**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview, and policy review, the provider failed to ensure two of five sampled residents (25 and 28) who received psychotropic medications (any drug that affects brain activities associated with mental processes and behavior) had an attempted gradual dose reduction (systemic dose reduction over time to determine if the condition could be managed with a lower dose or discontinuation of the medication) (GDR) or documented rationale to support that a GDR was clinically contraindicated (not appropriate based on the resident's condition, potential risks, or adverse effects) for those medications. Findings include: 1. Observation and interview with resident 28 on 8/5/25 at 4:30 p.m. revealed she: *Was in the common area of the facility, seated in a wheelchair with a blanket over her lap. *Was very hard of hearing, but answered simple questions and indicated:-The staff were good to her. -The food was good.-She had no concerns. Review of resident 28's 7/14/25 annual Minimum Data Set (a tool used to evaluate a resident's health status and to develop an individualized care plan to manage the resident's care needs) (MDS) assessment revealed she: *Had been admitted to the facility on [DATE]. *Had diagnoses of dementia (a group of symptoms affecting memory, thinking, and social abilities), depression, and traumatic brain dysfunction (a disruption in the normal function of the brain caused by an injury that affects how the brain works). *Had moderately impaired cognition, was rarely/never understood, and was unable to complete a cognitive screening. *Exhibited the following mood indicators: little interest in doing things, appearing down or depressed, having little energy, and a poor appetite. *Exhibited the following behaviors: wandering and rejection of care. *Was prescribed psychotropic medications that included an: -Antidepressant medication.-Antipsychotic medication. --The antipsychotic medication had not had a gradual dose reduction (GDR) attempted in the past year. --There was no documentation by the physician to support why a GDR was clinically contraindicated. Minimum Data Set (MDS) coordinator C had signed the assessment as completed on 7/20/25. Review of resident 28's care plan, dated 5/27/25, revealed:*The resident was taking psychotropic medications (antidepressant and antipsychotic) for her depression. -Her care plan goal was to take the lowest therapeutic dose of medication daily.-Her approaches included:--Education was provided to the family and the resident on the risks and benefits of those medications. --Staff were to observe the resident for side effects and report unusual findings to the nurse. --A GDR review was to be completed every six months. Review of resident 28's Pharmacy Recommendation form dated 7/17/25 revealed:*Director of nursing (DON) B had initiated the form and indicated that the resident was currently taking: -The antidepressant medication Sertraline 150 milligrams (mg) daily since 4/15/25 when the dosage had been increased. -The antipsychotic medication Olanzapine 5 mg daily, which had been started in February 2025, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same dose and was signed 7/22/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form on 8/5/25 and noted that she agreed with the consultant pharmacist's above plan. *The form had not included a description of the clinical contraindications to completing a GDR for those medications. Interview on 8/6/25 at 6:27 p.m. with administrator A, DON B, and MDS coordinator C regarding resident 28's psychotropic medications revealed:*DON B agreed she had asked regarding the psychotropic medications on the Pharmacy Recommendation form and: -The provider's consultant pharmacist's recommendation indicated no change and not to proceed with a GDR. -The resident's physician had signed the form.*They agreed the physician had not provided a written indication why a GDR would be clinically contraindicated. *Administrator A and DON B agreed that:-The physician should have documented on the form the rationale for the decision to maintain the current medications' dosage and not attempt a GDR. -The consultant pharmacist should have requested the physician to review the resident's psychotropic medications for possible GDRs. Interview on 8/7/25 at 11:47 a.m. with MDS Coordinator C regarding resident 28's psychotropic medications revealed she agreed that: *Resident 28's medical record had no documentation regarding the clinical contraindications of completing a GDR for her psychotropic medications. *Resident 28's physician should have documented the rationale for the decision to maintain the current medications' dosage and not attempt a GDR. *She expected that psychotropic medications were reviewed for possible GDRs every six months. 