**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interview, and policy review, the provider failed to ensure one of one sampled resident (3) with a pressure ulcer received the necessary dressing changes as ordered and interventions according to the resident's care plan to prevent his ulcer and infection from worsening. This citation is considered past non-compliance based on a review of the provider's corrective actions immediately following the incident. Findings include:1. Review of resident 3's electronic medical record (EMR) revealed:*He was admitted on [DATE] for intensive (extreme in degree of care) wound cares with intravenous (administration of medications directly into a vein) (IV) antibiotics. *He had a Brief Interview for Mental Status (BIMS) assessment score of 11, which indicated he had moderate cognitive impairment.*His diagnoses included: an unstageable pressure ulcer (a full-thickness wound where the depth cannot be determined because the base of the ulcer is obscured by slough, which is (yellowish, tan, gray, green, or brown dead tissue,) or eschar, which is (black, brown, or tan dead tissue) to his left lower leg/heel, non-pressure chronic ulcer (a persistent skin wound caused by conditions other than pressure), type two diabetes mellitus (the body does not use insulin properly), diabetic polyneuropathy (nerve damage complication of diabetes that causes pain), peripheral vascular disease (narrowing of blood vessels that reduces blood flow to limbs and organs), and cellulitis (bacterial skin infection that causes redness, swelling, and pain) of his left lower leg. *His current care plan interventions included:*A physician order initiated on 4/15/25 for staff to offload (remove or reduce pressure to body areas) his heels.*A physician order initiated on 4/15/25 for staff to ensure he utilized a crow boot (a specialized boot that redistributes pressure and stabilizes the foot) to his left foot and a custom shoe to his right foot when he was out of bed.*A physician order initiated on 4/15/25 for staff to monitor and document the location, size, and treatment and to report abnormalities, failure to heal, and signs and symptoms of infection to the medical doctor. *A physician order initiated on 4/15/25 to change the dressing to left lower leg/heel twice daily and as needed with betadine (topical antiseptic used to prevent and treat infections), adaptic (non-adhering dressing), 4x4's gauze pads, ABD (gauze pads to absorb wound drainage), wrap with kerlix (woven gauze bandage roll) and an Ace wrap (elastic bandage wrap). *A physician order initiated on 4/15/25 for IV Zosyn (an antibiotic) 4-0.5 GM/100ML therapy was to be administered three times daily through his PICC line (long, thin, flexible tube inserted into a vein in the arm, and threaded into a large vein near the heart to administer fluids or to draw blood samples). *A physician order initiated on 4/17/25 his left lower leg/heel ulcer was to be monitored weekly by licensed practical nurse (LPN)/wound nurse C.*He had been seen by the physician on 4/29/25 with much improvement to the pressure ulcer and less swelling and signs of infection to lower left leg/heel.*On 5/1/25 at 9:19 PM revealed resident 3's left lower leg/heel ulcer measurements were 12.10 Length (L) x 11.00 width (W) x 0.10 diameter (D).*Treatment administration record (TAR) documentation for 5/1/25 through 5/5/25 had been signed off by registered nurse (RN) J, RN K, RN M, and RN N, indicating resident 3's dressing changes to left lower leg/foot/heel had been completed twice daily, as ordered by the physician.*On 5/6/25, a progress note revealed resident 3's Left medial ankle wound communicating to left lower leg, rear. Left lower leg, pressure unstageable: 16.00 L x 32.50 W x 0.10 D.-On 5/6/25, LPN/wound nurse C had completed the dressing change after identifying that it had not been changed on 5/1/25 at 9:00 PM, and 5/2/25, 5/3/25, and 5/4/25, at 8:00 AM, and 9:00 PM as ordered. There was heavy drainage, wound bed wetness, and an odor noted during the dressing change. -Resident 3 had increased fatigue and was afebrile. *Resident 3's primary care provider was notified that resident 3 had not received wound care to his left lower leg/heel on 5/1/25 at 9:00 PM, and 5/2/25, 5/3/25, and 5/4/25, at 8:00 AM, and 9:00 PM as ordered. -Orders were received for blood work and to notify the infectious disease (ID) doctor for further management. *An order was received on 5/5/25 by the ID doctor for resident 3 to be sent to the emergency room for further evaluation. -Resident 3's laboratory results showed an up-trending white blood count (WBC) which was 16.0 on 4/28/25 and on 5/5/25 it was 20.2 which indicated he had an infection and a mild increase in C-reactive protein (CRP) (measures the inflammation in the body) which was 137.1 and reference range is less than 5.0 milligrams per liter (mg/L). -Radiography (X-rays) of his left tibia and fibula (two bones of the lower leg) did not show osteomyelitis (infection in the bone). *Resident 3's primary care provider and his family had been notified regarding his care on his dressing changes to his left lower leg/heal had not been changed as ordered by the provider. *Resident 3 returned to the facility on 5/6/25 after his evaluation in the ED. *Orders received from the ED included:-A doctor's order to continue IV Zosyn 4-0.5 GM/100ML every eight hours until seen by ID.-A doctor's order for doxycycline (an antibiotic) oral tablet, 100 milligrams (MG) by mouth twice daily for seven days.-To continue with the same wound care to his pressure ulcer on his left lower leg/heel as was previously ordered and follow up with the ID clinic on 5/20/25.*Resident 3 had blood drawn on 5/12/25 to be tested at the lab to recheck WBC and CRP (C-reactive protein).-Those lab results verified that there had been a decrease in his WBC and CRP levels. *Documentation in EMR indicated that resident 3 complained of more open wounds than he had previously on his left lower leg/heel.*A 5/13/25 doctor's order for wound care on resident 3's lower left leg/heel had increased from twice daily to four times per day and as needed. *Resident 3 had discharged on 5/21/25 to his private home. 2. Interview on 7/9/25 at 2:45 p.m. with director of nursing (DON) B and LPN/wound nurse C revealed:*Resident 3 had not received his scheduled physician-ordered dressing changes to his lower left leg/heel ulcers seven out of nine times.*Resident 3's lower left leg/heel pressure ulcers had gotten worse with heavy serosanguineous (a mixture of plasma and red blood cells) drainage and erythema (redness of the skin) and required additional oral antibiotics and continuation of IV antibiotics. They expected for the doctor's order for the dressing changes to resident 3's left lower leg/heel to be followed. *They expected each resident's care plan to be followed for any interventions listed. 3. Interview on 7/10/25 at 8:30 a.m. with RN J revealed he:*Verified those were his initials that were documented on the TAR for 5/2/25 at 9:00 p.m., which revealed this was a treatment that had not been completed.*Completed a dressing change on resident 3 but was not real sure which one it was.*Indicated the resident had multiple dressing changes that were to be completed. 4. Interview on 7/10/25 at 9:45 a.m. with RN K revealed he:*Verified those were his initials documented on the TAR for 5/3/25 and 5/4/25 at 8:00 a.m., which revealed this was a treatment that had not been completed.*Could not recall if he had completed the dressing change on resident 3's left lower leg/heel ulcer. 5. Interview on 7/10/25 at 12:30 p.m. with RN M revealed:*He verified those were his initials documented on the TAR for 5/3/25 at 9:00 p.m., which revealed this was a treatment that had not been completed.*He did not remember resident 3 or if he had completed the resident's dressing change on the left lower leg/heel ulcer.*He usually worked one day per month at the facility. 6. Interview on 7/10/25 at 1:18 p.m. with RN N revealed she:*Verified those were her initials documented on the TAR for 5/1/25 and 5/4/25 at 9:00 p.m., which revealed this was a treatment that had not been completed.*Could not justify doing the dressing change on resident 3's left lower leg/heel ulcer, as the previous one completed was done late. 7. Interviews on 7/10/25 at 3:45 p.m. with LPN O and RN K revealed education was provided to all staff on following physician orders, abuse and neglect, and skin and pressure injury prevention. 8. Review of the provider's updated 9/11/24 skin and pressure injury prevention program policy revealed:*A wound assessment will be completed:*When a pressure injury is identified: This assessment will include: a) Site, stage, size, appearance of wound bed, (use %) undermining, depth, drainage, (amount, color, type, consistency and odor) and status of peri-wound tissue;b) Treatment of the pressure injury, (cleansing, debridement, dressings);c) A review of the resident's current POC and medical status- and other possible risk factors, impaired healing due to diagnoses;d) Type of skin injury (MD/Provider is asked to identify type of injury, if needed-e.g., pressure, stasis (venous), ischemic (arterial), or neuropathic (Diabetic), and provide skin treatment orders. Reassess the wound at least weekly (If the wound has not improved within 2-3 weeks, contact MD/Provider for a change in treatment). * Pressure injuries are often made worse by continual pressure, heat, moisture, irritating substances on the resident's skin (i.e., perspiration, feces, urine, wound discharge, soap residue, etc.), decline in nutrition and hydration status, acute illness and/or decline in the resident's physical and/or mental condition.The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on 7/10/25 after record review review revealed the facility had followed their quality assurance process, education was provided to all nursing staff regarding the Provider Orders Policy, Abuse and Neglect Policy, and Skin and Pressure Injury Prevention Policy. Interview with staff revealed they understood the education provided regarding the topics, and the importance of following physician orders to prevent ulcers and infection from worsening. Audits were completed on following physician orders for dressing changes to ensure they are being completed as written. These were started on 5/9/25 and completed weekly x 4 weeks and then monthly x 2. These will be reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. Observations and staff interviews revealed the staff understood the education provided and the revised processes.Based on the above information, non-compliance at F686 occurred on 5/1/25, and based on the provider's implemented corrective action for the deficient practice confirmed on 7/10/25, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 9. Interview on 2/25/25 at 1:08 p.m. with resident 4 in her room revealed she: *Felt there was not enough staff to assist her with the care she needed. *Had waited 30 minutes to one hour, at times for her call light to be answered by the staff. *Felt the staff nurses and certified nursing assistants (CNAs) were really good but there was not enough of them to help the residents. Interview on 2/27/25 at 9:16 a.m. with resident 4 in her room revealed: *She stated having to wait a long period of time for staff to respond to her call light had become almost a daily event and staff response times were hardly ever within 15 minutes. *She said on 2/26/25 she had returned from physical therapy around 1:00 p.m. and had eaten her lunch in her room. *She then put on her call light for assistance to get into her bed. -After waiting quite a while, a staff member came into her room and turned the call light off and said she would be back as she left the room. -She stated they never come back and she sat in pain for a while. --She stated her pain level was at seven, nearing eight on the pain scale (a tool used to measure and describe the intensity of pain on a scale range from 0 to 10). --She stated her pain caused her physical distress. -She then put her call light on again and a staff member came in again and stated she was waiting for sheets to put on her bed, turned off the call light, and then left the room. --She waited in pain for another 15 to 20 minutes for the staff to return with the sheets to make her bed and then she was transferred into her bed by two staff using the full body mechanical lift around 2:30 p.m. *She stated the pain in her right leg caused her distress as she needed to lay down in her bed for the pain to ease. -She stated her pain was so intense she was frustrated and close to tears. 10. Interview on 3/5/25 at 10:45 a.m. with certified nursing assistant (CNA) S revealed: *She worked full-time at the facility on the day shift. *When fully staffed, she was responsible for assisting between eight to ten residents with their care needs. *When not fully staffed, she was assigned to assist 18 to 20 residents. -She stated that not being fully staffed occurred randomly, she estimated about 25% of the time she worked. *She had worked on 2/26/25 and recalled the interaction with resident 4 that day after lunch. -She stated they were fully staffed that day. -She stated resident 4 had complained to her about not being transferred to bed timely. -The resident stated she waited too long for her call light to be answered and was in pain. --She added the resident is always in pain and recalled that the resident had requested her pain medication. --CNA S recalled she had informed the nurse of resident 4's request for pain medication. Review of the 2/26/25 call light log for resident 4 revealed: *At 1:27 p.m. the call light was activated with a response time of 15 minutes and 47 seconds. *At 1:57 p.m. the call light was activated with a response time of 1 minute and 46 seconds. Record review of resident 4's call light log from 2/1/25 to 2/26/25 revealed there were 20 of 58 call light response times were over 15 minutes which indicated 35% of the staff's response times to resident 4's call light were over 15 minutes. Interview and review of resident 4's call light log on 3/5/25 at 10:27 a.m. with director of nursing (DON) B revealed: *He stated his expectation was that staff would respond to residents' call lights within five to ten minutes. *He acknowledged resident 4's call light response times were long and stated There is much going on during the day and he was unable to provide a reason for those long response times. Interview and record review on 3/5/25 at 11:00 a.m. with DON B regarding resident 4's report of pain on 2/26/25 revealed: *He confirmed CNA S had worked that day. *In reviewing resident 4's medication administration record (MAR) no pain medication had been administered on 2/26/25. *The resident's February 2025 MAR included twice daily pain evaluations. -He noted that her pain rating on 2/26/25 was 0 during Day Shift and 0 on Evening Shift. Further interview and record review on 3/5/25 at 12:23 p.m. with DON B regarding resident 4's February 2025 MAR, pain levels, and staff's comments revealed: *The February 2025 pain evaluations revealed 21 of 28 day shift ratings were 0 which indicated no pain. -One day shift pain level had been rated at six which indicated a moderate pain level. -There were no levels recorded of the resident having severe (rating of seven to nine) or excruciating pain (rating of 10). *Nineteen of 28 evening shift ratings were 0 which indicated no pain. -Seven times on evening shift her pain level had been rated at a four or five which indicated moderate pain. -There were no levels recorded of the resident having severe or excruciating pain during the evening shift. *MDS coordinator H's 2/25/25 progress note, provided by DON B revealed Resident states PRN Tramadol [pain medication] works to relieve their pain . States they sometimes get high pain but the Tramadol always helps to lower it to an acceptable level. *DON B was not sure of the reason why the resident's statements, CNA S's comment, and MDS coordinator H's progress note noted above were not accurately reflected in the resident's February 2025 pain evaluations. *DON B confirmed the resident's right leg caused her pain and that the staff should have responded timely to assist with her request to get into bed to relieve that pain. Review of resident 4's EMR revealed; *She had admitted to the facility on [DATE]. *Her 1/27/25 BIMS was 14 which indicated she was cognitively intact. *Her 1/27/25 admission MDS indicated she experienced frequent pain at an intensity rating of seven on the pain scale that interfered with her day-to-day activities. *Her current care plan revealed: -She used a full body mechanical lift for transfers with an XL full body sling. -She was dependent on staff to assist her with toileting, personal hygiene, showers, dressing, footwear, bed mobility, and transfers. -She was at risk for pain . -Interventions included that staff were to: --Evaluate efficacy of pain management. --Observe for non-verbal signs of pain. --Offer to medicate prior to therapy/treatment. --Utilize non-pharmacological intervention like talking to loved ones, watching television, resting, reposition, [and] elevate legs. 14. Interview on 2/27/25 at 7:30 a.m. with resident 65 regarding call light response time revealed: *One time she had to wait so long that it pissed her off so she wheeled herself over to the call buttons on the wall and pushed the emergency button. *She stated that the call light response times had been discussed as a concern in resident council meetings with no change or improvement. Review of resident 65's EMR revealed: *She had a BIMS score of 14 that had been completed on 12/17/24 which indicated she was cognitively intact. *She required the assistance of two staff and a total lift to transfer from her bed to her wheelchair. Review of call light times from 2/1/25 through 2/26/25 for resident 65 revealed: *Forty times the resident waited longer than 10 minutes for a staff response. *Three times she had waited for 50 minutes to one hour for her call light to have been answered. 15. Interview on 3/5/25 at 9:04 a.m. with administrator A regarding a staffing policy revealed: *Staffing was based on resident census and acuity. *She would have used her facility assessment to assist with staffing as well. 16. Review of the 8/2023 through 7/2024 facility assessment regarding staffing for the nursing department revealed: *Licensed nurses providing direct care needed was seven. *Nurse aides needed was 17. *Other nursing personnel (e.g., those with administrative duties) was eight. *Instructions were to consider if and how the degree of fluctuation in the census and acuity levels impact staffing. *This plan referred to CMS Minimum staffing rule. 17. Interview on 2/25/25 at 9:45 a.m. with resident 47 in her room regarding call light response wait times revealed: *She had waited long periods of time for her call light to get answered by the staff and she had experienced pain. *She required more assistance when she returned from dialysis because she felt weaker on those days. *She would be embarrassed if she had an accident related to waiting for staff to assist her. *She wore a Rooke Boot (a boot that provided redistribution of pressure along the calf to help treat and prevent lower-extremity skin breakdown) on her left foot. -The Rooke boot limited her mobility. -Staff were needed to help her transfer in and out of bed. Review of resident 47's EMR revealed: *She was admitted on [DATE]. *She had an 11/7/24 BIMS score of 15 which indicated she was cognitively intact. * Her dialysis schedule was Monday, Wednesday, and Friday. Review of call light times from 2/1/25 through 2/26/25 revealed resident 47 waited longer than 10 minutes for a staff response 51 times. 18. Resident council meeting held on 2/26/25 at 1:30 p.m. with residents 3, 10, 12, 61, and 62 regarding staff response to resident call lights revealed: *Call lights were not answered timely in the afternoon, evening, during meals, and at staff shift change. *Call lights had been brought up at resident council meetings in the past. *The staff response times would get better for a while, but then it would go back to long wait times. *They felt there was no consistency to address the call light issue. *They expressed that they were frustrated with the lack of oversight and response to the call lights. 19. Interview and resident council meeting minutes review on 3/4/25 at 9:50 a.m. with social services DD regarding resident council meetings revealed: *If an issue was brought up during resident council meetings a grievance form was filled out and it was given to the appropriate department to be addressed. *Call light issues were normally investigated by the administrator. *She confirmed resident call lights were an issue that had been brought up at multiple meetings. *Resident council meeting minutes dated 2/12/25 revealed under old business: -Staff stating they return and not returning in a timely manner. -Nine residents agreed it was resolved. -Six residents disagreed it was resolved, indicating it was still an issue. 20. Interview on 3/5/25 at 11:56 a.m. with administrator A and DON B regarding call lights revealed: *Call light time expectations for staff answering them was 10 minutes or less. *There may be times when an incident happened that the response could take longer. *Staff had been educated about answering call lights. *Staff were to inform the resident if extra help was needed. *It was their expectation that all staff would answer call lights. *They confirmed that residents requiring staff assistance should have had their needs met in a timely manner. *They were unaware of any psychosocial or emotional distress being caused to residents. 