodium), abnormal weight loss, vascular dementia with behavioral disturbance, major depressive disorder, and anxiety disorder. Review of resident 36's Order Summary Report included: *A 4/6/22 order, fluid RESTRICTIONS: 1)*Dietary* 240 ml/meal (720 ml/day) 2) *Nursing* 480 ml/day every day and night shift. *A 7/28/22 order, Based on lab report, CNP [certified nurse practioner] G [NAME] wrote order for: Fluid restriction 1,200 ml.- every shift for edema. *A 9/24/20 order, Daily weights-edema to lower legs-UNTIL stabilizes-in the morning for monitoring. *A 3/4/22 order, Thigh High compression stockings ON in AM; OFF at HS [hour of sleep] in the morning and bedtime for edema prevention. *A 1/10/22 order for Lasix 20 milligrams by mouth one time a day every Monday, Wednesday, and Friday for diuretic related to generalized edema. Review of resident 36's revised 10/6/22 care plan revealed: *Focus: -The resident has potential fluid volume overload E/B [as evidenced by] generalized edema. *Goal: -Resident will remain free of s/s [signs and symptoms] of fluid overload through review date, as evidenced by no pitting edema, weight WNL [within normal limits] as prescribed by doctor. *Interventions: -Weigh: daily -SUPPORT STOCKINGS: Apply and/or remove AM and HS-requires assistance from staff *There were no fluid restrictions or fluid intake monitoring listed on his care plan. Interview on 11/3/22 at 1:20 p.m. with lead food service assistant E revealed she: *Had been employed as lead food service assistant for six months. *Had been able to identify resident 36 as having fluid restrictions. -Was unable to state how many ml's daily fluid restriction he was to receive. -Thought he was to receive three ounces of water, two ounces of juice, and four ounces of coffee at each meal. --Had not known how many ml's this equaled (270 ml) and stated she was not good with numbers and was still learning. -Had not been aware of having any training on fluid restrictions. *Provided this surveyor with three different sheets of laminated paper she used as reference on resident 36's fluids to be given at meals. -One sheet stated resident 36 received OJ at meals. -The next sheet stated, Coffee and OJ. -The final sheet stated, Regular diet, coffee, juice all meals. *Agreed the laminated sheets did not state the amounts of the fluids that were to be provided to resident 36. Interview on 11/3/22 at 2:30 p.m. with FNS C revealed: *She had resident 36 listed as being on an 1,800 ml/day [milliliter per day] fluid restriction. -Had not been aware he was on a 1,200 ml/day fluid restriction. *It was her responsibility to ensure fluid restrictions and exact ml amounts were listed in the resident care plan. *Resident 36 was to receive eight ounces of coffee and four ounces of juice per meal (360 ml). *She tried to make reference material as simple as possible for the staff. -Like 1 cup of coffee, 1 cup of juice. *Fluid amounts need tightened up with all new staff. *Confirmed the fluid amounts referenced above by herself and staff were not accurate for resident 36. Interview on 11/3/22 at 1:50 p.m. of LPN H regarding resident 36's fluid restrictions revealed: *His fluid restrictions were documented by the nurse on the resident's treatment administration record. *The certified nurse assistants (CNA's) also documented fluid intakes in their daily task charting. -The totals were broken down by shift and there were no daily totals. -The nurse would then look at the resident's daily fluid intake and add the totals to determine if fluid restrictions were being followed. *The residents on fluid restriction were not provided fluids in their rooms beyond what was given at meals. Review of resident 36's October through November 2022 treatment administration record revealed: *Fluid restrictions were acknowledged by the nurse with a yes or no checkmark in a box. -There were no documented fluid intake totals for the day. Review of resident 36's 14-day fluid intakes documented in the CNA's task charting revealed there were no daily totals and no documentation on any fluid intakes outside of meals. Observation on 11/3/22 at 2:12 p.m. with LPN H of resident 36's room revealed: *Two 12 ounce (360 ml) beverage containers containing fluid on his night stand. *The beverage containers were not supposed to be in his room. Interview on 11/3/22 at 4:37 p.m. with DON B regarding resident 36's fluid restrictions revealed it was her expectation nursing and kitchen staff were to document the actual fluid amounts that were being consumed. 3. Review of the revised 5/26/22 Residents at Risk for Dehydration, Fluid Maintenance policy revealed: *7. DFN [director of food and nutrition], dietician, or designee will write the problem/goal for dehydration/fluid maintenance in the care plan. The approaches may include a variety of disciplines depending on the resident's individual needs. 8. Nursing, food and nutrition services, or other discipline will adjust the plan of care as necessary to meet goals. *Reference to an Instruction Sheet for completing a Fluid Restriction Worksheet (GSS [Good Samaritan Society] #195): -Use: Recommended when there is a diet order with a fluid restriction. -Purpose: To facilitate communication between nursing and food and nutrition services when planning how to provide a fluid-restricted diet order for a resident. *The Fluid Restriction Worksheet (GSS #195) included two sections: one for food and nutrition services and one for nursing services. -A table for each service area to document the types and amounts of fluids provided at mealtimes, during medication passes, and between meals as well as the total amount of daily fluids that could not be exceeded based on the resident's fluid restriction order. -A place for each service area to record the date, their signature, and their respective daily total fluid intakes for a resident. Based on observation, interview, record review, and policy review, the provider failed to: *Implement a process that ensured an accurate accounting of daily fluid intake for two of two sampled residents (45 and 36) with physician ordered fluid restrictions. *Ensure two of two sampled residents' (45 and 36) care plans had been revised to reflect a fluid maintenance goal and interventions to