2. Review of resident 25's 5/26/25 annual MDS assessment revealed she: *Had been admitted to the facility on [DATE]. *Had diagnoses of dementia and anxiety disorder. *Had moderately impaired cognition, was rarely/never understood, and was unable to complete a cognitive screening. *Exhibited the mood indicator of having a poor appetite. *Had not exhibited any behaviors. *Was prescribed psychotropic medications that included an: -Antianxiety medication. -Antipsychotic medication. --The antipsychotic medication had not had a GDR attempted in the past year. --There was no documentation by the physician to support why a GDR was clinically contraindicated. Minimum Data Set (MDS) coordinator C had signed the assessment as completed on 6/1/25. Review of resident 25's care plan, dated 5/27/25, revealed:*The resident was taking psychotropic medications (antianxiety and antipsychotic) for aggression, hallucinations (to see, hear, smell, taste or touch something that is not there), and delusional thinking (false beliefs and distorted views of reality). -Her care plan goal was to take the lowest dose of medication daily.-Her approaches included:--Education was provided to the resident's family and the resident on the risks and benefits of those medications. --Staff were to observe the resident for side effects and report unusual findings to the nurse. --A GDR review was to be completed every six months. Review of resident 25's Pharmacy Recommendation form dated 9/12/24 revealed:*DON B had initiated the form and indicated the resident was currently taking the antianxiety medication Ativan 0.25 mg three times daily since 6/27/23, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same [dose] and was signed 9/30/24 by the provider's consultant pharmacist. *The resident's primary physician had signed the form on 10/2/24. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of resident 25's Pharmacy Recommendation form dated 1/17/25 revealed:*DON B had initiated the form and indicated the resident was currently taking the antipsychotic medication Risperidone 0.25 mg daily since 3/22/23, and included a request to- - Please advise. *The pharmacy recommendation was No change, continue the same dose and was signed on 1/28/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form on 1/29/25. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of resident 25's Pharmacy Recommendation form dated 3/20/25 revealed:*DON B had initiated the form and indicated the resident was currently taking the antianxiety medication Ativan 0.25 mg twice daily since 4/18/23, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same dose and was signed 3/25/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form but had not indicated the date she had signed it. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of resident 25's Pharmacy Recommendation form dated 6/18/25 revealed:*DON B had initiated the form and indicated the resident was currently taking the antipsychotic medication Risperidone 0.25 mg daily since 3/22/23, and included a request to- - Please advise. *The pharmacy recommendation was to Continue the same dose and was signed 6/23/25 by the provider's consultant pharmacist. *The resident's primary physician had signed the form but had not indicated the date she had signed it. *The form had not included a description of the clinical contraindications to completing a GDR for that medication. Review of the provider's 3/6/19 Gradual Dose Reduction of Psychotropic Drugs policy revealed: *Purpose: Residents who use psychotropic drugs receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.*Performed By: Nurses and Pharmacist. *For any individual who is receiving a psychotropic medication to treat expressions or indications of distress related to dementia, the GDR may be considered clinically contraindicated for reasons that include, but that are not limited to:- The resident's target symptoms returned or worsened after the most recent attempt at a GDR within the facility.- The physician has documented the clinical rationale for why any additional attempted dose reduction at that time would be likely to impair the resident's function or increase distressed behavior.

Based on observation, interview, record review, and policy review, the provider failed to ensure resident care plans were revised to reflect the current enhanced barrier precautions (EBP) of eight of twenty sampled residents (1, 3, 6, 19, 21, 23, 27, and 28). Findings include: Refer to F880. Interview on 7/18/24 at 11:34 a.m. with Minimum Data Set (MDS)/infection preventionist (IP) C revealed: *It was her responsibility to complete the care plans. -Care plans were completed on admission, quarterly, and whenever things change. *She expected EBP to have been on the care plans, and a sign to have been on the doors to inform staff of residents with catheters, indwelling feeding tubes, and open wounds. *She confirmed that the care plans had not been updated to indicate EBP for any residents. *She had not been aware that some resident room doors were still not marked with a sign to indicate EBP. Review of residents 1, 3, 6, 19, 21, 23, 27, and 28's care plans revealed: *They had not been revised to indicate the need for EBP. Review of the provider's 10/07/21 Care Planning policy revealed, The facility will notify the resident and/or resident representative in advance of care to be furnished . as well as changes to the plan of care.