21. Review of the provider's 9/30/24 revised Call Lights policy revealed: *It is the policy of the facility to ensure that there is prompt response to the resident's call for assistance. *1. Facility shall answer call lights in a timely manner. If immediate assistance cannot be provided and there is not an emergent need, call light may be turned off and resident informed that staff member will be back to assist them shortly. *2. Orient all new residents to the call light at bedside as well as the call light in the bathroom and in the shower or tub rooms, as applicable. *3. If a call light is not functional, notify the Administrator or Maintenance Director immediately. Evaluate and provide another means in order for the resident to call for assistance (i.e. bell) until the call light is fixed. *4. Ensure call lights are placed within reach of residents. *5. Ensure that when the call light is triggered, it will either alert the staff visually or audibly or both. *6. For residents who are physically unable to depress the traditional call light but cognitively able to call for help, evaluate the need for alternate call system i.e., soft touch, mouth call light activator, etc. 11. Observation and interview on 2/25/25 at 9:04 a.m. with resident 64 in is room revealed: *He was sitting in his wheelchair with a full body lift sling under him. *He stated there were times he did not feel there was enough staff. *He stated there were times that it took a long time for his call light to be answered and when it was answered staff would tell him there were not enough people to help him. *He stated he has given up on turning on his call light. *He stated one time he was lying in bed and could not reach his urinal. He turned on his call light, but it was not answered before he had to urinate. He stated he urinated in the trash can beside his bed because he did not want to urinate on the floor. *He stated that he felt like a bother sometimes. *When he requested pain medication some staff would give him his pain medication, others would turn off his call light, walk out the door and not return. Interview on 3/4/25 at 9:38 a.m. with resident 64 regarding his call light revealed: *At times when he had to wait a long time for his call light to be answered he felt like the staff were just sitting around and did not want to help him. *He stated he did not like to have to wait for staff assistance and sometimes it made him upset. *He stated a times staff answered his call light promptly, turned off the call light, and told him they would return. -By the time they returned it was too late (he could not hold his urine anymore). *He felt if he was promised something by the staff it should be done. *He felt like he could not do anything about the time it took the staff to answer call lights, or return to assist him, and that made him mad. Review of resident 64's EMR revealed: *He was admitted to the facility on [DATE]. *His 2/19/25 BIMS assessment score was 12, which indicated he had moderate cognitive impairment. *He transferred with a full body mechanical lift with the assistance of two staff. *He required staff to set up or assist with his activities of daily living. *He was occasionally incontinent of urine. *Staff were to Remind, offer and assist with toileting as needed. I use the urinal for voiding. Review of resident 64's call light logs from 2/2/25 through 2/25/25 revealed: *He had utilized his call light 36 times: -12 times the response time was greater than 10 minutes. -Six times the response time was greater than 30 minutes. -Three times the response time was greater than 45 minutes. -The longest wait time identified was one hour four minutes and fifty-one seconds. 12. Interview on 2/25/25 at 8:57 a.m. with resident 51 in her room revealed: *She stated when she asked for staff to do something, at times it takes a while. *She stated she had been incontinent of urine while she waited for her call light to be answered by the staff and that happened more than one time. Observation and interview on 2/27/25 at 9:47 a.m. with resident 51 in her room revealed: *She was lying in bed. *Her call light was draped over the bedside table away from her bed and out of her reach. *She requested her call light be given to her so she could call someone. *She stated she felt very restless when she had to wait for her call light to be answered. Review of resident 51's EMR revealed: *She was admitted on [DATE]. *Her 2/18/25 BIMS assessment score was 9, which indicated she had moderate cognitive impairment. *She required staff assistance with all her activities of daily living. *She had a history of falling. Interview on 2/27/25 at 8:30 a.m. with licensed practical nurse (LPN) K revealed it was her expectation that residents' call lights be answered within ten minutes. 13. Observation and interview on 2/25/25 at 2:11 p.m. with resident 349 and his wife about call light response time revealed: *The resident was sitting in his recliner and his call light was on his bed out of his reach. *His wife stated, They have some definite issues with that here. *He stated he felt frustrated. *He would put his call light on to get help from staff to go to the bathroom, and it would sometimes take forever for his light to be answered. *He said sometimes, by the time he got help, it was too late, and he would become incontinent. *He said this made him feel like an old person. *He said he knew it was because they were short-staffed and [CNA V] is great, and she is doing all she can, but there was just too much work for the staff that's here. Review of resident 349's EMR revealed: *He was admitted on [DATE]. *He had a 2/17/25 BIMS assessment score of 13, which indicated he was cognitively intact. *He required substantial/maximal staff assistance with toileting hygiene. *He was at risk for falls related to his Parkinson's disease. *Staff were to: -Keep his call light within his reach. -Remind, offer and assist him with toileting as needed. No call light logs were available for review for resident 349's room. It was located in a part of an addition to the facility where call light audits had not been available. Based on observation, interview, record review, resident council interview, and policy review, the provider failed to ensure prompt response to call lights and necessary care and services were provided for eight sampled residents (4, 6, 12, 47, 51, 64, 65, and 349) and four additional council meeting residents (3, 10, 61, and 62) to maintain their physical, mental, and emotional well-being. Residents reported frustration, sadness, incontinence, and pain related to the delay in staff's response to their call lights and requests for assistance. Findings include: 1. Interview on 2/25/25 at 6:57 a.m. with registered nurse (RN) E regarding day shift staffing revealed: *RN E stated the halls/wings were staffed with two nurses. -One nurse was staffed on the T-wing/East-wing hall. -One nurse was staffed on the Red unit. *She stated the halls/wings were staffed with four certified nursing assistants (CNAs). -Two CNAs were staffed on the T-wing/East-wing hall. -Two CNAs were staffed on the Red unit. *She provided copies of the nursing staff report sheets for T-wing and the East-wing. -The report sheets identified residents that were to receive care and assistance with two people. -She stated the residents were identified as Pairs with Cares with pear signs posted outside of the resident rooms. 2. Observation and interview on 2/25/25 at 8:41 a.m. with resident 12 revealed: *He was sitting up in bed and watching television with his call light within his reach. *He stated there was not enough staff to help him and he started to cry. *He stated, I hate it here and the upper managers don't care about us, they just care about the money. *He had stated living here made him very depressed and he was tired of being here when no one cared. *He stated it had taken staff five minutes to three hours to answer his call light and sometimes staff had not come at all. *The staff's response to answer the call light had been terrible and made him feel upset and mad. *He stated at different times he had to call the receptionist's desk on the phone and tell her to send staff for help. *He could not get out of bed by himself and required assistance from staff. *He would have liked to have been out of bed every day. *He thought he had not been out of bed since Wednesday 2/19/25. *He said he had not received his scheduled shower on Sunday 2/23/25 and had not yet been offered a shower since then. *He had stated, They don't have enough help, and I get infections because they don't take care of me right. *He felt the incontinent products he used did not fit him properly, leaked, and had caused him to have rashes in his groin area and made his skin sore. *The resident continued to cry and paused when he was unable to speak about his care. *He asked staff for different incontinence products, but no alternative had been offered. -He was unable to release the adhesive strips on the incontinence products by himself timely and would become incontinent and unable to use the urinal. *He became frustrated and mad and would refuse staff assistance by the time staff responded to his call light. -He had become tired of waiting and figured what was the point. -He said the staff would respond, shut the call light off, tell him they would return, leave, and not come back to assist him. Review of resident 12's EMR revealed: *He was admitted to the facility on [DATE]. *He had a 11/26/24 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. *His diagnoses included immobility syndrome (paraplegic), chronic pain, rheumatoid arthritis, and spinal stenosis (narrowing of the spaces within the spinal canal). -He was non-ambulatory. *He required two staff for assistance with his activities of daily living. -He was identified as Pairs with Cares with pear sign posted outside of his room. -He required an EZ-stand lift (a mechanical lift used to assist from a seated to a standing position) for all transfers. Review of call light logs from 2/1/25 through 2/26/25 for resident 12 revealed: *He had utilized his call light 248 times. Of those: -45 times the response time was over 10 minutes. -40 times the response time was over 20 minutes. -21 times the response time was over 40 minutes. -16 times the response time was over 60 minutes. *The longest response time identified was one hour fifty-nine minutes and twenty-four seconds. 3. Observation and interview on 2/25/25 at 9:16 a.m. with resident 6 in his room revealed: *He was lying in bed with his call light within his reach. *He stated it could take staff one to two hours to respond to his call light. -Some staff would respond to the call light, shut it off, and leave his room without saying anything, and did not return to assist him. -Some staff were unable to assist him and would respond to the call light, tell him they would send someone to assist him, but no one would return. *He stated at different times he and his roommate had to call the receptionist's desk on the phone and tell her to send staff for help. Interview and observation on 3/4/25 at 10:09 a.m. with resident 6 in his room revealed: *He stated that he had pushed his call light at approximately 9:30 a.m. for assistance to get up out of bed. *The assistant director of nursing (ADON) C responded to the call light, shut it off, and told him she would send a CNA to assist him, and then left his room. *No CNA had come to assist him as of 10:09 a.m. *He stated some staff did a good job but most of them did not. *When surveyors were present staff would do better, but it would never last. *He stated it was all about the money and that was the facility's primary concern. -He stated that made him feel sad and mad and his concerns should be important. *He stated staffing issues had always been a problem and would stay a problem and he felt the staff's pay was not enough for the hard work that was done. Observation and interview on 3/4/25 at 10:20 a.m. with resident 6 in his room revealed: *The resident pushed his call light for staff assistance. -He stated he needed his urinary catheter drain bag emptied. -Licensed Practical Nurse (LPN) L responded to his call light at 10:29 a.m. and assisted him. Review of resident 6's electronic medical record (EMR) revealed: *He was admitted to the facility on [DATE]. *He had a 1/16/2025 Brief Interview for Mental Status (BIMS) assessment score of 15, which indicated he was cognitively intact. *His diagnoses included a history of an embolism with stroke, legal blindness, Type 1 Diabetes, neuromuscular dysfunction, tremor, and segmental and somatic dysfunction of the cervical region (impaired function of the spine). *He required two staff for assistance with his activities of daily living. -He was identified as Pairs with Cares with pear sign posted outside of his room. Review of call light logs from 2/1/25 through 2/26/25 for resident 6 revealed: *He had utilized his call light 116 times. Of those: -20 times the response time was over 10 minutes. -18 times the response time was over 20 minutes. -10 times the response time was over 40 minutes. -12 times the response time was over 60 minutes. *The longest response time identified was two hours forty-four minutes and twenty-nine seconds. 4. Observation on 2/26/25 at 11:39 a.m. of rooms on the East-wing and T-wing revealed: *Seven resident rooms had a Pairs with Cares symbol/sign posted on the outside of their doors. -Two of 18 residents in the East-wing were to be assisted by two staff with their cares. -Six of 21 residents in the T-wing were to be assisted by two staff with their cares. 5. Interview on 2/26/25 at 2:01 p.m. with director of nursing (DON) B regarding nursing department staffing revealed he stated: *They utilized their own staff and were contracting with two to three travel nurses to staff appropriately. *They were currently orienting three new nursing staff employees. *The staffing ratio for the day shift for the facility units/halls were four nurses, two medication aides, and nine CNAs. *The staffing ratio for the evening/night shift for the facility units/halls was three nurses, and seven CNAs. *They currently had two to three CNA positions available for hire. *The units/halls would have had a shortage of CNAs on occasion related to staff callouts and illness. -Other staff on the units/halls and other licensed staff from management would have assisted during those staffing shortages. 6. Observation of call lights on 3/5/25 from 8:34 a.m. through 8:49 a.m. of the T-wing hall revealed: *Call lights for residents 313 and 325's rooms were alarming when the surveyor began observing at 8:34 a.m. *At 8:48 a.m. the assistant director of nursing (ADON) C responded to room [ROOM NUMBER]'s call light. -That was a minimum time of 14-minutes for staff to respond. *At 8:49 a.m. CNA R responded to room [ROOM NUMBER]'s call light. -That was a minimum time of 15-minutes for staff to respond. 7. Interview on 3/5/25 at 8:50 a.m. with restorative aide O revealed she stated she thought 10 minutes would be an appropriate amount of time to answer a resident's call light. 8. Interview on 3/5/25 at 9:17 a.m. with CNA R revealed an appropriate amount of time to answer a call light would be within seven to eight minutes, or as soon as possible.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility-reported incident (FRI), record review, and interviews with facility staff failed to ensure the safety of one of one sampled resident (1) whose tunneled chest catheter (a thin tube inserted into a vein in the chest, neck, or groin and tunneled under the skin to a large vein near the heart referred to as a central venous catheter (CVC) to allow access to the vein for medication administration) was removed by registered nurse (RN) (C), not trained to safely perform that task. Findings include: 1. Review of providers 10/25/24 DOH FRI report revealed: *Resident 1 is receiving intravenous (IV) antibiotics for osteomyelitis [a bone infection that causes bone tissue inflammation and swelling]. *She had a tunneled chest catheter placed in her right chest area and on 10/17/24, that tunneled chest catheter was removed by RN C. -Although resident 1 had questioned RN C about removing it, she was told it was no longer needed. -The nurse practitioner was not notified of the mistake (the removal of her tunneled chest catheter). -She had approximately 1 month of IV antibiotic treatment remaining at the time of the reported incident. 2. Review of resident 1's electronic medical record revealed: *Multiple references to a peripherally inserted central catheter (PICC) usually inserted into a vein in the upper arm rather than to the tunneled chest catheter or CVC that resident 1 had in her right chest. -Flush PICC line before and after medication administration every shift. -PICC dressing change to be completed every Wednesday. *She is currently hospitalized . *Resident 1's diagnoses included: -End stage renal disease -dependence on renal dialysis -chronic pain. -Osteomylelitis *She had a (brief interview of mental status) BIMS score of 10, which indicated moderate cognitive impairment. -Resident 1 was on an antibiotic therapy related to an Osteomyelitis infection. *On 10/10/24, she had a tunneled chest catheter placed at the hospital on the right side of her chest and returned from the hospital on [DATE]. *On 10/17/24, an order from resident 1's nurse practitioner directed ok to remove PICC (a thin tube inserted into a vein in the arm, leg or neck and threaded into a large vein near the heart to allow long-term access to the vein) line. *On 10/18/24, an order was received from resident 1's nurse practitioner for placement of a new tunneled chest catheter to be placed on 10/22/24. 3. On 10/28/24 at 4:10 pm PICC line removal policy, and IV medication administration policy and PICC line training/education was requested from administrator B. -Administrator B did not provide a PICC line removal policy by the end of the survey on 10/29/24. *Staff training and education requested for RN C revealed the education packet did not include: -Tunneled chest catheter placement or removal. -IV medication administration. -Administrator B did not provide an IV medication administration policy. 4. Interview on 10/28/24 at 4:35 p.m. with RN C revealed: *He has been employed at the facility for one year and two months. *He had no training during his employment at the facility regarding: -IV medication administration. -The placement or removal of PICC lines or tunneled chest catheters. -He states the only training he received was what was included in the training packet he completed when he was hired. *He reported resident 1 had one PICC line present on the date that he removed the line. -He thought resident 1 had a PICC line present because that's the way it is noted in the chart. -He reported that the line he removed was located in resident 1's right upper chest. -He stated Sometimes PICC lines can be present in that location of the body. -He stated he was aware resident 1 had an order for antibiotics through 11/16/24. *He stated that he removed the PICC line because he got an order from the nurse practitioner to do so. -He stated, In my defense, I had the resident lie flat and hold her breath while I removed it. 5. Interview on 10/29/24 at 8:27 a.m. with assistant director of nursing (ADON) F revealed: -She participated in antibiotic stewardship and infection control. -Every morning, she receives a list of residents who were receiving an antibiotic. *Resident 1's antibiotic therapy was discussed at the intradisciplinary team (IDT) meeting on 10/17/24. -Note in resident 1's chart regarding the (IDT) meeting on 10/17/24 that indicated resident was not on an antibiotic, was written in error. -There was no order received by the facility to discontinue resident 1's IV antibiotic therapy. -Resident 1 was receiving IV antibiotic therapy on 10/17/24. 6. Interview on 10/29/24 at 9:36 a.m. with director of nursing (DON) A revealed: *He was aware that the nursing staff had received an order from the nurse practitioner to remove resident 1's tunneled chest catheter. *An order was not received to discontinue resident 1's IV antibiotic therapy. -He was aware that the day before resident 1's catheter was removed, her nurse practitioner came to the facility for a visit with her and documented to continue her IV antibiotics through 11/16/24. -He stated, Its possible that the nurse read the date of 11/16/24 and thought it said 10/16/24 as the date that the antibiotic therapy was to be completed. *He did not visualize the IV line that resident 1 had. *He stated that the facility received approximately one resident weekly with a PICC line present. -He stated the facility rarely receive residents with a tunneled chest catheter present. *He was not aware of any nursing education for the placement or removal of PICC lines or tunneled chest catheters. *He stated the pharmacy came on 9/12/24 to complete staff education for all nursing staff. *He states that the facility did not have a policy that includes PICC line removal or tunneled chest catheter removal. 7.Interview on 10/29/24 at 10:10 a.m. with Administrator B revealed: *She did not visualize the tunneled chest catheter that resident 1 had. -She was not aware of any policies regarding PICC line or tunneled chest catheter placement or removal. -She denied any education was provided by the facility to staff regarding PICC line or tunneled chest catheter placement or removal. *She denied any competencies regarding PICC line removals had been completed. 8.Interview on 10/29/24 at 11:10 a.m. with licensed practical nurse (LPN) E revealed she: *Had no education regarding IV antibiotic therapy while employed at this facility. *Did not administer any IV antibiotics to resident 1. *Denied being present at a pharmacy training in September 2024. 9.Interview on 10/29/24 at 11:15 a.m. with RN D revealed she: *Had administered IV antibiotics to resident 1 one time. *Had not had any training regarding IV antibiotic medication administration during her employment at this facility. *Was present at a pharmacy presentation in September 2024 but stated that no training was completed that day.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) complaint online report, observation, interview, and policy review, the provider failed to implement pressure ulcer prevention interventions to prevent the development of pressure ulcers for one of one sampled resident (3). Findings include: 1. Record review of the SD DOH complaint revealed: *Resident 3 was coded that she did not have skin issues. -She had a pressure ulcer that had worsened. -She had no wound interventions in place to ensure her wound healed. -She did not have documentation in her electronic medical record of her refusing repositioning. -She did no have documentation of her being educated to why repositioning would be beneficial to her wound healing. 2. Observation on 8/19/24 at 4:45 p.m. revealed resident 3 was sleeping in bed on her back, with her call light within reach. 3. Observation on 8/20/24 at 4:45 p.m. revealed resident 3 was again sleeping in bed on her back with her call light within reach. 4. Observation and interview on 8/20/24 at 8:53 a.m. with resident 3 with certified medication aide (CMA) P and certified nursing assistant (CNA) Q revealed: *They were repositioning her in bed because she had shifted down her mattress. *CMA P stated resident 3 does have pain because her legs are stiff. *Resident 3 asked CMA P why they were moving her and told her it was because she said she was uncomfortable when she got her medications. *She had bilateral heel boots on, and refused to have a pillow placed between her legs and said Maybe later. *Resident said when she was at home her husband had taken care of her wounds but could no longer care for her. *She had a carton of Boost supplement, drank a few sips and said that was enough. 