meet their individualized needs. Findings include: 1. Observation and interview on 11/1/22 at 10:30 a.m. with resident 45 and his spouse revealed: *He was admitted on [DATE] from a local hospital following treatment for congestive heart failure (CHF). *They had not known if any specific interventions such as restricting his daily fluid intake were being implemented related to that diagnosis. Observations on 11/2/22 at 7:45 a.m. and 11/3/22 at 8:30 a.m. of resident 45 eating breakfast in the north dining room revealed: *On 11/2/22 he had a cup (240 milliliter [ml]) of water, a cup (240 ml) of chocolate supplement drink, and a beverage mug (360 ml) in front of him. *On 11/3/22 he had two cartons (240 ml each) of chocolate supplement, a cup (240 ml) of water, and a covered beverage mug (360 ml) in front of him. Observation on 11/2/22 at 2:15 p.m. of resident 45 in his room revealed: *There were three covered beverage mugs (360 ml each) on his over bed table, one bottled water (240 ml), and another covered beverage mug (360 ml) on his nightstand. Review of resident 45's medical record revealed his diagnoses included: heart failure, chronic obstructive pulmonary disease, Parkinson's disease, ischemic cardiomyopathy, and arteriosclerotic heart disease. Review of resident 45's 11/2/22 Order Summary Report revealed: *A physician order dated 10/18/22: 2000 ml fluid restriction. 480 ml/meal for dietary, 560 ml/day for nursing every shift for CHF. *No orders for the use of a diuretic medication. Review of resident 45's October 2022 Treatment Record that included daily fluid intake amounts between 10/18/22 and 10/31/22 revealed: *A daily fluid intake entry for the day shift and a daily fluid intake entry for the night shift. -Resident 45 had exceeded his 2000 ml fluid intake on one day (10/28/22) during that timeframe. Review of resident 45's care plan revised on 10/24/22 revealed: *An incorrect goal related to his risk for and history of dehydration and potential fluid deficit related to use of a diuretic. *Interventions included: Offer drinks of choice during resident interactions. Explain importance of adequate nutritional intake. Praise resident's progress or efforts. Observe for s/s [signs and symptoms] of dehydration: sunken eyes, dry mouth, changes in mental status, fever, etc. Report to nurse. *There was not a goal or interventions related to: -His risk for potential fluid overload related to his heart related diagnoses. -The amount of his daily fluid restrictions, how his fluids were expected to be allocated throughout the day, and who was responsible for providing those fluids per physician order. -Monitoring, assessment, and physician notification of pre-determined weight increases by licensed nursing staff per physician order. -His 10/12/22 physician order for compression stockings to be placed on resident 45 during the day and removed at night related to his CHF diagnosis. Interview on 11/2/22 at 7:50 a.m. with lead food service assistant K regarding residents requiring fluid restrictions revealed: *Each day food services was provided an updated Diet Type Report. -It identified any resident with a fluid restriction and their specific fluid restriction order. *Resident 45 had no fluid restrictions listed on the 11/2/22 Diet Type Report. -If he had, food service staff would have provided fluids, including supplements, according to the amount food service had been ordered to provide per the Diet Type Report. *Nursing staff calculated the total amounts of fluids consumed by residents with fluid restrictions at the end of each meal. Interview on 11/3/22 at 10:45 a.m. and 1:15 p.m. with food and nutrition supervisor (FNS) C revealed she: *Was notified of dietary order changes including fluid restrictions by e-mail from nursing services when a new diet was ordered. *Posted that e-mail in the kitchen for food service staff to see, updated and redistributed the daily Diet Type Report to each dining room. *Had not known resident 45 had a current physician order for fluid restriction. -Knew he had a fluid restriction in the past that was stopped, but it had been restarted. *Had not notified food service staff that restriction was restarted. -That was her responsibility. *Confirmed resident 45's mealtime fluid restrictions had not been followed by food service staff. Interviews on 11/2/22 at 3:00 p.m. with certified nurse assistant (CNA) L and on 11/3/22 at 1:30 p.m. with CNA M revealed: *Resident 45 had no fluid restrictions. *He was offered fluids daily in his room during afternoon and evening snack pass in addition to what he received at mealtimes and with his medications. Interview on 11/3/22 at 1:45 p.m. with registered nurse J regarding resident 45 revealed: *She thought he was on fluid restrictions in the past, but that had been discontinued. -Verified he was still on fluid restrictions by checking his current physician orders. *CNAs were not allowed to offer or provide fluids to residents on fluid restrictions. -That was the responsibility of licensed nurses. *Food service staff were suppose to track mealtime fluid intakes, but they did not document or communicate that information to nursing staff. *She referred to the amount of fluid food service staff were suppose to give resident 45 at each meal (480 ml) and used that number in her daily fluid intake total whether she knew if he had consumed that amount or not. *His daily fluid consumption was not accurately accounted for and his fluid restriction order had not been followed. Interview on 11/3/22 at 5:20 p.m. with director of nursing (DON) B revealed: *Resident 45's care plan had not been revised to reflect his current physician ordered fluid restrictions or any individualized approaches related to that problem. -It was the responsibility of all interdisciplinary team members care plans during care conferences and whenever new physician orders occurred to review and revise those plans as needed. *The GSS #195 form was not currently used. -That form required communication between nursing staff and food and nutrition services regarding decisions about when and who would have provided resident 45's fluids, completion and monitoring of his daily fluid intake. *The current process had failed to accomplish those things.