2. Observation and interview on 7/16/24 at 9:24 a.m. with resident 23 revealed: *She had a urinary catheter and wore a leg bag. *Nursing staff assisted her with her catheter. -She stated, They wear gloves but not a gown. *There had not been any signage on the door that indicated EBP. Observation on 7/16/24 at 10:19 a.m. with resident 19 revealed: *A urinary catheter bag was hung from the night table drawer. *There had not been any signage on the door that indicated EBP. Observation on 7/16/24 at 2:07 p.m. with resident 28 revealed: *A urinary catheter bag in a basin on the floor next to his recliner. *There had not been any signage on the door that indicated EBP. Observation and Interview on 7/16/24 at 2:18 p.m. with resident 6 revealed: *She had seen the physician today for sores, like fever blisters on her right lower leg that were open areas. *She stated that staff had worn gloves but not gowns when they assisted her. *There had not been any signage on the door that indicated EBP. 3. Review of the provider's January 2024 Management of C. [Clostridium] Difficile Infection revealed: *Housekeeping staff shall adhere to standard and contact precautions. *Perform daily cleaning of the resident's room and high touch surfaces using bleach wipes or bleach/water ratio solution (3/4 cups bleach to 1 gallon of water). Review of the provider's July 2023 Indwelling Catheter Care policy revealed: *Implement EBP and apply gloves and gown. Review of the provider's July 2024 Tube Feeding policy revealed: *Implement Enhanced Barrier Precautions. Based on observation, interview, and policy review the provider failed to ensure: *One of one sampled resident (10) who was on precautions for Clostridium Difficile (C-Diff) had their room cleaned with bleach by one of one housekeeping staff (K). *Eight of eight sampled residents (1,3,6,19,21,23,27, and 28) had been placed on enhanced barrier precautions (EBP). 1. Observation of resident 10's door to her room revealed there was a red P and a drawered storage container that contained personal protective equipment (PPE). Interview on 7/16/24 at 9:00 a.m. with medication aide/certified nursing assistant (CNA) M regarding precautions for resident 10 revealed she had C-Diff. Interview on 7/16/24 at 9:30 a.m. with housekeeper K regarding the cleaning of resident 10's room revealed she: *Had used Lysol to clean the top of surfaces and sprayed into sinks. *Had used AF79 concentration for cleaning the toilets. *Had pH7 ultra had been used to clean the room floors. *Would have used pH7Q Dual to clean up any bodily fluids. Interview on 7/16/24 at 10:15 a.m. with licensed practical nurse (LPN) L regarding resident 10's C-Diff revealed: *Resident 10 had been taking an antibiotic for her infection, but was not currently taking one. Interview on 7/16/24 at 10:57 a.m. with Minimum Data Set (MDS)/infection preventionist (IP) C regarding the cleaning of a room with a resident on C-Diff precautions revealed: *She was not aware that housekeeping had not cleaned with bleach. *They discuss precautions in the morning meeting. *She had not been aware of the need for enhanced barrier precautions for residents with catheters, indwelling feeding tubes, and open wounds. Interview on 7/16/24 at 11:23 a.m. with housekeeper K regarding education on cleaning resident rooms with C-Diff precautions revealed: *She had not received any education before today on using bleach to clean the rooms. *She had worked here for almost two years. Observation and interview on 7/16/24 at 8:16 a.m. with resident 21 while seated in her recliner revealed she had a catheter due to her not being able to pee. *There had not been any signage on her room to indicate EBP. Interview on 7/16/24 at 10:16 a.m. with LPN L regarding residents with open wounds requiring dressing changes revealed resident 3 had a daily dressing change and resident 27 had dressing changes twice a day. Observation on 7/16/24 at 10:30 a.m. of resident 3 and 27's doors revealed there had not been any signage indicating EBP. Observation on 7/16/24 at 2:14 p.m. of resident 1 while lying in her bed and LPN L administering medication via her feeding tube revealed: *Resident 1 had any signage on her door to indication EBP. *LPN L had worn PPE while administering medication to resident 1.

Based on interview, record review and policy review the provider failed to ensure residents and/or their representative received a written notice with information regarding the transfer to the hospital and to provide a copy of the transfer notice to the Office of the State Long-Term Care Ombudsman for one of one sampled residents (17) reviewed for facility-initiated hospital transfer to the hospital. Findings include: 1. Interview and record review on 4/12/23 at 9:50 a.m with resident 17 revealed she: *Could not remember when she had gone to the hospital. *Was not sure what a bed hold was. *Went to the [name of hospital] on 11/18/22. *Had kidney stones. *Was transferred to [name of hospital] for treatment. 2. Interview on 4/13/23 at 3:14 p.m. with administrator A revealed: *They provide education to the residents about the bed hold policy upon admission. *She confirmed they do not send bed hold information with a resident when they are transferred to a hospital. *The responsible party was notified by phone when a resident was transferred. *They had not notified the ombudsman of transfers or discharges. 3. Review of the Bed Hold Notice Upon Transfer policy dated 3/6/19 revealed: *1. Upon admission, the Eastern Star Home of South Dakota, Inc. will provide to the resident and/or the resident representative written information that specifies: a. If a resident requires transfer to an acute hospital or takes a therapeutic leave, his/her bed at the Eastern Star Home of South Dakota, Inc. may be held indefinitely. b. If a resident has Long-Term Care Insurance these leaves may or may not be covered or be subject to certain stipulations. c. Medicaid allows reserved bed days that the resident is absent from the facility due to an inpatient hospital stay. The resident may be absent from the facility for a maximum of five days. Medicaid also allows for non-medical or therapeutic leave days for a maximum of fifteen consecutive days. d. Conditions upon which the resident would return to the Eastern Star Home of South Dakota, Inc.: i. The resident requires the services which the Eastern Star Home of South Dakota, Inc. offers; ii. The resident is eligible for Medicaid nursing facility services.