5. Interview on 8/20/24 at 11:53 a.m. with resident 3's family revealed: *Resident 3 accepted repositioning if she was comfortable and without pain. *He stated resident 3 had three pressure ulcers and the one on her sacrum (tailbone) was down to the bone and was the size of a half dollar. She had been cared for at home for 7 years and the wounds had healed, but would open easily with any movement. -The family used foam surgical tape and rolled towels for repositioning. -Pillows were kept under her feet to prevent heel wounds. -She would refuse to move from her recliner, which was brought from home, to bed because it was uncomfortable. - They could have stood her up and adjusted the cushion for repositioning. *Family stated she laid in a crappy diaper for half an hour, and they were short on help. *She had been placed on hospice care last week and they were readjusting her oxycodone (pain medication) so she doesn't sleep as much. *Call light staff response had taken an hour at times, and she would call her family and they would call the facility and ask someone to go help her. *They had talked to social service director N and she would file grievances. *She didn't get the heel boots until after the right heel wound had already started. Before that, she had been wearing regular nursing home slippers. 6. Interview on 8/20/24 at 9:14 am. with Registered Nurse (RN) D regarding resident 3 revealed: *She had a history of wounds at home and had come back but were getting better. *The heel wound was newer, and she had an order for heel protector boots. *Resident 3 had refused to wear the boots, and her refusals were documented. - She would wear them now because of the heel wound. *RN D said the wounds could have been prevented if she would have worn the Prevlon heel boots. *She would refuse repositioning because she couldn't see the TV while lying on her side. *She had refused physical therapy. 7. Interview 8/21/24 at 9:08 with CNA R regarding resident 3 revealed: *She would get repositioned every 2 hours but would refuse at times. *When she complained of pain it would have been reported and the nurse would get pain medication for her. 8. Record review of call lights response from 6/1/24 to 8/20/24 for resident 3 revealed on multiple occasions it had been on for 20-38 minutes. 9. Review of resident 3's care plan dated 3/13/24 revealed: *The skin ulcer prevention interventions did not include repositioning *She had heel protectors ordered but didn't care to wear them as she preferred socks. *Prevalon boots were not included in her care plan but were ordered on 8/2/24. 10. Review of resident 3's skin/wound note on 6/27/24 at 4:44 p.m. revealed Reviewed resident's sacrum/bilateral buttocks. When resident first admitted to facility resident resident had a stage 3 pressure, it healed and resident developed a rash. Rash has healed and resident's sacrum/bilateral buttocks has re-opened. Due to previously having a stage 3, it is classified as a stage 3 with re-opening. Current measurement: 13x13.0.01 cm. writer applied triad and border foam to area. Faxed provider update and for new orders. Updated family. 11. Review of resident 3's skin/wound care orders revealed: *On 5/28/24 Following facility standing wound orders. Cleanse with normal saline, pat dry, cover with collagen gel, apply bordered foam. *On 5/31/24 Reviewed resident's sacrum/buttocks. Current measurement: 10 x 8.5 cm. Applied current orders: Cleanse with normal saline, pat dry cover with collagen gel, apply bordered foam. Applied barrier cram to erythema. *On 6/20/24 Clean wound, apply medihoney and cover with bordered foam dressing daily until resolved. *On 6/28/24 PCP-ok to apply collagen particles mixed with triad daily and as needed with incontinence episodes to sacrum/bilateral buttocks ok to discontinue medihoney/borderfoam. *On 7/19/24 Updated orders: 1. Sacrum: cleans with wound cleanser, apply skin prep, apply collagen particles, and cover with hydrocolloid. 2. Bilateral buttocks: apply triad mixed with collagen particles. *On 8/19/24 Ok for [NAME] hopice to eval and treat. *On 8/19/24 Received fax from hospice . New orders: right heel-cover with optifoam dressing every other day. Coccyx-apply therahoney, then calcium alginate and cover with optifoam dressing every day. 12. Review of resident 3's wound assessments details report for her sacrum/buttocks and right heel revealed: *The reports were signed and completed by a licensed practical nurse (LPN). -There was no collaboration between a registered nurse (RN) and he LPN for skin assessments. *The wound was on the bilateral buttocks/sacrum. *The wound was facility-acquired 7/4/24 *The status, type, classification, clinical stage and measurement size in centimeters in Length (L) x width (W) x depth (D) of that wound was documented as follows: -On 6/6/24 active, rash, erythema (redness) and measured 10.00 x 8.50 x 0.01. -On 6/13/24 active, rash, erythema and measured, 9.00 x 6.50 x 0.01. -On 6/20/24 active, rash, erythema and measured, 9.00 x 7.00 x 0.01. -On 6/27/24 healed, rash, erythema and measured, 0.00 x 0.00 x 0.00. -On 7/4/24 active, pressure ulceration, stage 3, and measured 13.00 x 11.00 x 0.01. -On 7/11/24 active, pressure ulceration stage 3 and measured 13.50 x 12.0 x 0.01. -On 7/18/24 active, pressure ulceration, stage 3 and measured 15.00 x 12.50 x 0.01. -On 7/25/24 active, pressure ulceration, stage 3 and measured 12.50 x 12 x 0.01. -On 8/8/24 active, pressure ulceration, stage 3 and measured 13.00 x 12.50 x 0.10. -On 8/1/24 active, pressure ulceration, stage 3 and measured 12.50 x 12.0 x 0.01. -On 8/12/24 active, pressure ulceration, stage 3 and measured 3.20 x 4.50 x unknown. -On 8/19/24 active, pressure ulceration, stage 3 and measured 3.40 x 4.00 x 1.10. *On 8/1/24 active, pressure blister, deep tissue pressure injury and measured 2.0 x 3.50 x unknown. -On 8/8/24 active, pressure blister, deep tissue pressure injury and measured 2.0 x 3.50 x unknown. -On 8/12/24 active, pressure blister, deep tissue pressure injury and measured 2.70 x 2.20 x unknown. -On 8/19/24 active, pressure blister, deep tissue pressure injury and measured 4.10 x 2.90 x unknown. Summary Resident 3's Sacrum and buttocks wounds were healed 6/27/24 and a facility acquired pressure injury that measured 13.00 x 11.00 x 0.01 on 7/4/24 as a stage 3 and had worsened and measured 3.40 x 4.00 x 1.10. Her right heel wound was a facility acquired deep tissue pressure injury that measured 2.0 x 3.50 on 8/1/24 and had worsened to 4.10 x 2.90. 13. Record review of the providers skin and pressure injury prevention program policy dated March 23, 23 revealed: *To provide care and services to prevent pressure injury development to promote the healing pressure injuries/wounds that are present. 14. Grievances were reviewed, but none were found from resident 3.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, record review, and policy review, the provider failed to honor a resident's refusal to shower and to follow that resident's bathing preferences as directed on their care plan for one of one sampled resident (1). Failure to do so resulted in the resident expressing feelings of anger and mistrust towards a staff member. This citation is considered past non-compliance based on a review of the corrective actions the provider implemented following the incident. Findings include: 1. Review of the provider's SD DOH FRI submitted on 5/28/24 at 11:22 a.m. revealed: *Resident 1 reported certified nurse aide (CNA) E was rough with her on the morning of 5/27/24. *She reported that CNA E forced her to wake up at 7:10AM and demanded she take a shower because she urinated on herself, and grabbed her by the arms and pushed her down into the chair. 2. Interview on 6/19/24 at 1:36 p.m. with resident 1 regarding the above incident revealed: *A staff member came in her room around 7:00 a.m. and woke her up. *She had not seen that staff person before. *The staff person startled her and was tried to tell her to get up to take a shower. -She asked the staff person who she was. -She said the staff person said, I don't work here, I'm just a temporary. *The staff person grabbed her by both arms and slammed her down in the shower chair. -Resident 1 said that she told the staff person to get your hands off me or I'm going to deck you. *She said that she was manhandled. *She said her shoulders were hurt because that staff person grabbed her. *She did not like to wake up that early and would rather have gotten up around 8:00 a.m. or 9:00 a.m. *She went to physical therapy after that incident and told the therapist about the situation. She thought that the therapist informed the head therapy gal. *Her son visited that morning, and she also told him about the incident. -Her son immediately informed the manager about the situation and demanded that that CNA was not to go into his mother's room anymore. 3. Interview on 6/19/24 at 2:58 p.m. with physical therapy assistant (PTA) H and physical therapist (PT) I regarding resident 1 revealed: *PTA H confirmed he was present on the day of that incident. *He remembered resident 1 having had mentioned being upset about not wanting to get up that early to shower. *He did not recall her saying anything about being manhandled. *PT I indicated if a resident concern was serious enough like this incident described, they would have reported it to administrator A or director of nursing (DON) B. *Neither of them reported resident 1's concern to anyone. 4. Interview on 6/19/24 at 4:25 p.m. with resident 1 regarding the above incident revealed: *She did not recall having been incontinent that morning. *She said, I may have piddled because she was startled. *She did not believe she was soaked with urine that morning. *She said in regards to having been awakened for bathing, It made me mad, first fucking thing in the morning. 5. Interview on 6/20/24 at 9:05 a.m. with CNA G regarding the above incident revealed: *She confirmed she was working that day. *She remembered hearing about the situation but had not witnessed it. *Resident 1 did not always like to shower, especially in the morning. *She confirmed she worked with CNA E that day and did not have any concerns with how CNA E had interacted with other residents. *She confirmed CNA E worked the entire shift from 6:00 a.m. to 6:30 p.m. 6. Interview on 6/20/24 at 9:18 a.m. with licensed practical nurse (LPN) D regarding the above incident revealed she: *Confirmed she was working that day. *First learned of the incident when the resident's son came to her that morning and told her that he did not want CNA E involved in his mother's care going forward. *Spoke to resident 1 and she told her CNA E had came in and hoisted her. *Said that resident told her she had reported the incident to PTA H earlier. *Recalled feeling frustrated about the situation because neither PTA H nor CNA E had told her about the incident. *Helped resident 1 with filling out a grievance form on 5/27/24 and gave that form to the manager on duty, LPN C, and texted administrator A that same day to let her know about the incident. *Told CNA E not to go into resident 1's room or answer her call lights anymore that day. *Indicated that day was her first time working with CNA E, but she was great at getting her job done and reported no other concerns with CNA E's demeanor. *Spoke with PTA H and reminded him to let them know if a resident tells [him] anything like that. *Confirmed that LPN C was on site that day from about 8:00 a.m. to around 4:00 p.m. 7. Interview on 6/20/24 at 10:49 a.m. with CNA E regarding the incident between her and resident 1 revealed: *She signed up for a full shift on 5/27/24. *They were overscheduled that day, so she was reassigned to help with showers in the rehabilitation (rehab) unit. *She had never worked on that unit before, and she did not know those residents. *She was not briefed on who the residents were, if they needed help with transferring, or anything directed on their care plans. -She was given a piece of paper with resident names and room numbers on it and was told those residents needed a shower that day. *No one told her that resident 1 did not like to wake up that early in the morning, or that the resident would rather shower in the evening. *Before breakfast that day, she knocked and walked into resident 1's room and introduced herself. -The resident needed to use the toilet. -She placed the resident's wheelchair next to her bed. -The resident was not steady. *She tried to explain to the resident that she needed to shower because her brief and clothes were wet. -She said the resident said to her, I don't give a fuck about being wet. -She was trying to convince her that you [resident 1] really need to shower. -Resident 1 said to her again, I don't want to shower. *She helped the resident undress and transfer to the toilet. *Resident 1 stood up from the toilet suddenly and looked unsteady, so she placed her right hand on the resident's left arm to guide her to the shower chair to prevent her from falling. *CNA G came in to help. *CNA E informed the nurse about the situation immediately. *She said after that incident, she had helped the resident two more times before the nurse instructed her to not go into resident 1's room anymore. -Resident 1 put her call light on twice after breakfast and was perfectly sweet. -The resident's son was the one who requested other staff to care for resident 1, not the resident herself. *She confirmed she worked the rest of her shift. *She confirmed that before she started working for the facility, she reviewed an orientation packet that included training on abuse and neglect. *Either administrator A or DON B contacted her on 5/28/24 to inform her of the investigation process and they would be in touch with her regarding her employment. *She received a notification from her staffing company that she was put on the do not return list for this facility. 8. Interview on 6/20/24 at 12:02 p.m. with LPN C regarding the above incident revealed: *She confirmed she was filling in as the manager on duty that day. -She was the only manager in the building that day, and it was a very busy day. *LPN D had informed her of the situation, but she said her understanding of the situation was resident 1 was frustrated with being here and had trouble with a CNA transferring her. *She had instructed LPN D to help resident 1 fill out a grievance form. *She did not review the grievance form before LPN D had slipped the form under the door of either the social worker or the administrator. *Her impression of the situation was not manhandling. -If I had been told that there was alleged abuse, I would have called [DON B] or [administrator A] right away. *Administrator A reeducated her, and the management team, regarding the provider's abuse and neglect policy and when to report incidents. *She spoke with resident 1 the next day and the resident had not reported any concerns at that time. *During shift change, staff were to have reviewed the daily assignments sheets, reviewed diets, special equipment, how residents transfer, and their code status. *Staff were to have a Kardex pocket care plan as well. 9. Interview on 6/20/24 at 12:29 a.m. with administrator A and DON B regarding the incident between resident 1 and CNA E revealed: *It was their expectation to have been notified immediately regarding any potential abuse or neglect situations. *Administrator A was notified of the situation through a grievance form on 5/28/24. *She immediately suspended the CNA pending the investigation and spoke with resident 1 regarding the incident. *She spoke with CNA E to obtain her side of the story. *As part of the investigation, she: -Interviewed other residents on the rehab unit to learn if there were any other resident concerns. -Interviewed staff to learn about their involvement. -Informed the director of therapy of the situation so she could educate therapy staff about what to report, when to report, and who to report to. -Reeducated staff from all departments about the provider's abuse and neglect policy and expectations for reporting. *Her expectation would have been to allow resident 1 to refuse the shower and to come back later or have a different staff member come back later to assist the resident. *Administrator A denied she had received a text from LPN D on 5/27/24 regarding the incident. *She informed the staffing agency to not allow CNA E return to the facility. 10. Review of the grievance form written by LPN D on 5/27/24 revealed: *The form was filled out at 12:30 p.m. *LPN D received information from both resident 1 and resident 1's son. *Under the Describe Grievance or Satisfaction section: -0700 [7:00 a.m.] - Resident reports that this morning CNA had come in to get her up. -Resident reports that CNA had put shower chair in front of her and resident had stated 'I don't want a shower this early.' -CNA then had said 'Well you peed all over yourself.' -Resident reports that then CNA [picked her] up by both her arms and placed her in shower chair. -Resident reports that CNA had told her she didn't [work] here and resident had replied 'Well why are you here.' -Resident also reports that CNA was very rough with her this morning. *The Resolution section read, Reported to DOH [Department of Health], see investigation Finding in file. 11. Review of the provider's investigation into the incident revealed the following: *When the administrator received the grievance form on the morning of 5/28/24, she immediately suspended CNA E pending the investigation. *A skin assessment was completed on resident 1 with no new skin concerns identified. *The resident expressed her experience through additional interviews. *Other staff and residents were interviewed regarding CNA E. -All other residents interviewed verbalized having been free from abuse and neglect. -No new concerns from other staff members were identified. *CNA E's staffing agency was notified that she was not allowed to return to the facility. *Resident 1 and her son were informed of the outcome of the investigation and indicated satisfaction with the grievance outcome. *A complaint was submitted to the South Dakota Board of Nursing regarding CNA E. 12. Review of resident 1's electronic medical record revealed: *She was admitted on [DATE]. *Her most recent Minimum Data Set assessment was completed on 5/22/24. -The Brief Interview for Mental Status score was 13, indicating she was cognitively intact. *CNA E documented resident 1 had received a shower on 5/27/24. -It was documented the resident required total dependence [of staff] of one person physical assist with the shower. *The resident's last documented shower before the incident was on 5/23/24 at 1:15 p.m. *Resident 1 was incontinent of bladder and continent of bowel on the morning of 5/27/24. *She had physician's orders for the following pain medications: -Acetaminophen Oral Tablet 500 MG [milligrams] (Acetaminophen) Give 500 mg by mouth three times a day for Pain don't exceed Tylenol 3gm [grams]/24 hours. That had a start date of 5/22/24. --On 5/27/24, she reported her pain level at a 0 out of 10 for the three doses administered. --On 5/28/24, she reported her pain level at a 4 out of 10 at the 9:00 a.m. dose, 7 out of 10 at the 1:00 p.m. dose, and 4 out of 10 at the 5:00 p.m. dose. -Acetaminophen Oral Tablet (Acetaminophen) Give 650 mg by mouth every 6 hours as needed for pain or fever. That had a start date of 5/16/24. --She did not take any of the as needed (PRN) acetaminophen between 5/27/24 and 5/31/24. -oxyCODONE HCl Oral Tablet 5 MG (Oxycodone HCl) Give 2.5 mg by mouth every 4 hours as needed for pain management until 6/13/24. She did not use the PRN oxycodone during May 2024. Review of resident 1's care plan at the time of the incident (5/27/24) revealed: *A focus area that read, [Resident 1] requires assistance with [activities of daily living] (bed mobility, transfers, dressing, walking, personal hygiene, eating and toileting). Initiated on 5/16/24. Revised on 5/28/24. -An intervention under that section read, Assist resident with shower/bathing 2 showers per week in evening. Initiated on 5/16/24. Revised on 5/16/24. *There was nothing in her care plan at the time of the incident indicating how the resident was to have been transferred. -An intervention was added on 5/28/24 that read, [Resident 1] is independent with toileting hygiene and transfers will self-propel in wheelchair without pedals, she will at times remove her foot pedals and will at times remove the bag off the back of the wheelchair for foot pedals. Initiated on 5/28/24. Revised on 6/19/24. Review of the therapy provider's progress notes revealed: *Resident 1 received occupational therapy and physical therapy services on 5/27/24. *The occupational therapist assistant's note read: -Pt [patient] presents supine [laying on her back] in bed and requires supervision to push up into sitting at EOB [edge of bed]. -Pt ambulates to bathroom with use of FWW [front wheeled walker] and transfers onto toilet with use of grab bars with CGA-SBA [contact guard assist-stand by assist] for safety. -Pt ambulates throughout facility with FWW and CNA and demonstrates ability to ambulate from room to therapy gym. -There was no mention of the resident's demeanor or any complaints during the occupational therapy session. *The physical therapist assistant's note read: -Patient pleasant and cooperative with no new complaints. Denies any new pains/soreness. 13. Review of the provider's February 2024 Grievances policy revealed: *Procedure: - .2. The facility Administrator has been designated to receive all grievances. - .6. During the investigation, the facility will put in place immediate action to prevent potential violation of resident's rights. -7. If the grievance includes suspected abuse, neglect, injury of unknown source, or misappropriation of property, abuse protocol will be followed. (See Abuse and Neglect Policy) -Process: Party initiating the comment of Grievances or Satisfaction: -- .If there is a grievance that needs immediate attention, please bring it to your charge nurse's attention right away so it can be addressed by the facility Administrator. --Some situations that require a more immediate response include but are not limited to: .situations that could be abuse such as yelling, rough treatment, hitting, etc. -Process: Staff Member: -- .Submit the forms to the Charge Nurse. Alert the Administrator if immediate action needs to occur. -Process: Charge Nurse and Management Team Members: -- .If it is a Grievance, determine if immediate intervention is needed. Alert the administrator if immediate action needs to occur. 