Based on observation, interview, record review, and policy review, the provider failed to ensure kitchen cleanliness was maintained for: *One of one main kitchen, located in a separate building from the long term care facility. *One of one serving kitchen, located in between the facility's north and south dining rooms. *One of two ice dispensers located in the north dining room serving area. Findings include: 1. Initial walk through observation and interview of the main kitchen on 11/1/22 from 9:07 a.m. to 9:30 a.m. with food and nutrition supervisor (FNS) C revealed: *The main kitchen produced 600 meals a day, providing meals to the independent living, assisted living, and long term care residents. -These meals were placed into stainless steel holding pans and taken by rolling carts from the main kitchen to the serving kitchen located in the long term care facility. *The warming oven contained a large amount of burned and dried food particles covering the entire inside bottom, walls, and door of the oven. *The gas stove cast iron cooking grates were coated in dried grease and burned on blackened food particles. *The oven and stove were on a daily cleaning checklist that staff were to follow and initial. 2. Initial walk through observation and interview of the serving kitchen on 11/1/22 at 9:30 a.m. with FNS C revealed: *The holding pans would be removed from the rolling carts and placed into two separate steam tables. -These tables would then be pushed into the two adjacent dining room serving areas for meal service. *The gas stove in this kitchen was used only to fry eggs. -Observed the stove's cast iron cooking grates were coated in dried grease and burned on blackened food particles. *The stove was on a daily cleaning checklist that staff were to follow and inital. Further observation and interview on 11/1/22 at 9:35 a.m. of the north dining room serving area with FNS C revealed: *The ice dispenser had a large amount of white crusty build-up, resembling lime scale, around one of the two ice dispensing outlets. *This same white crusty build-up was also noted along the back splash of the dispenser where ice is placed into cups. *Maintenance was to clean and de-scale the ice machines once a month. Interview on 11/2/22 at 8:15 a.m. with maintenance worker D revealed: *They had a once monthly maintenance schedule to flush all ice machines and internal cleaning of the machines and dispensers. *He thought the kitchen staff were responsible for cleaning the exteriors of the ice dispensers. *There was white crusty build-up resembling lime scale on the exterior of the north ice dispenser. Further interview on 11/2/22 at 3:15 p.m. with FNS C confirmed: *The oven and stove grates in both kitchens were coated with dried food and grease. *The expectation was for all surfaces, including the ovens and stoves, to be cleaned on a weekly basis. *The main kitchen ovens were supposed to be sprayed and cleaned weekly on Sunday. -They were gas ovens and were shut off daily after seven p.m. -There was no kitchen staff scheduled past seven p.m. to perform the oven cleaning task. *Kitchen staff had cleaning schedules, but she was having difficulty getting staff to complete the tasks. -They are signing they are doing it, but obviously it is not getting done. I am so upset with them. -She had depended on lead cook's F and G to be following up on the completion of the cleaning tasks. -Staff had let it fall off when staffing was low and never picked it back up. That will change. *Maintenance had always cleaned the exterior of the ice dispensers in the past. -Maintenance should be responsible for cleaning all inside and outside of ice machines and dispensers as chemicals are used. -She had not wanted her kitchen staff to be using strong chemicals to clean the exterior of the ice dispensers while they were working with food handling. -The policy had not stated who was responsible for this task. *There was a system failure on cleaning of the exterior of the ice dispensers. 3. Review of the provider's August through October 2022 cleaning logs revealed: *All a.m., p.m., and prep cook, daily cleaning schedules were completed and initialed by staff. -The logs had contained a check-off item stating All equipment used-cleaned and sanitized-grill, fryer, ect . Review of the provider's 2/15/22 policy Cleaning schedule-Food and Nutrition Services revealed: *Cleaning schedule -1. The director of food and nutrition services (DFN), senior living dining director or designee is to post written daily, weekly and monthly cleaning assignments in the kitchen areas. -5. The DFN, food and nutrition supervisor, senior living dining director, senior living manager or person in charge is responsible for monitoring employees to ensure that cleaning duties are completed in a satisfactory and timely manner. *The policy had listed multiple items to be cleaned but had not included ovens or stove grates. Review of the provider's 3/28/22 policy Ice Machines Use and Maintenance-Food and Nutrition Services revealed it had not stated which department was to perform external ice machine and dispenser maintenance.