14. Review of the provider's February 2024 Abuse and Neglect policy revealed: *Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. -The facility follows the federal guidelines dedicated to prevention of abuse and timely and thorough investigations of allegations. -These guidelines include compliance with the seven (7) federal components of prevention and investigation. *Types of Abuse and Examples: Physical -Physical abuse includes but not limited to infliction of injury that occur other than by accidental means and requires medical attention. Examples: hitting, slapping, kicking, squeezing, grabbing, pinching, punching, [NAME], twisting, and roughly handling. -Any person in a position of power or authority may potentially cause harm to a resident. Potential aggressors include but are not limited to, facility staff, .other visitors. *If abuse/neglect is suspected the facility will: -1. Take immediate steps to assure the protection of the resident(s). This may involve separation from the alleged abuser and/or provision of medical care. -2. Notify the appropriate/designated organization/authority that an investigation is being initiated immediately following intervention for the resident's safety. -3. Conduct a careful and deliberate investigation centering on facts, observations and statements from the alleged victim and witnesses. -4. Notify law enforcement authorities if indicated (i.e., a crime such as physical or sexual abuse, theft, etc.) -5. Report the investigation findings to all necessary state and/or local agencies and any other identified persons as required by law. *VII. Reporting/Response . -All allegations and/or suspicions of abuse must be reported to the Administrator immediately. If the Administrator is not present, the report must be made to the Administrator's Designee. -All allegations of abuse will be reported to your state agency immediately (within 2 hours) after the initial allegation is received. *In section 1150 B of the policy: -Reporting: All allegations and/or suspicions of abuse/neglect must be immediately reported to the facility Administrator or designee in the absence of the administrator. -Failure of an employee to report an allegation and/or suspicion of abuse will result in disciplinary action. -The Administrator is the Abuse Coordinator. -The abuse coordinator must submit a preliminary investigation report to their required state agency immediately once assurances for the resident's or other resident's safety have been established. The provider implemented actions to ensure the deficient practice does not recur was confirmed after: record review revealed the facility had followed their quality assurance process, provided education to all staff working within the facility regarding abuse, neglect, and reporting, and resident's rights, review of those educational materials and staff signature sheets of acknowledgement of that education, and interviews with several staff from various departments including housekeeping, social services, nursing, and therapy revealed staff understood the education provided regarding abuse, neglect, and the reporting process. Based on the above information, non-compliance at F550 occurred on 5/27/24 when resident 1's right to refuse a shower was not honored when staff gave her a shower after she verbalized she did not want to take a shower, and her previously care planned preferences for showering and bathing were not followed. Based on the provider's implemented corrective actions the deficient practice confirmed during the survey from 6/19/24 to 6/20/24, the non-compliance is considered past non-compliance.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the South Dakota Department of Health (SD DOH) complaint online report, observation, interview, record review, and policy review, the provider failed to ensure: *One of one sampled resident (2) had staff supervision in place to prevent a hot liquid burn. *Two of two sampled residents (2, and 3) had hot liquid safety evaluations completed, were documented accurately, and interventions in place to prevent potential burns from hot liquids. Findings include: 1. Review of the 3/5/24 SD DOH facility reported incident regarding resident 2 revealed: *On 3/4/24 at approximately 10:30 a.m. resident 2 was in her wheelchair in the central dining room. *She placed hot water from a coffee/water dispenser into a personal plastic cup to make tea. *When the cup was filled with water, she pressed the lid onto the cup and placed the cup between her thighs on top of the wheelchair seat. *Resident 2 then used her arms to wheel herself out of the dining room and into the hallway toward her room. *When she entered the hallway, resident 2 yelled which caught the attention of a nearby nurse. *The plastic cup that held the hot liquid melted and spilled the hot water onto her inner thighs. *Resident 2 was quickly taken to her room by the responding nurse and cold compresses were applied to the areas. *The nurse completed a skin assessment that revealed a reddened skin area of 1.2 centimeters (cm) in width x 6.2 cm in length. *Physician's orders were obtained for treatment of the burn. Observation on 3/12/24 at 10:40 a.m. during the initial walk-through tour revealed: *Automatic coffee/ hot water dispensers in the following areas: -The central dining room. -The rehabilitative dining area. -Across the hallway from the nurse's station, but that coffee/hot water dispenser had been out of service. Interview on 3/12/24 at 11:45 a.m. with activities director D who was assisting with the central dining room meal service revealed: *The central dining room doors remained open all day. *Activities were conducted in that dining area such as bingo, or other scheduled activities for the residents to participate in. *Staff, visitors, and residents were free to come in and out of the central dining room for beverages if they chose. *The residents were able to get beverages independently. Interview on 3/12/24 at 11:50 a.m. with dietary manager F revealed: *Coffee and hot water were available for residents, visitors, and staff. *The doors of the central dining room stayed open because the room was used throughout the day. *Residents were in and out of the dining room for activities or leisure. *She confirmed residents could get hot water or coffee independently. *Insulated coffee cups were stored on a table nearby and were available if someone wanted a beverage. Review of resident 2's electronic medical record (EMR) revealed: *She was admitted on [DATE]. *Her Brief Interview for Mental Status (BIMS) score of 12 indicated she had mild cognitive impairment. *Hospice services had began on 1/18/24. *Her diagnoses included the following: -Anemia. -History of amnesia. -Cirrhosis of the liver. -Osteoarthritis. -Congestive heart failure. -Atherosclerotic heart disease. -Chronic kidney disease. -Atrial fibrillation. -Anxiety disorder. *The physician was contacted on 3/4/24 and an order was received to continue monitoring the burn area. Apply cold/ice pack as needed. *An additional physician's order was received on 3/5/24 for Sulfadiazine cream to burn twice daily with an applied thickness of 1/16 inch. *Wound assessments and physician-ordered wound treatment was reviewed and completed by nursing staff. *The wound was healing. Review of resident 2's 1/15/24 admission Hot Liquids Safety Evaluation revealed: *The total score of the evaluation was four, that indicated she was at risk for injury related to handling hot liquids, and individualized interventions were to have been put in place. *Section B: Made decisions regarding tasks of daily life was documented with a score of one, and marked modified independence. *Section G: Demonstrates ability to handle eating equipment (cup, glass, utensils) was documented with a score of three, and marked no. *Section III: Determination -I. --A was blank: A Score of 3 or > (greater) list interventions put in place, in comments section below. --B was documented: Resident is not considered to be at risk related to hot liquids at this time. -II. The additional comments section was blank. Review of resident 2's 3/5/24 Hot Liquids Safety Evaluation revealed: *The form was documented with a score of four. *However, the evaluation was still documented: Resident is not considered to be at risk related to hot liquids at this time. *A note was added in the comments section, Resident used a cup for hot water that was not appropriate for hot water and it melted. Review of resident 2's 1/15/24 care plan revealed: *Interventions: [Resident name] has a burn to her inner right thigh from hot liquid. [Resident name] was educated on the importance of proper container use, use of a lid, and to ask for help pouring and transporting hot liquids. Initiated: 3/8/24. *Those interventions were not added to her care plan until after the resident was burned with hot water on 3/4/24. *If nursing staff had completed the admission Hot Liquids Safety Evaluation correctly, resident 2 should have had staff assistance when she had hot liquids from the time of her admission and the need for staff assistance would have been added to her care plan at her admission. Interview on 3/13/24 at 9:45 a.m. with resident 2 in her room revealed: *She was seated in her wheelchair next to her bed. *When asked about the incident that had resulted in her burn, she said she used a plastic cup that she thought would work for hot drinks. *She was in the central dining area after breakfast. *She went to the coffee/hot water dispenser while in her wheelchair to make a cup of hot tea. *She put hot water into her plastic cup, placed the cup between her legs, and wheeled out of the central dining room into the hall and toward her room. *Shortly after she got to the hall, she felt a hot sensation against the skin of her legs, yelled, and threw the cup from between her legs and onto the floor. *A nurse came over and helped her to her room and placed a cold cloth on the area. *The plastic cup had melted from the hot water. *The nurses would check the area twice a day, put a cream on it, and cover it with a bandage. *The wound was healing. *She had gotten hot beverages independently since her admission and that was the first time she had been burned. *After the burn incident, a nurse asked her to request staff assistance when she wanted hot beverages and she agreed to that. *The cup that she used when she had gotten burned was thrown away after the incident. 2. Observation on 3/12/24 at 12:23 p.m. in the central dining room with resident 3 revealed: *She left her spot at the dining room table, and wheeled her wheelchair next to the coffee/hot water dispenser. *She placed an insulated cup under the coffee spout, filled the cup with coffee, placed a lid on top of the cup, set the cup to her right between the side of the wheelchair and her right thigh and then wheeled back to her room. *Staff were present in the central dining room assisting other residents with their meals, but none of the staff approached and offered assistance to resident 3 with the hot coffee. Review of resident 3's EMR record revealed: *She was admitted on [DATE]. *Her BIMS score of 14 indicated her cognition was intact. *Her diagnoses included the following: -Cerebral Palsy -Adrenal gland disorder -Cancer of the left lower lung and bronchus -Anemia -Charcot's joint, left ankle and foot -Unsteadiness Review of resident 3's Hot Liquids Safety Evaluation revealed: *She had not had an evaluation completed in the last quarter *Her last evaluation was completed on 2/25/23 with a score of 4. *That score indicated she would require interventions regarding hot liquids and staff assistance. Review of resident 3's revised 3/5/24 care plan revealed: *There were no interventions related to the resident's handling hot liquids or the need for staff assistance. Interview on 3/12/24 at 4:45 p.m. with administrator A regarding residents 2 and 3 revealed: *Hot Liquids Safety Evaluations were to have been completed on admission, quarterly, and with a significant change of condition. *The Minimum Data Set (MDS) coordinator was primarily responsible for completing the Hot Liquids Safety Evaluations when the MDS assessments were done. *The floor nurses would complete the Hot Liquids Safety Evaluations when needed. *She confirmed that resident 2 and 3's evaluation forms had been documented incorrectly. *If a resident had scored higher than a three on the evaluation, the resident should have had staff supervision which would include the staff getting the hot beverage and delivering it to the resident in their room or the dining area. *Education on how to complete the evaluations would be prioritized to ensure the forms were completed accurately. *She agreed resident 2 should have had staff assistance according to their Hot Liquids Safety Evaluation scoring. *Resident 3 should have had a hot liquid evaluation completed the past quarter. *On prior evaluations resident 3 had scored a three or higher and should have had staff supervision with hot liquids. *The nurses had difficulty with completing the evaluations due to other duties on the floor. *They had issues filling the MDS coordinator position and had not had someone in that position consistently. -The current MDS coordinator was new to the position and had started at the beginning of 2024. Review of the provider's revised 3/23/23 Hot Liquid Safety policy revealed: *Hot Liquid Safety Evaluation will be completed on admission, re-admission, quarterly, with significant change, and as needed. *The Hot Liquid Safety Evaluation includes the following: -Vision -Decision Making Ability -Altered Level of Consciousness -Psychomotor Retardation -Upper Extremity Impairment -Upper Extremity Tremors -Ability to handle eating utensils -Diagnoses *Procedure: 1. Complete the [facility corporate name] Hot Liquids Safety Evaluation (West) to determine if the resident scores 3 or greater. 2. If resident scores 3 or greater proceed to care plan and implement individualized interventions for safe handling of hot liquids.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on the South Dakota Department of Health (SD DOH) complaint online report, record review, interview, and policy review, the provider failed to follow physician orders to provide pain medication before scheduled wound care was completed for one of one sampled resident (1). Findings include: 1. Review of the South Dakota Department of Health facility complaint online report revealed: *A family member of resident 1 had concerns regarding the resident receiving his pain medication, specifically his oxycodone that was prescribed for pain. *That family member reported that resident 1 was frequently in pain, would cry out in pain, and noticed a substantial decline in his health. *On 2/10/24 the resident requested to go to the emergency room (ER) due to complaints of his pain and rated his pain a 10 out of 10 scale rating (A pain scale with 10 being the worst pain you could experience) according to the records provided. The resident was admitted to the hospital for acute encephalopathy and cellulitis of the right lower extremity. He was later discharged into hospice care on 2/13/24 and passed away on 2/16/24. 2. Review of resident 1's electronic medical record (EMR)revealed: *The resident's diagnoses included Type 2 diabetes, chronic kidney disease, atherosclerotic heart disease, depression, and a history of [NAME]-[NAME] disease (a genetic disorder that caused blisters and erosions on the skin). *There were multiple days in January 2024 where there was no pain rating obtained by staff or only one pain rating documented for resident 1. * A Wound Care progress note dated 1/10/24 indicated that the resident had an unstageable pressure ulcer (An ulcer that has full-thickness skin and muscle tissue loss and covered in dead tissue making it difficult to stage) measuring 4 centimeters (cm) in length x 3 cm in width with no measurable depth with an area of 12 square (sq) cm. The resident reported pain 10/10 on the pain scale. *Resident 1's Medication Administration Record (MAR) indicated that he only had acetaminophen for pain as needed for pain twice daily. That was not administered on 1/10/24 when resident complained of the above 10/10 pain. *Wound nurse/licensed practical nurse (LPN) C had sent a fax on 1/10/24 to the resident's medical provider that stated, CNP [certified nurse practitioner] wound provider recommends lidocaine 4% gel or stronger oral pain medication for dressing changes based on 10/10 [pain scale] rating with recent dressing changes. Would you approve lidocaine and recommend an oral pain medication? *The medical provider's order was received and noted on 1/12/24 for lidocaine gel, would schedule Tylenol at that time. Administer tramadol 25 milligram (mg) thirty minutes before the dressing change, no more than once daily. *Review of the resident 1's January MAR revealed: -A physician order dated of 1/12/2024 for tramadol 25 mg tablet by mouth for thirty minutes before the scheduled dressing change. -A physician order for acetaminophen 500 mg tablet by mouth as needed for mild pain was only administered four times in the month of January (Dressing changes to resident 1's right heel was scheduled daily). *Review of resident 1's January Treatment Administration Record (TAR) revealed that the resident received wound care to the right heal on 1/12/24 through 1/21/24. *According to the January MAR the resident only received the tramadol 25 mg in four out of the ten dressing changes scheduled from 1/12/24 through 1/21/24. *According to the January MAR lidocaine gel was not documented as being administered from 1/12/24 through its discontinued date on 1/23/24. *Wound nurse/LPN C had sent a fax on 1/22/24 to the resident's medical provider stating Resident c/o [complains of] 10/10 pain with dressing changes with new order of tramadol 25 mg. Would it be possible to increase? Wound care CNP would like to debride site but still too painful with this medication and lidocaine. *An order was received and noted on 1/23/24 to increase tramadol to 50 mg PO (by mouth) daily PRN [as needed] with dressing changes. *Resident 1's January TAR revealed that resident 1 received wound care daily from 1/24/24 through 1/31/24. *Resident's January MAR revealed that resident had only received tramadol 50 mg before the scheduled wound care twice out of eight dressing changes. *On 2/1/2024 the resident was prescribed oxycodone 5 mg tablet by mouth every 6 hours as needed for pain. That medication was to have been given thirty minutes before the residents scheduled dressing changes. *The February TAR indicated that the resident received wound care from 2/2/24 through 2/8/24. *Resident 1's February MAR indicated that the resident had not received the oxycodone 5 mg tablet before his scheduled dressing change on 2/3/24, 2/7/24, and 2/8/24. *A nursing progress note dated 2/4/24 at 9:55 a.m. stated, Yelling out of room wanting for staff [requesting staff assistance], not using call light. Non-pharmacological interventions: reorientation to situation. Pharmacological intervention: NA *There was no documentation found that the resident's pain had been assessed or that the physician-ordered pain medication was offered or administered at that date and time. *A nursing progress note dated 2/7/24 at 4:26 p.m. stated that resident refused wound care (That was confirmed to have been due to his pain through an interview with wound nurse LPN C on 2/13/24 at 4:30 p.m.) *A nursing progress note dated 2/8/24 at 1:48 p.m. stated Resident attention seeking, moaning, and yelling from room all day long and stopped when wife and daughter came to visit resident. As soon as [the] family [had left,] resident started to moan and yell from [his] room despite all needs being met. Despite medication being given on time . No non-pharmacological or pharmacological interventions were noted. *Review of the February 2024 MAR indicated that on 2/8/24 the resident received his scheduled morning dose of acetaminophen 1000 mg, but the physician ordered oxycodone 5 mg had not been administered. *A progress note dated 2/8/24 from the resident's primary care provider CNP stated Resident continues to complain of right heel pain. Review of the [February 2024] MAR shows Oxy IR [oxycodone immediate release] has not been utilized to fullest extent. Resident had only received four doses [of the Oxy IR] since the initiation of that medication ordered on 2/1/24. He had been receiving scheduled acetaminophen twice daily. He had one additional PRN [as needed] dose of acetaminophen that could have been utilized. He had received no PRN doses of acetaminophen since [the physician's order] change on 2/1/24. His pain does not appear to be well managed with PRN dosing. *The resident's pain was only assessed once on multiple days in January 2024 other days there was no assessment of his pain documented. *Resident 1's care plan dated 12/26/23 revealed that the pain interventions included the following: -Evaluate the efficacy of pain management. -Medicate before therapy and treatment. -Notify the physician if there was inadequate pain relief. -Observe for non-verbal signs of pain. -Provide analgesics as ordered. -Utilize non-pharmacological interventions. 3. Interview on 3/12/24 at 1:45 p.m. with LPN/wound nurse C revealed: *When asked about the resident's pain medication before the resident's scheduled dressing change. She stated that he would often refuse medications and his scheduled dressing changes due to his complaints of pain. *She was only able to provide documentation for one day where resident 1 had refused his dressing change. When asked specifically about the lidocaine gel she stated that the wound care CNP normally would apply it for the resident's wound debridement and that was why it was never documented on the MAR. 4. Interview on 3/12/24 at 3:10 p.m. with long term care (LTC) unit manager E revealed the resident's pain was supposed to have been assessed every shift. 5. Interview on 3/13/24 at 10:30 a.m. with LPN/wound nurse C and director of nursing (DON) B revealed: *They were not able to locate any documentation for the dates requested that the physician ordered pain medication was administered before the scheduled dressing changes and documented in the MAR for resident 1. *They both agreed that if it was not documented they would not be able to prove that the resident received his pain medication before his dressing change. *When asked how it was determined that medication was ineffective when the dosage increases were requested, they were not able to answer that question. *DON B expected that the resident would have been assessed for pain and administered his pain medication before his scheduled wound care. 6. Review of provider's March 2023 Pain Management Policy revealed: *The process for managing pain included assessing for potential pain, recognizing the presence of pain, identifying characteristics of pain, addressing the causes of the pain, developing and implementing interventions for pain (including pharmacological and non-pharmacological interventions), monitoring effectiveness of the interventions, and modifying interventions as necessary. *Comprehensive pain assessments were to have been completed upon admission, with the quarterly review, whenever there was a significant change in condition, and when there was onset of new pain. *Pain was to have been assessed at least twice daily during the day and the night shifts.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. Observation on 11/2/23 at 11:20 a.m. of resident 37 revealed: *The resident was sitting in her recliner with a walker next to the recliner and she was watching TV. The call light was attached to the recliner. *The resident was able to respond to questions asked appropriately but was confused as to why she was being asked questions. Interview on 11/2/23 at 11:25 a.m. with CNA I regarding resident 37's care revealed: *The resident was able to reposition herself. *Resident 37 would ambulate with a gait belt and assist of 1 staff member and a walker. *CNA I thought the pressure ulcer on the coccyx was healed. *Staff would attempt to assist the resident to the bathroom every 2 hours, but the times could be inconsistent from 1.5 hours to 2.5 hours dependent on staff availability. Review of resident 37's 10/2/23 care plan revealed the following interventions: Apply a moisture barrier to the peri-area after an incontinent episode. The call light should be in reach. Remind, offer, and assist the resident with toileting as needed. Review of resident 37's EMR revealed: *The resident had diagnoses of the following: -Unspecified dementia. -Mild protein-calorie malnutrition. -Iron deficiency anemia. -Type II diabetes mellitus. *Resident was on a constant carbohydrate diet. *The November 2023 Medication Administration Record (MAR) for resident 37 revealed resident 37 was taking Preservision multivitamin 2 caps once daily for a supplement. No other supplements for the pressure ulcer had been ordered. *A 10/11/23 Braden scale and clinical evaluation indicated resident 37 was at low risk for developing pressure ulcers with a score of 22. *A 10/14/23 progress note revealed the following: -A CNA reported a skin alteration for resident 37. -The note reported a blanchable red area measuring 0.5 cm x 0.5 cm, intact area on the coccyx. -The progress note also reported redness to the bilateral groin area. -The area was cleansed with soap and water, patted dry, and barrier cream was applied. -The resident's physician and family were notified. -The manager on call was also notified. *A 10/19/23 progress note revealed a Stage 2 (partial thickness loss of dermis presenting as a shallow open ulcer with red or pink wound bed without slough or bruising) coccyx pressure ulceration, which was previously thought to have been MASD (Moisture Associated Skin Damage). -The area of redness/MASD measured 9.2 cm x 5.8 cm. -The opened pressure ulcer area measured 1 cm in length x 1 cm width x 0.01 cm depth. -Intervention for the coccyx area included cleansing with normal saline or soap and water then covering with a bordered foam dressing every 3 days or as needed if soiled or removed. Review of resident 37's 10/2/23 care plan revealed: *The resident had a pressure ulcer to her L (left) lateral ankle and coccyx area. *Interventions included: -The wound treatment mentioned above. -Keep skin clean and dry. -Pressure relieving mattress. -Reposition at least every 2 hours. -Heel protection boots at bedtime. Review of the October 2023 Treatment Administration Record (TAR) revealed: *Wound care to the coccyx started on 10/19/23. *Wash the area with soap and water or normal saline and cover with bordered foam dressing every three days and as needed if soiled or removed. Telephone interview on 11/2/23 at 12:08 p.m. with resident 37's daughter revealed: *She stated that she believed the pressure ulcer on her mother's coccyx was a result of not being toileted regularly. *She stated that family had concerns about staff providing proper care to their mother specifically on the weekends. Observation on 11/6/23 at 11:24 a.m. of LPN/wound nurse R completing skin monitoring on resident 37 revealed the area on the coccyx was healed. Interview on 11/9/23 at 09:21 a.m. with LPN/would nurse R regarding resident 37 revealed: *The initial pressure ulcer prevention interventions that were started on the 10/2/23 admission included the following: -Two-hours bathroom checks. -Pressure relieving mattress. *The resident had a blanchable reddened area on right side of the coccyx that was identified on 10/14/23 related to MASD due to incontinence. *A 10/16/23 wound round form revealed, that resident 37 had a reddened area on the coccyx measuring 9.2 cm in length x 5.8 cm in width x 0.01 in depth. *A moisture barrier cream was ordered on 10/16/23 to have been applied during bathroom changes. *New interventions and care changes were communicated to CNAs through morning stand-up huddles, the resident's care plan, and the [NAME]. Review of resident 37's [NAME] revealed there was no moisture barrier cream listed. *LPN/Wound nurse R stated that the barrier cream was best practice and stated she had no concerns that the intervention was getting done. Barrier cream use for the resident was not documented by the staff. *A 10/19/23 wound round form revealed a stage 2 pressure ulcer with an open area pressure ulcer measuring 1 cm x 1 cm x 0.01 cm. *The wound healed on 11/4/23. Interview on 11/9/23 at 11:05 p.m. with DON B, LPN unit manager J, and regional nurse consultant HH revealed: *A grievance was filed by the resident's daughter-in-law on 10/13/2023. The grievance report indicated a concern that the family had not felt that the resident had been changed regarding her incontinence all morning and that she had not received breakfast. *When asked how interventions for bath rooming every 2 hours was being completed, regional nurse consultant HH stated they could not ensure that residents were toileted every two hours. 3. Observation on 10/31/23 from 11:09 a.m. through 2:11 p.m. revealed: *Resident 39 was lying in bed with a foot cradle supporting the blankets off of her feet. *Heel protector boots were lying on the sink counter in the resident's room. Observation and interview on 10/31/23 at 2:21 p.m. of CNA U performing personal care for resident 39 revealed: *CNA U stated that resident 39 stayed in bed much of the time throughout the day and night. *She was supposed to have been repositioned every 2 hours while she was in bed. *When asked about the heel protector boots, CNA U was not aware when resident 39 was to wear those heel protector boots. *CNA U used a rounding sheet to provide care for those residents she had been assigned to care for. *The rounding sheet that was used for resident 39's care had not listed the heel protector boots. Observation on 10/31/23 at 4:54 p.m. revealed resident 39 was lying in bed and was still not wearing those heel protector boots. Review of the October 2023 TAR revealed that LPN MM had documented that resident 39's heel protector boots were on during the day of 10/31/2023. Review of resident 39's 7/11/23 care plan revealed: *The resident had the potential for impairment to skin integrity. *The intervention included heel protection boots should have been on at all times. Interview on 11/3/23 at 3:09 p.m. with LPN/unit manager M revealed CNAs would use the [NAME] and the rounding sheet to provide care and implement interventions for the residents from the information listed on the [NAME] and the rounding sheets. Review of resident 39's EMR revealed: *A 10/24/23 Braden scale and clinical evaluation indicated the resident scored a 12 and was categorized at high risk for skin breakdown. *A 06/22/23 Skin Evaluation indicating that resident 39 had a stage I pressure ulcer (a reddened, painful area on the skin that does not blanch when pressed) on her R (right) great toe measuring 0.8 cm in length and 0.5 cm in width and a stage I pressure ulcer on her R second digit that measured 0.5 cm in length and 0.3 cm in width. *A foot tent was ordered to keep the blankets off of her feet, heel lift boots were to be worn, and a low-loss air mattress to the bed. Interview 11/6/23 8:53 a.m. with CNA W was employed with a contract agency revealed: *She stated that today was her first shift on her assigned wing. *When asked how she would know what the care needs were for resident 39, she stated that she was given a rounding sheet with their resident's code status and how the resident's transfer. *When asked about the heel protector boots sitting in the resident's wheelchair. She had no knowledge about them or if they needed to have been placed on the resident's feet. *CNA W admitted she did not known much about the resident and was going to assist the resident out of bed until she was stopped by another staff member that explained to her that the resident stays in bed. Observation on 11/6/23 at 9:58 a.m. revealed resident 39 lying in bed and the heel protection boots were still sitting in the resident's wheelchair in her room. Interview on 11/6/23 at 9:59 a.m. with RN NN regarding resident 39 revealed: *She had been employed for a month. *She had no knowledge as to when the heel protector boots were supposed to have been on but reviewed the resident's EMR and stated that those heel protector boots should have been on at all times. *When asked where that intervention was documented to ensure the heel protector boots were put on, RN NN reported that she had documented that the heel protector boots were on but acknowledged that she had not checked to ensure those heel protector boots were on prior to documenting in the EMR. Interview and review of resident 39's [NAME] on 11/7/23 at 9:44 a.m. with LPN/wound nurse R revealed. *The heel protector boots should have been listed on the [NAME] so that the CNAs caring for resident 39 knew those boots should have been on at all times. *It was confirmed by LPN/wound nurse R that the heel protection boots were not listed on the [NAME]. *LPN/wound nurse R stated that she would have completed a teachable moment with the CNA. That would have been an informal reeducation for the CNA regarding the heel protector boots. Interview on 11/9/23 at 10:32 a.m. with LPN unit manager M regarding resident 39's pressure ulcers to her toes revealed: *The cause of the resident pressure ulcers on her toes were from the friction of the resident's sheets. The resident would wrap herself in the sheets and the heel protector boots still left the toes exposed to the friction of the bed sheets. *The foot cradle was ordered and the pressure ulcers to the toes have since healed. *They were starting to use the rounding sheet more by adding more interventions for the residents. *She agreed that communication was an issue with ensuring that direct care staff implemented resident's care plan interventions. Interview on 11/9/23 at 11:05 a.m. with director of nursing (DON) B, LPN unit manager J, and regional nurse consultant HH revealed: *Unit managers were responsible to ensure that interventions and changes to the resident's care plans were communicated to direct care staff. *That was completed through the [NAME], rounding sheets, and staff stand-up huddles. *All direct care staff were given access to Point Click Care (the provider's electronic medical record). *Managers would educate direct care staff on how to use Point Click Care and where to find the [NAME]. -LPN unit manager J was attempting to develop a better system to communicate interventions to the direct care staff and was currently working with quality improvement on the issue. Review of the 3/23/23 Skin and Pressure Injury Prevention Program Policy revealed: *Nursing personnel who would have been providing care to the residents would have been instructed in the individual interventions for each resident. *Nursing personnel would monitor response to the resident's plan of care and ensure implementation of the resident's individualized plan of care. Based on observation, interview, record review, and policy review, the provider failed to ensure interventions that had been put in place were consistently implemented and documentation was consistent for four of four sampled residents (3, 37, 39, and 193) who developed pressure ulcers after admission to the facility. Findings include: 1. Interview on 10/31/23 at 10:30 a.m. with resident 193's wife revealed she had found a large blister on his right heel the previous night. She was surprised staff had not found it. She had informed the nurse at that time. The nurse had placed a foam dressing over his right heel the morning of 10/31/23. They had given him heel protector boots. He had told her his heels were causing him pain. Observation and interview on 10/31/23 at 10:30 a.m. with resident 193 revealed: *He was seated in his wheelchair. *He had bilateral heel protector boots on. *The back part of his heels on both of his feet rested against the outer edge of the foot pedals. *He stated his heels hurt and liked to keep his feet off of the foot pedals. Observation and interview on 11/2/23 at 9:19 a.m. with licensed practical nurse (LPN)/wound nurse R and registered nurse (RN) L of resident 193's heels after his shower revealed: *A large intact blister on his left heel. *A large opened area with the skin from the blister attached to his right heel. *LPN/wound nurse R would be measuring and placing dressings on his heels after she had clarified the treatment order. *No dressing was applied to his heels at that time. Observation on 11/2/23 at 11:30 a.m. of resident 193 revealed he was seated in his wheelchair. He had slipper socks on both feet. He did not have his heel protector boots on. Review of a 11/2/23 11:10 a.m. progress note by LPN/Wound nurse R revealed: *She had contacted the dermatologist office on 11/1/23 regarding his bullous phemigoid (a rare skin condition that causes large, fluid-filled blisters. They develop on areas of skin that often flex such as the lower abdomen, upper thighs, or under the arms.) and the blisters on his heels. *The dermatologists nurse reported back to her that their team felt the blisters on his heels were a manifestation of his bullous pemphigoid due to recently finishing prednisone. *Resident 193 will see the dermatologist on 11/15/23 for a full review at that time. Observation and interview on 11/2/23 at 3:00 p.m. of a dressing change for resident 193 by LPN/wound nurse R and RN/Minimum Data Set (MDS) coordinator E revealed: *He was lying in bed without his heel protector boots on. *He had no dressing on either of his heels. *An Optifoam Gentle EX dressing was placed on each of his heels. *His left heel blister was intact and measured 3.0 centimeters (cm) in length by 3.8 cm in width. *His right heel had an open blister that was reddened and had no drainage. The measurements were 3.1 cm in length by (X) 4.8 cm in width X 0.1 cm in depth. *LPN/wound nurse R stated a new service My Wound Care Plus would be making an initial visit on 11/13/23. Either a physician or a nurse practitioner would come and assess resident's wounds and order treatments. *LPN/wound nurse R stated the blisters on his heels were from his bullous phemphigoid. *She agreed the dermatologist had not seen the blisters to ensure they were not pressure ulcers. *She agreed the blisters were full skin thickness and looked different than the other blisters he had. *She agreed she did not know a lot about bullous phempigoid. Observation on 11/6/23 at 9:35 a.m. revealed resident 193: *Seated in his wheelchair in his room and he was wearing his regular shoes. *His heel-protector boots were lying on his bed. Interview on 11/6/23 at 10:00 a.m. with certified nursing assistant (CNA) T revealed: *She was a traveling CNA and picked up shifts at the facility and was under contract for thirteen weeks. *She had not worked on the yellow hall, where resident 193's room was located, prior to today. *Shift change rounds were completed with the night CNA. *Used a report sheet when making rounds and could write more information on the sheet regarding the care of the residents. *Stated she had given her report sheet to someone else. *Found a report sheet for the yellow hall and agreed the information for resident 193 only included his code status and how he was to have been transferred. *Stated it had not been reported to her that he had pressure ulcers to his heels, was to wear heel protectors, and was not to wear regular shoes. *Observations on 11/6/23 at 11:00 a.m. and again at 12:01 p.m. revealed resident 193 was in the hallway by his room and then in the dining room. He was not have wearing his heel protector boots. Continuous observation on 11/6/23 from 4:15 p.m. through 4:49 p.m. of resident 193 revealed he was lying in bed on his back. He did not have the heel protector boots on. His feet were slightly elevated on a pillow, but his heels were still touching the bed. He was only wearing socks. Interview on 11/6/23 at 4:57 p.m. with LPN D regarding resident 193's heel protector boots revealed: *She stated that resident 193 had his heel protector boots on today. *When she was informed of the above observations and the interview with CNA T she stated she was surprised by that. She was sure she had observed him with them on. *Report in the mornings for the CNA's was the off-going CNA would give report to the on-coming CNA. *The nurse would inform the CNAs if there had been any changes with the residents. *She would not review the residents conditions with the CNAs if they had not worked in the halls. *She thought the off-going CNA would have informed them of what care the residents required. Interview on 11/6/23 at 6:00 p.m. revealed LPN/unit manager J and RN/MDS coordinator E stated they had given CNA T education regarding resident 193's need for his heel protector boots. Observations on 11/7/23 at 8:05 a.m. and again at 10:00 a.m. revealed resident 193 did not have his heel protector boots on. He had regular shoes on and was seated in his wheelchair. The first observation in the dining room and the second one was in his room. The heel protector boots were observed lying on the floor between his bed and his bedside table. Interview on 11/7/23 at 11:16 a.m. with CNA W regarding resident 193 revealed: *When asked why he did not have his heel protector boots on earlier. She stated she had initially been told he did not need them and then was told he did when she laid him down in bed. *She was not sure who had told her he did not need the heel protector boots. *She had not worked on the yellow hall prior to today. *She was a traveling CNA. *She had access to the resident [NAME] but had not looked at it to check what each resident needed. Review of resident 193's electronic medical record (EMR) revealed: *He was admitted on [DATE] after a hospitalization. *His diagnoses included: Parkinson's and mild cognitive impairment. *A previous diagnosis of bullous pemphigoid disorder was added on 10/27/23 from his dermatologist. Review of resident 193's 10/24/23 nursing admission assessment revealed he had: *Bruising to the top front of his left hip, right shin, and left shin. *He had complaints of feeling pins and needles sensation in his feet. Review of resident 193's 10/24/23 admission Braden Scale (assessment used for the risk for developing pressure ulcers) and clinical evaluation documentation revealed his score was a 5 which placed him at high risk for developing a pressure ulcer. Review of resident 193's 10/24/23 baseline care plan revealed: *Skin integrity had been triggered from his initial nursing assessment. *The interim focus area was Resident has (Specify: potential for/an actual) impairment to skin integrity. Potential for or an actual skin impairment had not been specified. *Goals included: -Resident will continue to have skin intact. *Interventions included: -LOW RISK - Skin weekly. Report changes to the nurse. *Off load heals as ordered and turn and reposition every two hours and as needed had not been chosen as interventions. Review of resident 193's skin alteration evaluation's revealed: *On 10/27/23 he had a blister to the shin of his left leg and a skin tear to his right elbow. *On 10/29/23 closed blisters to his bilateral heels had been added. *On 11/5/23 the only documentation was for other. Scattered blisters due to bullous pemphigoid diagnosis. Review of resident 193's 11/1/23 Braden Scale and clinical evaluation documentation revealed his score was a 13 which placed him at high risk for developing a pressure ulcer. Review of resident 193's 11/2/23 wound assessment for his right and left heel blisters revealed: *His left heel blister was intact and had not been classified as a pressure injury or staged. *His right heel blister was open and had not been classified as a pressure injury. It's clinical stage was listed as Partial Thickness. *Both were facility acquired. Review of resident 193's care plan for skin impairment revealed: *Focus revised on 11/2/23. -[Resident] has an actual impairment to skin integrity skin tear to right hand and bulbous [bullous] pemphigoid. This is a chronic skin issue and will continue to develop blister to all areas of my skin and it is unpreventable. I am seen by [name of dermatology clinic]. *Goal had not been updated since 10/27/23. *Interventions: -Revised 11/2/23 Coordinate care with [name of dermatology clinic] and primary care provider and determine plan of care and any treatment needed. -Revised 11/2/23 High Risk-Skin weekly. Report abnormalities to the nurse. *There had been no interventions added to specify the treatment for his bilateral heel blisters. *There had been no interventions added to specify any preventative skin interventions for other skin conditions other than his bullous phemphigoid. Review of a 11/3/23 physician's order revealed resident 193's primary care physician deferred any wound care to Dakota Dermatology. Review of a 11/7/23 faxed communication to the dermatologist revealed Resident has light bleeding to blister at right heel, ok to use collagen one a day until resolved or until seen by you clinic? There had been no reply from the dermatologist by the end of the survey on 11/9/23. Review of resident 193's [NAME] as of 11/6/23 revealed under resident care: *Assist with application of appliances if needed. *High-risk skin inspections weekly, Report abnormalities to the nurse. *There were no specific instructions for his heel protector boots. Review of the CNA skin monitoring observation documentation from 10/25/23 through 11/6/23 for the question Does the resident have a skin alteration? Yes was only documented on 10/29/23, 10/31/23, 11/4/23, and 11/6/23. Interview on 11/8/23 at 3:59 p.m. with director of nursing (DON) B and regional nurse consultant HH revealed: *Wound rounds were done weekly. *DON B stated LPN/wound nurse R would be taking a wound care course. *Had not been aware resident 193's intervention for bilateral heel protector boots had not been consistently followed. *They were not aware LPN/unit manager J had provided education to CNA T regarding resident 193's heel protector boots. *Agreed after LPN/unit manager J had provided education to CNA T The intervention should have been entered on the [NAME]. Review of the provider's 3/23/23 Pressure Injury Prevention policy revealed: *General preventative measures included: -Repositioning, need for a specialized mattress, wheelchair cushion, reducing friction, and shear. *Interventions and preventative measures would be implemented for resident with risk factors of moisture, friction and shear, bed-fast resident, chair-fast residents, immobility, bowel and/or bladder incontinence, poor nutrition, and impaired cognitive status. *Additional clinical conditions, treatments, and abnormal laboratory values could also indicate a resident was at risk for a pressure injury. Those included: -Impaired/decreased mobility and decreased functional ability. -Conditions, such as end stage renal disease, terminal cancer, or diabetes. -Medications that could affect would healing. -Blood flow impairment. -Cognitive impairment. -A healed ulcer. The history of a healed pressure injury and its stage is important since areas of healed stage 3 or 4 pressure injuries are more likely to have recurrent breakdown. 4. Interviews and observations on 10/31/23 at 4:15 p.m., 11/2/23 at 9:45 a.m. and again at 3:40 p.m. with resident 3 revealed she: *Was in her room seated in a recliner chair watching television. *Was not able to carry on an extensive conversation during each visit, but responded to questions that indicated she had no concerns. Review of the 10/22/23 quarterly Minimum Data Set (MDS) assessment for resident 3 revealed: *The Submission Information for MDS was listed as export ready, which indicated it had not yet been submitted. *Her Brief Interview for Mental Status (BIMS) was scored at 03, which indicated she had severe cognitive impairment. *No behaviors, mood indicators, or reports of pain were coded on the MDS. *She needed a helper to perform more that 50 percent of the effort with all mobility tasks. *She frequently incontinent of bladder but continent of bowel. *Skin conditions was marked as No pressure ulcer/injury and Yes for skin tears. Review of resident 3's care plan revealed actual impairment to skin integrity stage I [one] pressure ulcer to right buttock, date initiated: 10/09/2023, revision on: 10/17/2023. Review of the Order Summary for resident 3 revealed order dates of: *4/13/23, Pressure relieving mattress. *7/13/23, SKIN CARE: Apply bordered foam dressing for protection (sacrum) change q [every] 3 days or as needed every day shift every 3 day(s). *10/17/23, WOUND CARE: Cleanse open area to right buttock with wound cleanser and cover with bordered optifoam. Change dressing every 3 days and prn [as needed] if soiled. Reposition resident as frequent as possible and monitor area for any signs of infection and update provider if signs are present. Hospice nurse to assess weekly. one time a day every 3 day(s) for skin alteration AND as needed for skin alteration change prn if soiled. Review of the weekly Skin Evaluations revealed: *On 10/13/23, Resident has alteration in skin integrity was marked as Yes. Coccyx was listed as the Site with a description of redness under the heading for NON PRESSURE ULCER. There was no documentation in Additional Skin/Treatment Note. On 10/15/23, Resident has alteration in skin integrity was marked as Yes. Right gluteal fold was listed as the Site with the Type of open area under the heading for PRESSURE ULCER. The measurements for Length [L], Width [W], and Depth [D] were blank, and the Stage was not selected. Review of Skin/Wound notes for resident 3, written by LPN/wound nurse R, revealed: *On 10/9/23, the first note to acknowledge the wound, Reviewed open area to resident right buttock. Current measurement: 1.9 [centimeters (cm)] x [by] 1.7 x 1.01 cm. Applied wound care per current orders. *On 10/16/23, Current measurement: 1.8 x 1.5 x 0.02 cm. *On 10/17/23, Reviewed open area to resident right buttock with hospice nurse. Hospice nurse staged as a pressure I [one] injury ro right coccyx, continuing with plan of mepilex every 3 days. Amending wound rounds ot [to] show as stage I pressure injury. *On 10/23/23, Reviewed pressure ulcer to resident right buttock with [hospice] RN. Current measurement 1x1.1x0.02cm. Review of WOUND ASSESSMENT DETAILS REPORT for resident 3, completed by LPN/wound nurse R, revealed the wound decreased in size but was consistently labeled as a skin tear instead of a pressure ulcer, as follows: *On 10/9/23, right buttock, Type Skin Tear, Classification Type 3: Total Flap Loss, Source: Facility-acquired, Date identified: 10/3/23, Clinical Stage: Full Thickness, Size (cm): 1.90 x 1.70 x 0.01 (L x W x D). *On 10/16/23, Type and Classification the same as 10/9/23, Size (cm) 1.80 x 1.60 x 0.02 (L x W x D). *On 10/23/23, Type and Classification the same as 10/9/23, Size (cm) 1.10 x 1.10 x 0.02 (L x W x D). *On 10/30/23, Type and Classification the same as 10/9/23, Size (cm) 1.00 x 1.10 x 0.02 (L x W x D). *On 11/4/23, Type and Classification the same as 10/9/23, Size (cm) 0.40 x 0.30 x 0.01 (L x W x D). Interview on 11/8/23 at 4:18 p.m. with DON B and RNC HH revealed there was a discrepancy between the type and classification of skin tear or stage I pressure ulcer on the Skin Evaluations, Skin/Wound Notes, and the Wound Assessment Detail Reports. Interview on 11/8/23 at 5:04 p.m. with RN/MDS coordinator E revealed she: *Believed the coding of skin tear on the 10/22/23 export ready MDS was accurate. *The first note that identified it as a pressure ulcer was 10/23/23, which was after the assessment reference date (ARD) of 10/22/23 for the MDS. Interview on 11/8/23 at 5:32 p.m. with RN/MDS coordinator E and LPN/wound nurse R revealed they confirmed the wound was a pressure ulcer before the ARD and the MDS coding would have to be changed before it was submitted.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the facility failed to ensure sufficient nursing staff to provide care or complete/accurate documentation for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253). The census of the facility was 95 at the time of the survey. These failures placed residents at risk for unmet care needs and negative outcomes. Findings include: 1. The provider failed to ensure staff were provided with accurate information about each resident's transfer equipment needs, including sling size, and were competent to safely use the mechanical lift equipment for nine of twelve sampled residents (1, 9, 24, 32, 33, 60, 77, 79, 244). Refer to F689 Base A. 2. The provider failed to ensure staff provided adequate supervision, appropriate interventions, and adequately understood the door exit system to prevent unwitnessed elopements for two of two sampled residents (10 and 55). Refer to 689 Base B. 3. Interview on 10/31/23 at 10:30 a.m. with resident 6 regarding call light response time revealed: *It had taken an hour and an half [90 minutes] one time to answer her call light. *Staff would have answered her light then would have returned later to help her. Interview on 11/6/23 at 10:10 a.m. with sixteen residents (5, 7, 12, 19, 23, 28, 38, 46, 53, 58, 62, 67, 71, 73, 74, and 81) who attended resident council meetings replied with the following: *When asked if the residents received the help and care they needed without waiting a long time, the residents stated, -Call light buttons are not being answered. -It can be 3-4 [three to four] hours at night. -The staff stick their hand through the doorway and turn off the call light and walk away. *When asked about receiving snacks at bed time or when requested, the response was No. Refer to F809. *When asked if they felt the rights of the residents were respected and encouraged, the response was No. Examples provided by the residents included: -Not receiving timely meal trays when choosing to eat in the resident's room. -Not getting a bath or shower when requested, and having to take a bath or shower when staff offer to do it or it would be marked as a refusal. -Not getting enough opportunities to do restorative exercises. -Tired of being asked every shift if the resident had a bowel movement during the day when they should know because they had to help the resident use the toilet. Refer to F561 Review of the handwritten Resident Council Minutes for six months revealed concerns related to nursing services had been reported as follows: *On 6/14/23: -Call lights: Staff will shut off light and not come. Sometimes not getting them [bathes]. -Nursing: sometimes nurses dont [do not] help if CNA [certified nursing assistants] not around. -Snacks: Feels staff ignor [ignore] snacks - not getting. -Therapy: would like one more restorative. Walking programs - sometimes not happening. *On 7/12/23: -Call lights: Still shutting call light off and not answering, staff visiting at station instead of answering call lights. and -Nursing: some [staff] good, some not so good - set at desk, grumpy. -Snacks: Some [residents] state [they are] getting (East) [snacks], some [residents] state [they are] not getting. *On 8/9/23: -Call lights: Under Resolved column - better, but still some' -Nursing: would like to walk outside of therapy - restorative. *On 9/13/23: -Call lights: Same concerns - too long. Shutting light off and not returning -Nursing: some say they [staff] are going to do something - didn't come back. *On 10/11/23: -Activities: snacks [-] if [activity coordinator C] not here dont [do not] always get done. -Call lights: Still issue [,] turn off and waiting long times over an hr [hour]. Residents are missing activities cause of it. -Kitchen: Late w/meals [with meals] - room trays, nurses aides not willing to warm up food. -Nursing: Nurses & [and] aides [CNAs] still issues with saying come back and dont [do not]. Snacks at night late. Issues with water pass during day. Refer to F565. Interview on 11/06/23 at 9:03 a.m. resident 64's response to call lights revealed: *CNA not very good, she stands outside my door but doesn't come in to help me. *No shower since last Friday *No help here, no shower given on Monday. Observation and interview on 11/06/23 at 11:04 a.m. with CNA W from Clipboard Health-while transferring resident 64 revealed: *CNA W had picked up shifts the last two months. *Did not get orientation. *She learns as she goes. Interview on 11/8/23 at 2:20 p.m. RN F revealed: * Responsible for 23 or more residents,. *One nurse in the building on night shift when another nurse goes home sick,. *One nurse is responsible for 17 skin assessments, medication administration, physician orders, CNA's and phone calls. Interview on 11/6/23 at 4:48 p.m. with Administrator (ADM) A revealed they have been conducting call light audits since call light reports are not available with the call light system in the building. Review of fifteen (15) call light audit forms provided by ADM A completed between July 18, 2023 and November 5, 2023 revealed: *The quantity of audit forms did not meet the expected Instructions stated on the form, Daily x [times] 4 weeks. *Call light observations recorded 61 times included: -36 observations were noted with a.m. (morning) times. -3 observations were noted as p.m. (afternoon) times. -22 observations did not specify whether the observations were a.m. or p.m. *Recorded room locations included 4 on [NAME] (100 rooms), 28 on Center (200 rooms), 25 on East (300 rooms), and 3 rooms that were not specified by room number. *Of the 61 observations, 51 observations met the criteria for the acceptable call light time of answered in under 10 minutes. *Observations that did not meet the criteria included: -7/19/23, room [ROOM NUMBER] at 10:40 a.m. - 10:57 a.m. for 17 minutes and room [ROOM NUMBER] at 10:57 a.m. - 11:30 a.m. for 33 minutes. Comments were noted as 1:1 [one to one] caretaker hired by family had to request help and [staff name] on break until 10:55 a.m. -9/3/23, room [ROOM NUMBER] at 9:50 a.m. - 10:02 a.m. for 12 minutes. There were no Comments or Summary of findings recorded. -9/9/23, room [ROOM NUMBER] at 8:32 - 8:53 (a.m. or p.m. not specified) for 21 minutes. The Summary of findings noted, Center aides cannot seem to work together. -9/10/23, room [ROOM NUMBER] at 8:09 - 8:37 (a.m. or p.m. not specified) for 28 minutes and 307 at 8:12 - 8:23 (a.m. or p.m. not specified) for 11 minutes. The Summary of findings noted, 329 took a while due to 2 CNA's in 2 assist room & 1 CNA in [resident initials] room. -9/30/23 - 10/1/23, room [resident initials] at 8:00 a.m. - 8:21 a.m. for 21 minutes. There were no Comments or Summary of findings. -10/7/23, room [ROOM NUMBER] at 9:00 a.m. - [call light time turned off had a dash mark]. Comments noted Aid [CNA] never shut light off. -10/28/23, room [ROOM NUMBER] at 9:39 - 9:52 (a.m. or p.m. not specified) for 13 minutes. There were no Comments or Summary of findings. -11/4/23 - 11/5/23, room [ROOM NUMBER] at 9:05 - 9:30 (a.m. or p.m. not specified) for 25 minutes and room [ROOM NUMBER] at 9:02 - 9:12 (a.m. or p.m. not specified) for 10 minutes, and room [ROOM NUMBER] at 5:38 -5:51 (a.m. or p.m. not specified) for 13 minutes. There were no Comments or Summary of findings. Interview on 11/9/23 at 10:40 a.m. with ADM A and review of Weekend MOD [manager on duty] Checklist, MOD schedule, and November 2023 On Call nurse schedule revealed: *The MOD is expected to be in the building for three to four hours on the weekend, and should include being present for at least one meal. *The MOD is also on call for the weekend. *The on call nurse is scheduled to be the evening manager on weekdays in the building through the evening shift change and available every weekend. *The MOD checklist listed general duties to be addressed included: -Any staffing issues -Door alarms working -Wanderguard system working -Any customer complaints -Meals served timely (7:15 a.m., 11:15 a.m., 5:15 p.m.) -Ensure water pass occurs (10:00 a.m., 2:00 p.m., 10:00 p.m.) -Snack pass (2:00 p.m., 8:00 p.m.) -Call lights answered timely (Less than 5-8 minutes) 4. The provider failed to ensure interventions that had been put in place were consistently implemented and documentation was consistent for four of four sampled residents (3, 37, 39, and 193) who developed pressure ulcers after admission to the facility. Refer to F686. Review of the provider's Facility Assessment revealed: *It had updates of 10/23/22, 4/16/23, 6/30/23, and 7/13/23. *It had been reviewed with the quality assurance/performance improvement (QAPI) committee on 10/25/22 and 8/16/23. *Staff that had been involved in completing the assessment included: Administrator A, DON B, Governing Body Representative/regional director of operations, medical Director social service designee Q, business office manager H, dietary manager N, licensed practical nurse/unit managers J, M, and Y, human resource director GG, and Minimum Data Set coordinator E. *The provider is licensed for 110 residents with an average daily census of 90 residents with approximately 15% being short-term residents (13-14 residents). *Pertinent facts considered when determining staffing and resource needs are the residents sleep schedule, bathing schedule, dietary needs, weekend activities, community outings, and religious preferences. Based on the provider's resident population and resident needs for care and support, their approach to staffing was ensure they had sufficient staff to meet the needs of the residents at any given time and to simultaneously meet the requirements of Centers for Medicare and Medicaid Services regulations F725, F741, F802, and F839. their staffing plan included: -One full-time DON. -The ratio of registered nurses (RN) and LPNs to certified nursing assistants (CNA) shall be sufficient to assure professional guidance and supervision in the nursing care of the residents. Facility retains sufficient staffing to maintain a 24-hour licensed nurse (8-hours are a RN, 7 days a week). -CNAs and Restorative Aides [RA] are scheduled based on resident needs and current census. The typical staffing level for each shift as follows: --CNAs and RAs: Day shift 9-10 scheduled Night shift: 5-6 scheduled. --CNAs and RAs are scheduled for 12, 8, or 4 hours shifts. --Qualified Medication Aides (QMA) are scheduled to support the nurses and CNAs. QMAs are scheduled 12, 8, or 4 hour shifts. QMAs are scheduled 1-3 per day depending on resident needs and current census. -The facility provides enough support personnel to safely and effectively carry out the functions of the food and nutrition service. The minimum staffing consists of one cook and one dietary aide per meal. Based upon the licensed occupancy , the Dietary Manager may serve as a member of the line staff to meet this requirement. Interview on 11/9/23 at 1:31 p.m. with DON B and RNC HH revealed they agreed there was a need to address sufficient staffing and competencies related to the repeated pattern of concerns of timeliness to call lights and room trays and snack delivery. Refer to F561, F565, F802, and F809.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Interview on 10/31/23 at 3:38 p.m. with CNA X regarding her orientation for working at the facility revealed: *She had not received any orientation at the facility prior to working. *She had not completed any competency for the full-body lift use. *She stated this is her fourth time working here. *She does not know where in the chart to find the resident care plans. *Rounding sheets had been provided and used as a patient care guide. Interview on 11/9/23 at 8:33 a.m. with human resource director GG regarding orientation of agency staff revealed she and staffing coordinator WW coordinated the agency staff orientation. Interview on 11/9/23 at 9:12 a.m. with staffing coordinator WW revealed: *She had been staffing coordinator since August/September 2022. *She assembled an orientation packet with an agency orientation checklist on top along with the user's EHR log-in credentials and would leave the packet at the center nurses station. *The charge nurse was responsible to have the agency staff complete the orientation packet before starting their shift. *She would then sign the orientation packet as completed and gave the packet to human resource director GG. *When asked about LPN LL's agency orientation checklist, she could not locate her agency orientation checklist. Interview on 11/9/23 at 9:56 a.m. with staffing coordinator WW confirmed that LPN LL had not completed an agency orientation checklist. Based on observation, interview, record review, review of provider policy and Facility Assessment, the provider failed to ensure nursing staff were verified as competent to perform tasks in accordance with the provider's policies prior to performing them and had adequate knowledge and access to resident information to meet resident needs for 41 of 54 residents reviewed during the survey (1, 3, 5, 6, 7, 9, 10, 11, 12, 19, 23, 24, 26, 28, 32, 33, 36, 37, 38, 39, 46, 53, 58, 60, 62, 64, 67, 71, 72, 73, 74, 75, 77, 79, 81, 84, 87, 91, 193, 244, and 253). Findings include: 1. Interview on 10/31/23 at 5:32 p.m. with director of nursing (DON) B revealed: *When asked how they verified the competencies of agency staff, he replied, Good question. *He understood that agency staff who picked up shifts through the [name of agency] app (an electronic recruitment and scheduling app) were their own independent contractor. *The agency app made it possible for agency staff to pick up a shift on a moment's notice. *He confirmed there was a need to determine how they would verify competencies at the time the agency contractor showed up for the shift they picked up. Observation and interview on 11/6/23 between 6:00 p.m. and 6:30 p.m. at East nurses desk, with dietary manager (DM) N while room trays were being delivered, revealed: *A cart with wheels was setting across from the nurses desk with mugs on the top tray of the cart that were filled with water. *When asked about the mugs -Agency certified nursing assistant (CNA) KK replied that she did not know the reason for the cart of water mugs. She explained this was the second day she had worked there. -Agency licensed practical nurse (LPN) LL replied she had not been aware the cart was there. She confirmed it looked like the water mugs were new since there were no straws in them. -DM N confirmed the water mugs had been filled by dietary staff for the 3:00 p.m. water pass, and it appeared they had not been passed. Observation and interviews on 11/9/23 between 8:45 a.m. - 9:10 a.m. revealed: *An overhead announcement was heard for all staff to Center for daily huddle. *Housekeeping supervisor AA confirmed the routine practice had been for daily stand-up in the conference room for managers followed by an all staff huddle at Center during the weekdays. *LPN/unit manager J reported that ADM A prepared the daily huddle information on a typed sheet, staff would sign-off on the Staff In-Service Sheets, and that information and the sign off sheets were kept in a binder at the Center nurses desk. *LPN/unit manager Y reported the daily huddle today was earlier than usual and it worked better when the breakfast meal was done. Interview on 11/9/23 at 9:19 a.m. with DON B revealed: *The Daily Stand Up Meeting sheet was reviewed during the daily huddles on weekdays. *Nursing department staff used the unit sheets that listed the residents in two columns for shift to shift report. Review of the unit sheets for East and T-Wing revealed the only resident specific information listed included each resident's advance directive code status and the assistance and equipment needs for transferring each resident between surfaces. Review of daily huddle reports for two weeks from the Center binder revealed Staff In-Service Sheets with signatures and Daily Stand-Up Meeting typed sheets that included the following topics: *10/26/23 Night shift, topics: admissions, discharges, room and dining changes, resident appointments, MDS [Minimum Data Set] interviews due and care conferences, influenza vaccine, dining room to chart meals, bathing preferences, sling and Hoyer [mechanical lift] use *10/30/23 at 10:00 a.m., topics: admissions, discharges, room and dining changes, resident appointments, MDS [Minimum Data Set] interviews due and care conferences *10/30/23 NOC [night] shift, topics: Hoyer [mechanical lift] use, bath preferences, and walkie-talkies. *10/31/23 at 10:00 a.m., topics: discharges, pending admissions, room and dining changes, resident appointments, MDS [Minimum Data Set] interviews due and care conferences, and a separate typed page that listed 6 bulleted items: 1 bullet addressed a specific resident, 2 bullets addressed operational topics, 1 bullet addressed a policy, and 2 bullets addressed care needs including, Please attempt to complete some baths today per schedule. *11/8/23 at 6 p.m., topics: discharge, change of conditions, and Misc [miscellaneous] that included elopement and Wanderguard training, mechanical lift training, new flooring being installed on East . *11/9/23 with no time listed, topics: discharge, room and dining changes, resident appointments, care conferences, risk events, change of conditions, and the same Misc [miscellaneous] as 11/8/23 with the addition of Fire Watch initiated this morning. Interview on 11/9/23 at 9:37 a.m. with ADM A confirmed there were gaps in the daily huddle documentation because we were doing one on one trainings related to the survey team findings. Interview on 11/9/23 at 1:31 p.m. with DON B and regional nurse consultant (RNC) HH agreed there was a need to address sufficient and competent staffing in nursing and/or dietary. Review of the Facility Assessment, last updated on 7/13/23 and last reviewed by the QAPI (quality assurance and performance improvement) committee on 8/16/23, revealed: *Purpose: The purpose of the assessment is to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies .Using a competency-based approach focuses on ensuring that each resident is provided care that allows the resident to maintain or attain their highest practicable physical., and psychosocial well-being. *Guidelines for Conducting the Assessment: 4. The facility assessment should serve as a record for staff and management to understand the reasoning for decisions made regarding staffing and other resources and may include the operating budget necessary to carry out facility functions. *Part 1: Our Resident Profile: -1.1. Licensed number of residents: 110 total with possibility of 110 maximum. -1.2. Average daily census: 90 residents, of which approximately 15% [percent] are short-term. -1.5. Major Rug-IV [resource utilization groups-four] Categories that give an overall picture of acuity levels. --Major Rug-IV Categories: Percent of population Rehabilitation: 19%, Extensive Services 47%, Special Care 32%, Clinically Complex 34%, Behavioral Symptoms and Cognitive Performance 35%, Reduced Physical Function 98%. --Special Treatment and Conditions: number of residents with behavioral health needs - 17 --Assistance with Activities of Daily Living: number of resident needing assist of 1-2 staff plus dependent for transfer 73 + 6 = 79, toilet use 79 + 3 = 82. -1.6. We strive to maintain a respectful and neighborly environment for our staff and residents. in response to this diversity, we strive to maintain activities, traditions, meals, and an environment that is reflective of many cultures .We strive to ensure residents have a choice in their activities of daily living. Our dietary staff regularly solicit input from the resident council regarding menu and food preparation. -1.7. Other pertinent facts we consider when determining staffing and resource needs are our resident's sleep preferences, bathing schedules, dietary needs, weekend activities, community outings and religious preferences. *Part 2: Services and Care We offer Based on our Residents' Needs -Activities of daily living: bathing, showers .eating, support with needs related to hearing/vision/sensory impairment, supporting resident independence . -Mobility and fall/fall with injury prevention: transfers, ambulation, restorative nursing . -Skin integrity: pressure ulcer prevention and care, skin care, wound care .with repositioning, w/c [wheelchair] cushions and pressure relieving mattresses. -Mental health and behavior: manage the medical conditions and medication-related issues causing psychiatric symptoms and behavior, identify and implement interventions to help support individuals with issues such as dealing with anxiety, care of someone with cognitive impairment, care of individual with depression, trauma/PTSD [post traumatic stress disorder] . -Nutrition: individualized dietary requirements, liberal diets, specialized diets .culture or ethnic dietary needs . -Provide person centered/directed care: --Build relationship with resident/get to know him/her; engage resident in conversation. --Find out what resident's preferences and routines are; what makes a good day for the resident; what upsets him/her and incorporate this information into the care planning process. --Make sure staff caring for this resident have this information. --Provide culturally competent care: learn about resident preferences and practices regarding culture and religion, stay open to requests and preferences and work to support those as appropriate. --Identify hazards and risks for residents. *Part 3: Facility Resources Needed to Provide Competent Support and Care for our Resident Population Every Day and During Emergencies -3.1. The following is a list of staff/services that are typically provided for our residents. Some of these services are covered by multiple staff members . --Nursing Services: Director of Nursing (DON), Assistant Director of Nursing, Registered Nurses (RN), Licensed Practical Nurses (LPN), Certified Nursing Assistants (CNA), Certified Medication Assistant, CCN [??] Nurse, Treatment Nurse --Food and Nutrition Services: Dietary Director, Dietary Aide, Cook, Registered Dietitian --Hospitality aide -3.2. Staffing plan --Licensed nurses: DON (1 FTE [full-time equivalent]) .RN or LPN charge nurse: Minimum of 2-4 [two to four] for each shift based [on] resident needs and current census. Nurses are scheduled for 12, 8, or 4 hour shifts always with no less than 2 licensed nurses on duty per shift. --Direct care staff: The typical staffing level for each shift is as follows . CNAs and restorative aides: Day = 9-10 scheduled, Night = 5-6 scheduled. Nurse aides and Restorative Aides are scheduled for 12-, 8-, or 4-hour shifts. Qualified Medication Aides (QMA) are scheduled to support the nurses and CNAs. QMAs are scheduled 12,8,or 4- hour shifts. QMA are scheduled 1-3 per day depending on resident needs and current census. --Dietary: The minimum staffing consists on one cook and one dietary aide per meal. Based upon the licensed occupancy, the Dietary Manager may serve as a member of the line staff to meet this requirement. -3.3. Avantara [NAME] nursing schedule is reviewed by nursing leadership on a weekly/daily basis to ensure adequate staffing and consistent assignments. Avantara [NAME] utilizes a consistent staffing model to coordinate staffing assignments for the facility. -3.4. All employees complete training and competencies on the following upon hire: --Company policies regarding effective communication for direct care staff .problem resolution procedure .cell phones and cameras. --Environmental Services: *hazard communication .Preventing Slips; Trips and Falls . --Clinical Services: .*elopement, .caring for visually .impaired; caring for depression / delirium and dementia; *dietary and hydration needs of residents; resident rights; *person-centered care/management for persons with dementia, depression, delirium, and trauma,

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A. Based on closed record review, interview, and policy review, the provider failed to monitor and assess resident for frequency of bowel movements and constipation as well as identify and assess resident with significant weight loss for one of one sampled resident (2). Findings include: 1.Review of resident 2's closed medical record revealed: *He had originally been admitted on [DATE]. *His diagnoses included the following: unspecified ileus (inability of the intestine to contract normally and move waste out of the body), bowel obstruction, influenza A, history of malignant neoplasm of the large intestine, hypertension, and chronic obstructive pulmonary disease. *A 1/13/23 physician's progress note had report of constipation and to continue: -Bisacodyl suppository rectally daily as needed. -Milk of Magnesia 30 milliliters (ml) orally daily as needed. -Miralax 17 grams (gm) orally daily as needed. -Magnesium Oxide 400 milligrams (mg) orally twice a day. -Senna-S two tablets orally nightly. -Encourage adequate water intake. -Continue to monitor and adjust as needed. *From 1/16/23 through 1/22/23, he had only one large bowel movement (BM) in those seven days. *From 1/1/23 through 1/23/23, he received one dose of Milk of Magnesia 30 ml on the 1/23/23, the day he was admitted to the hospital. *From 1/1/23 through 1/23/23, there was no nursing documentation addressing his constipation or having a bowel assessment completed by nursing. *From 1/23/23 through 1/30/23, he had been hospitalized for an ileus versus small bowel obstruction. *From 1/31/23 through 3/7/23, there was no BM recorded between 2/15/23 and 2/17/23 and only one medium BM in the eight days between 2/21/23 and 3/1/23. *From 1/31/23 through 3/7/23, there was no nursing documentation addressing his constipation or having a bowel assessment competed by nursing. *On 3/8/23, he had been transferred to a hospital and had not returned to the facility. 2.Continued review of resident 2's medical record revealed: *A 2/20/23 physician's progress note reflected he had lost more than forty pounds since his 10/10/18 admission and had lost almost twenty pounds since October 2022. -He had a poor appetite and complaints of nausea. -Labs had been ordered to evaluate his weight loss. -He was started on Mighty Shake supplement three times daily. -It's not clear whether his poor appetite and nausea is from the side effect of the sertraline or from the recent intestinal obstruction. *Recorded weights from 9/15/22 through 3/1/23 were: -On 9/15/22, his weight was 178 pounds. -On 10/22/22, his weight was 180 pounds. -No weights were documented for November 2022. -On 12/27/22, his weight was 169 pounds. -On 1/30/23, his weight was 165.6 pounds. -On 2/12/23, his weight was 162 pounds. -On 3/1/23, his weight was 151 pounds. -From 9/15/22 through 3/1/23, he had a 15 percent weight loss. *Meal intake documentation from 1/1/23 through 1/22/23 and from 1/31/23 through 3/7/23 had not been documented for 104 of the 174 meals he should have been offered. *From 1/1/23 through 3/8/23, his weight loss had not been addressed in nursing documentation until 2/20/23 when the physician had assessed him, that was 67 days after the first noted weight loss. -He was started on Mighty Shakes three times daily. *On 8/17/22 and 2/17/23, the registered dietician (RD) had evaluated him. -The 2/17/23 Dietary Evaluation reflected: --Resident 2 was on a regular National Dysphagia Diet (NDD) level 2 (foods that may be chopped or ground and were moist, soft-textured, and easier to swallow) and 4 oz Mighty Shake at each meal. --He had had an insidious weight loss due to decreased oral intake. --He was at risk of malnutrition. --Weight had been trending down over time, more recently with decreased appetite-stated food has been tasting the same, but just not feeling like eating. Added Mighty Shakes yesterday per his preference. Goals for wt [weight] in the 160-170# [pound] range through next review. *His 2/6/23 care plan reflected: -He was at risk for altered bowel function. -He was at risk for alteration in nutritional status related to: Altered texture. I frequently refuse to follow the order. -He would have less episodes of constipation. -He would have been free of signs and symptoms of dehydration and malnutrition. -He would maintain his weight. Interventions included: --Monitor my bowel movements and document if I have not had a bowel movement in three days, or offer a laxative or stool softener as needed. ---I prefer to maintain a weight of 180-190 pounds. --Monitor for signs and symptoms of dehydration and weight loss. --Obtain weight as ordered. -His weight loss was not documented in his comprehensive individualized care plan. 3. Interview on 3/22/23 at 2:15 with dietary manager (DM) I regarding resident 2's weight loss revealed: *He ate most of his meals in his room. *She had noticed he was not eating as well because his food tray was coming back to the kitchen and the food had not been eaten. *He did have snacks in his room, but she did not know if he was eating them. *He was on a Mighty Shake three times a day, but he was not drinking them. *The registered dietician (RD) came to the facility every Tuesday. *There was a nutrition risk meeting held every Tuesday when the RD was in the facility and residents' weights were reviewed at that time. *The RD and nursing were required to monitor resident's weights. *The RD was the one who completed all the dietary evaluations. Interview on 3/22/23 at 2:26 p.m. with registered nurse H regarding resident 2's constipation and weight loss revealed: *He had been able to inform staff if he had not had a bowel movement. *He had been able to inform the nurse when he had not had a bowel movement and ask the nurse for a laxative. *If a resident had not had a bowel movement for two days, then she would have administered a laxative. *The floor nurses would get a list of resident names from one of the nurse managers for the residents who had not had a bowel movement and needed to have been administered a laxative. *He had snacks in his room he could eat independently. *He was not compliant with his diet and had not liked staff to assist him. *He ate his meals in his room. *She was not sure how often he would have eaten snacks or accepted an alternate if he had not liked what was served at scheduled mealtimes. Interview on 3/22/23 at 3:25 p.m. with RD J regarding resident 2's weight loss revealed: *She came to the facility weekly on Tuesdays. *Since he had returned from the hospital on 1/31/23 she had been looking at resident 2's weights and intakes weekly. *Initially he had refused to try a dietary supplement and then in February 2023 he had agreed to try the Mighty Shakes three times a day with meals. *His intakes were 75 to 100 percent at meals times, when they were documented. *She was responsible to complete all dietary assessments, the nutritional section of the Minimum Data Set assessment, update the resident care plans, reviewing residents' menus, educating staff, and reviewing all residents' nutritional status' in the facility. *Had not been aware his weight loss was not addressed in his comprehensive individualized care plan. *She organized and ran the monthly nutrition risk meetings where residents who were at risk or had a nutritional problem had been discussed by the interdisciplinary team. -Her Nutrition Risk meeting notes about resident 2 reflected: --On 1/17/23 his weights from 8/11/22 through 12/27/22; he had been on Lasix 40 mg (a medication used to remove extra fluid from the body) daily; and his diet order with meal consumption of 75 to 100 percent. Then, --On 2/6/23, her notes only indicated his diet order was not entered into his electronic medical record. --On 3/7/23, her notes reflected his weight was 151 pounds and he had been down eleven pounds in one month, down sixteen pounds in three months, and down twenty-four pounds in six months. ---He was getting 4 ounces of Mighty Shake three times a day. ---He was on the NDD 2 diet. ---His meal intakes were at 75 percent. *She had not documented in the resident's medical record what was discussed at these meetings because she had not had the time. Continued interview on 3/23/23 at 8:29 a.m. with RD J regarding documentation of resident meal intakes revealed she: *Was aware meals had not been documented consistently. *Used what information was documented to complete her assessments. *Had informed administrator A and interim director of nursing (DON) B at the Nutrition Risk meetings about the missing documentation. Interview on 3/22/23 at 4:07 p.m. with administrator A, interim DON B, and DON C regarding resident 2's constipation and weight loss revealed: *Interim DON was training the current DON. *Resident 2 had been assessed on 1/14/23 by his physician and no changes had been made to his bowel regimen at that time. *The interdisciplinary team (IDT) had met each weekday morning and reviewed the dashboard on PointClickCare (the provider's electronic record keeping system). *The dashboard would have assisted the IDT by pulling information to show them which resident had not had a bowel movement in three days or if a resident had a weight loss. *They all had thought maybe the system was not working appropriately because resident 2 had only been on the list for not having a bowel movement on 1/20/23. *Agreed he should have been offered a laxative on 1/20/23. *They had expected the nurses to administer a laxative if the resident had not had a bowel movement in three days. *They all had not been aware meals were not being consistently documented. *Care plans were reviewed an updated when the MDS (Minimum Data Set) was completed. *His daughters had reported he might have had cancer but there was no documentation to support a cancer diagnosis. *Administrator B was aware RD J was not documenting in resident's medical records after Nutrition Risk meetings were held. *They all had agreed any member of the IDT could have documented in the resident's medical record what had been discussed in the Nutrition Risk meeting. 4. A policy had been requested from administrator A on 3/22/23 at 2:45 p.m. for a bowel policy or protocol. Interim DON B had brought in a printed page from a slide show used to educate staff after the provider's last survey in October 2022. This printed page indicated: *Importance of Documentation of Bowel Movements -Identify Change of Conditions -Identify if resident is exhibiting signs and symptoms of dehydration or constipation *Bowel Movement Protocol -If a resident had not had a Bowel Movement in 72 hours Milk of Magnesium should be given and abdominal assessment should be completed for bowels sounds. -If not bowel movement after 24 hours of receiving Milk of Magnesium should be given a suppository. -If no bowel movement within 24 hours after suppository Primary Care Physician should be notified for further follow up. Review of the provider's January 2021 Weighing the Resident policy revealed: *The purpose of this procedure is to determine the resident's weight and height, to provide a baseline and an ongoing record of the resident's body weight as an indicator of the nutritional status and medical condition of the resident . *5. Report significant weight loss/weight gain to the nurse supervisor who will then report to the RD and physician. *7. The threshold for significant unplanned and undesired weight loss/gain will be based on the following criteria (where percentage of body weight loss = [equals] [usual weight - [minus] actual weight] / [divided by] [usual weight] x [times] 100): -1 month - 5% [percent] weight loss is significant, greater than 5% is severe. -3 months - 7.5% weight loss is significant, greater than 7.5% is severe. -6 months - 10% is significant, greater than 10% is severe. Review of the provider's September 2019 Care Planning policy revealed: *Individual, resident-centered care planning will be initiated upon admission and maintained by the interdisciplinary team throughout the resident's stay to promote optimal quality of life while in residence. *9. Care plans should be updated between care conferences to reflect current care needs of the individual resident as changes occur. B. Based on observation, interview, record review, and policy review, the provider failed to ensure timely physician notification after a fall, follow physical therapy recommendations for a restorative program, and ensure resident bathing was completed and documented for one of one sampled resident (1). Findings include: 1. Interview and observation on 3/21/23 at 2:58 p.m. with resident 1 and her daughter-in-law revealed: *Resident 1 had Steri-strips applied to the left side of her neck and a yellowish colored bruise extending from the left side of her forehead to below the outer area of her left eye. -There was what appeared to have been dried blood on her skin and the Steri-strips. *Her daughter-in-law stated she would be leaving soon and asked the surveyor to return to visit with resident 1 at that time. Observation and interview on 3/21/23 at 5:20 p.m. with resident 1 revealed she: *Got up from her bed and went into her bathroom without using her call light for assistance or her walker. *Was coming out of the bathroom, using a four-wheeled walker, and returned to her bed. *Was admitted for skilled rehabilitation therapy after a stay in the hospital. *Had cancer and was planning on returning to her home. *Had fallen on the 3/14/23 while getting ready to attend her care conference. -Her injuries from the fall included: --Hitting her head on the floor causing a goose egg and bruise to her forehead, that was a greenish yellow in color and extended from the left side of her forehead to below the outer side of her left eye with a dark purple colored area about the size of a dime in the left outer corner of her eye. --A skin tear approximately three inches long to her right arm forearm that had been closed together with Steri-strips. There was dried blood on and around those Steri-strips. --A skin tear approximately one inch long near her jugular vein on the left side of her neck that had been closed together with Steri-strips. There was dried blood on and around the Steri-strips. --Bruising to her left clavicle in an area that was approximately three inches by five inches. --Bruising to her left hip that extended down her leg and she stated it was painful. --She indicated her four wheeled walker and wheelchair had been sitting close together and her foot got caught in the walker, and that had caused her to fall. --She stated she was bleeding all over and had to wait for a while as the nurse called the doctor because she hit her head. --She was sent to the emergency department (ED) at the hospital on that day for the injuries from her fall. Review of resident 1's medical record revealed: *She was admitted on [DATE] and her diagnoses included cancer of the pancreas and kidney, adult failure to thrive, depression, and repeated falls. *Her 2/23/23 Brief Interview of Mental Status (BIMS) score was a 15, meaning her cognition was intact. Review of resident 1's physician admitting medication orders revealed she had been on Apixaban (a blood thinner) and sertraline (an antidepressant). Review of resident 1's 3/21/23 comprehensive individualized care plan revealed: *She was at risk for falls related to her poor safety awareness, decline in functional status, and history of falls. *A 1/13/23 goal was to prevent further falls. *She had poor insights to her deficits. *She used a walker as an assistive device during ambulation to prevent falls. *She was at risk for pain due to her cancer diagnosis. *Her discharge plan was to have completed rehabilitation and to have been discharged home. Review of resident 1's progress notes revealed: *On 3/14/23 she had a care conference scheduled. -She had fallen just prior to the care conference and was unable to attend. -Her son and daughter-in-law attended the conference. -Her discharge plan was to return home. --Her safety at home was a concern as she had multiple falls while in her home. Review of resident 1's fall records revealed: *She had numerous falls in her room prior to 3/14/23. *She had fallen in her room on 3/14/23 at approximately 2:30 p.m. -The nurse on duty had faxed her physician on 3/14/23 at 2:35 p.m. and related she had a fall and had hit her head. --The nurse had not notified the physician on this fax that she was on a blood thinner. --The physician did not respond to this fax. -The nurse called another physician on 3/14/23 at 6:31 p.m. and received a physician's order for a non-emergent transfer to the hospital emergency department (ED) for treatment. --This was a three hour and 25-minute time span from when the fax had been sent to her physician and when the nurse called a different physician for an order to transfer to the ED. --Resident 1 left the facility at 7:10 p.m. for the ED and was seen there at 7:29 p.m. --The initial fax was responded to by that physician the next day, on 3/15/23 at 6:56 a.m. with an order to continue to monitor her. Interview on 3/23/23 at 9:00 a.m. with agency registered nurse K regarding resident falls revealed: *When a resident had a fall, she would assess them and if there was an obvious injury, she would have called the residents primary physician or the physician on call. --She would not have faxed the physician. *If a resident was on a blood thinner, fell, and hit their head she would have notified the physician right away. --She indicated if a resident was on a blood thinner, fell, and hit their head it might cause a brain bleed up to two weeks after the initial fall. Interview on 3/23/23 at 11:16 a.m. with administrator A, interim DON B, and DON C regarding resident 1's falls revealed: *She had a fall on 3/14/23 and hit her head on the floor while she had been getting ready for her care conference. -She had not used her call light for assistance. *Administrator A's expectations for when a resident fell were: -A fall with an injury would have required the nurse to notify the physician by telephone. -If there was not an injury related to the fall, the nurse could notify the physician by facsimile. -Interim DON B and administrator A would have expected the nurse to telephone the physician when resident 1 had fallen on 3/14/23 due to the extent of her injuries and the fact that she was taking a blood thinner. -Interim DON B would have expected the facsimile that had been sent to the physician to include that resident 1 had been taking a blood thinning medication, and it had not. -Administrator A was not sure why there had been a delay in resident 1 receiving emergency care on 3/14/23 after her fall as we don't have that documentation piece. -The nurse that faxed the physician had not been educated on calling versus faxing a physician after a fall with injury. Review of the provider's November 2019 Falls Management policy revealed: *Post Fall/Injury Resident Management: -9. Contact provider and resident representative and document in the medical record, including time and person spoken with. If transferred, document transferring agency/responders. -11. The Director of Nursing or designee will be notified immediately for falls resulting in major injury or transfer. 2. Continued review of resident 1's 3/21/23 comprehensive individualized care plan revealed the following: *A 1/13/23 intervention of Skilled Rehabilitation Therapy evaluation and treatment as indicated. -There was no documentation of a restorative nursing care program. *She was taking a psychoactive medication for her depression and to have been monitored for any ill effects related to the anti-depressant. *Her discharge plan was to have completed rehabilitation and to have been discharged home. Continued review of resident 1's progress notes revealed: *A 3/13/23 progress note from the certified nurse practitioner that indicated the following: -She had a 1/20/23 PHQ-9 Score (a multipurpose instrument for screening, diagnosing, monitoring and measuring the severity of depression) of 11 (she had moderate depression). -She attributes worsening of her depression symptoms for not participating with PT (physical therapy) and OT (occupational therapy) at this time. -Increase restorative activities. -May increase her sertraline dose in the future if moving to a different hallway and increased restorative activities do not help in improving her mood. -Continue Sertraline 50 mg daily. -No dose reduction at this time as patient is dealing with major health issues and high PHQ-9 score. *On 3/14/23 she had a care conference scheduled. -She had fallen just prior to the care conference and was unable to attend. -Her son and daughter-in-law attended the conference. -She would be starting restorative nursing therapy as her skilled therapy had ended. -Her discharge plan was to return home. --Her safety at home was a concern as she had multiple falls while in her home. Interview on 3/22/23 at 10:35 a.m. with interim director of nursing (DON) B regarding restorative program for resident 1 revealed: *Resident 1's restorative program had not been added to her electronic medical record. *She indicated the restorative nursing aide might have been documenting the restorative care on paper form. Interview and review of restorative medical records on 3/22/23 at 1:19 p.m. with restorative nursing aide F regarding resident restorative nursing care revealed: *She was the only restorative nursing aide employed at the facility. -She had one day off every two weeks. -She had 36 residents on her case load that day. -Her resident case load was assigned by the nursing department with recommendations from the skilled therapy department. *Resident 1's restorative nursing care started on 3/17/23, was to have been completed six times per week, and had included the following: --Walking 250 feet with stand by assist and a front wheeled walker. --Active range of motion with her upper extremities using dumbbells for 15 repetitions. --Upper extremity arm bike for 15 minutes. --Riding a NuStep bike for 15 minutes. ---Resident 1 liked to ride the NuStep bike. ---Resident 1 had not liked the other restorative programs and restorative nursing aide F had not been completing them with her. ---She would notify the nursing department if a resident had not liked to do a specific area of the restorative program. ---She had not notified anyone that resident 1 had not liked the other areas of her restorative program. *She documented resident 1's restorative nursing care on paper form. *She had received a 3/22/23 new nursing order transfer form from the nursing department for restorative nursing care that remained the same as the orders from 3/17/23. Interview on 3/22/23 at 2:49 p.m. with physical therapist (PT) G regarding resident 1's therapy and restorative nursing care revealed: *Restorative nursing care was to assist residents in maintaining their current level of functioning. *When a resident was discharged from skilled nursing therapy, the therapist would develop a restorative program for the nursing department to implement for that resident. -Depending on the restorative program required, the program should have been started right away, within a couple of days, or a week. *Resident 1 had been discharged from skilled therapy on 3/6/23 as she had reached her highest level of functioning. -There had been a restorative nursing program written for her on 3/8/23. --He would have expected her restorative nursing program to start within a week or 10 days after 3/8/23. -Resident 1's restorative program started on 3/17/23 that was 11 days after PT G had written the restorative program. Interview on 3/23/23 at 11:16 a.m. with administrator A, interim DON B, and DON C regarding resident 1's restorative nursing care program revealed: *Administrator A's expectation was that: -Restorative nursing would have been set up within a week or two of a resident that was discharged from skilled therapy. -All areas of resident 1's restorative program should have been implemented. --If there had been any issues with resident 1's restorative program it should have been brought to someone's attention. -Interim DON B indicated when a physician order for restorative nursing was received, a nurse would enter the order in the computer, educate the restorative aide as to the order, and clarify the order if needed for frequency of visits or an increase of the restorative nursing care. -Both administrator A and interim DON B's expectations for resident 1's 3/13/23 physician ordered restorative nursing care should have been started on or about 3/13/23. Review of the provider's March 2021, Restorative Nursing policy revealed: *Policy: -Generally restorative nursing programs are initiated when a resident is discharged from formalized physical, occupational, or speech therapy. *Procedures: -3. Implementation of a Restorative nursing program may also occur following a course of physical, occupation or speech therapy. In these cases, the therapist will: provide resident specific training to the appropriate staff members; assist the Restorative team in establishing initial Restorative goals; and suggest interventions/approaches. -8. Measurable objectives and interventions must be documented in the resident's care plan and medical record. -10. Restorative nursing staff will document the program performed on the Point of Care Kiosks/computers. -11. A physician's order is not needed for a Restorative Nursing Program. Review of the provider's revised May 2021 Following Physician Orders policy revealed: *Policy: -To correctly and safely receive and transcribe physician's orders so correct order is followed/administered. *Procedure: -1. All physician's orders will be received by a licensed nurse, therapist, or dietitian. -2. Orders may be received through written communication in the resident's chart, verbally, by Fax, electronically entered into PCC, or per the telephone. -6. If the order is for a medication or treatment, it should be entered in the MAR/TAR [medication administration record/treatment administration record]. 3. Interview on 3/22/23 at 9:50 a.m. with resident 1 revealed she: *Had not had a bath for about 6-8 weeks and would prefer a bath over a shower. *Had not liked to complain. Review of resident 1's documented bathing records from 2/2/23 through 3/22/23 revealed: *She had received a shower on 2/2/23, 2/9/23, 2/16/23, 2/22/23 and a bed bath on 3/2/23. -The next documented bathing record was on 3/22/23. -That was 20 days between receiving a bath or shower from 3/2/23 until 3/22/23. Interview on 3/22/23 at 12:25 p.m. with interim DON B and administrator A regarding bathing of resident 1 revealed: *They thought she had received one the week before 3/22/23 but could not find any documentation to support that. *They were not aware that her preference would have been for a bath rather than a shower. *They had started asking what preferences residents had upon their admission, they were unsure of the date of when that had started. -Resident 1 had no bathing preferences identified on her admission. Interview on 3/23/23 at 10:35 a.m. with director of nursing (DON) C and administrator A regarding bathing for resident 1 revealed: *Bathing documentation was completed in each resident's electronic medical record. *They had identified an issue with the bathing documentation not being completed. *Agreed there was no bathing documentation to support resident 1 had received a bath for 20 days. *When a resident refused a bath, it would have been documented. -There was no documentation to support resident 1 had refused a bath. Review of the provider's September 2019 Bathing policy revealed: *POLICY -The purposes of this procedure are to promote cleanliness, provide comfort to the resident and to observe the condition of the resident's skin. The resident has the right to choose timing and frequency of bathing activity. Bathing preferences are asked upon admission and during quarterly care conference. C. Based on closed record review, interview, and policy review, the provider failed to ensure timely family/representative notification when resident had a change in condition for one of one resident (3). Findings include: 1. Closed record review for resident 3 revealed: *He had died in the facility on 2/28/23. *On 2/24/23 he had become lethargic with complaints of not feeling well and hurting all over. *On 2/24/23 he was seen by his physician and a chest x-ray was ordered and completed. *On 2/25/23 he was started on Augmentin for right upper and left lower lobe infiltrates (pneumonia). *On 2/27/23 he became short of breath and his oxygen saturation was seventy-seven percent on room air (normal oxygen saturation is ninety-five to one hundred percent). *The physician had assessed him and wrote new orders to discontinue Augmentin, start Doxycycline, resume Duonebs, discontinue Tramadol, start Rocephin intravenously (IV) daily, and draw labs. *On 2/28/23 at 4:00 a.m. he was found in his bed with no vital signs present. *There was no documentation his family or representative had been notified of his change of condition until after his death. Interview on 3/22/23 at 2:44 p.m. with RN H regarding resident 3's change of condition revealed: *She had been working on 2/27/23 when his physician came to assess him. *She was not the nurse in charge of his care on 2/27/23 but had assisted with getting the IV started and mixed the Rocephin for administration. *She had not known if any of the nursing staff had attempted to contact his family when residents' condition changed. *It was an expectation nursing staff contact a resident's family or representative when a resident had a change of condition. *Resident 3 had a daughter who came to the facility after his death. Interview on 3/23/23 at 9:30 a.m. with Interim DON B regarding resident 3's change of condition revealed: *She was unsure if any of the nursing staff had attempted to contact resident 3's family or representative when he had a change of condition. *She expected nursing staff to document in the resident's medical record when they contacted residents' family or representatives. *After he died the facility initially could not get a hold of his representative because there had not been a working phone number in his medical record. *His daughter was contacted by social service director D on the morning of 2/28/23 via social media and was asked to call the facility. *The daughter then called the facility and was informed of his death. Review of the provider's December 2019 Notification of Change of Condition policy revealed: *The facility will provide care to residents and provide notification of resident change in status. *1. The 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: -&quo

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Review of resident 1's fall records revealed: *She had fallen in her room on [DATE] at approximately 2:30 p.m. *The nurse on duty had faxed her physician on [DATE] at 2:35 p.m. and related she had a fall and had hit her head. *The nurse had not notified the physician on this fax that she was on a blood thinner. -The physician did not respond to this fax. *The nurse called another physician on [DATE] at 6:31 p.m. and then received a physician's order for a non-emergent transfer to the hospital emergency department (ED) for treatment. -This was a three hour and 25-minute time span from when the fax had been sent to her physician and when the nurse called a different physician for an order to transfer to the ED. Refer to F684, finding B1. 4. Review of resident 1's medical records revealed the following: *Her [DATE] comprehensive individualized care plan included: -A [DATE] intervention of Skilled Rehabilitation Therapy evaluation and treatment as indicated. -There was no documentation of a restorative nursing care program. *A [DATE] progress note from the certified nurse practitioner that included, Increase restorative activities. *On [DATE] she had a care conference note that included she would be starting restorative nursing therapy as her skilled therapy had ended. Interview and review of restorative medical records on [DATE] at 1:19 p.m. with restorative nursing aide F regarding resident restorative nursing care revealed her restorative nursing care started on [DATE]. Refer to F684, finding B2. 5. Review of resident 3's closed medical record revealed: *He had died in the facility on [DATE]. *On [DATE] he had become lethargic with complaints of not feeling well and hurting all over. *On [DATE] he was seen by his physician and a chest x-ray was ordered and completed. *On [DATE] he was started on Augmentin for right upper and left lower lobe infiltrates (pneumonia). *On [DATE] he became short of breath and his oxygen saturation was seventy-seven percent on room air (normal oxygen saturation is ninety-five to one hundred percent). *The physician had assessed him and wrote new orders to discontinue Augmentin, start Doxycycline, resume Duonebs, discontinue Tramadol, start Rocephin intravenously (IV) daily, and draw labs. *There was no documentation his family or representative had been notified of his change of condition until after his death. Refer to F684, finding C1. Based on observation, interview, record review, and policy review the provider fail to ensure nursing staff were competent and had sufficient training for: *Monitoring and assessing one of one sampled resident (2) for frequency of bowel movements and constipation. *Assessing one of one sampled resident (2) with significant weight loss. *Timely notification of a physician for one of one sampled resident (1) after a fall resulting in significant injury and requiring transportation to an emergency department. *Initiating a restorative nursing program timely for one of one sampled resident (1). *Timely notification of family/representative for one of one sampled resident (3) with a significant change of condition. Findings include: 1. Review of resident 2's closed medical record revealed: *On [DATE] he had reported complaints of constipation to his physician. *From [DATE] through [DATE] he had only one large bowel movement in those seven days. *There had been no nursing documentation addressing his constipation or having a bowel assessment completed by nursing. *From [DATE] through [DATE], he had been hospitalized for an ileus versus small bowel obstruction. Refer to F684, finding A1. 2. Review of resident 2's closed medical record revealed: *A [DATE] physician's progress note reflected he had lost more than forty pounds since his [DATE] admission and had lost almost twenty pounds since [DATE]. *Meal intake documentation from [DATE] through [DATE] and from [DATE] through [DATE] had not been documented for 104 of the 174 meals he should have been offered. *From [DATE] through [DATE], his weight loss had not been addressed in nursing documentation until [DATE] when the physician had assessed him, that was 67 days after the first noted weight loss. *On [DATE] and [DATE], the registered dietician (RD) had evaluated him. Refer to F684, finding A2.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and policy review, the provider failed to protect two of two residents (71 and 73) from mistreatment while receiving care from staff. Findings include: 1. Interview on 9/27/22 at 2:24 p.m. with resident 71 regarding her care revealed: *Resident 71 recalled on 9/25/22 after supper, but before bedtime, certified nursing assistant (CNA) W assisted her to go to the bathroom with the sit-to-stand aide. *CNA W did not put the sling on correctly and resident 71 slipped through the sling and landed hard onto the toilet. *Resident 71 said CNA W got upset with her and said, I'm not going to take care of you again, and abandoned her in the bathroom. *She had to wait a long time for another aide to help her off the toilet. *Resident 71 said she felt mad at CNA W for leaving her, helpless because she could not stand up on her own, and sad as she cried after the incident. *She thought she had mentioned this incident at her care conference. Interview on 9/29/22 at 11:11 a.m. with director of nursing (DON) B and social services designee (SSD) D revealed: *Neither of them were aware of the incident mentioned above. *SSD D indicated they had resident 71's care conference earlier in the week and she mentioned having to wait a long time for staff to answer her call light, however resident 71 had not mentioned anything about the incident mentioned above. Interview on 9/29/22 at 1:35 p.m. with SSD D revealed: *She talked with resident 71 to learn the full details of the incident. *Resident 71 told SSD D the same details of the incident mentioned above. *SSD D reviewed the working schedule from 9/25/22 and confirmed that CNA W had worked on that day and had been assigned to resident 71's hallway. *SSD D completed a grievance form, informed administrator A, and submitted reports to both adult protective services and the local police department. Interview on 9/29/22 at 2:22 p.m. with human resources director (HRD) H about CNA W's employee file revealed: *CNA W worked at the facility previously and was terminated from her position in January 2020 due to a substantiated allegation of abuse and neglect. *She was rehired in February 2021. *CNA W's employee file in the provider's electronic human resource software program indicated that she was terminated on 1/27/20 for the reason of employee misconduct. *The provider had access to this information of terminated for employee misconduct upon the rehire process in February 2021. *HRD H admitted they should have investigated further on why CNA W was previously terminated before rehiring her. *HRD H said she should have uploaded the corrective action form from January 2020 to their electronic human resource software program so that the leadership team could all have access to the form. -The corrective action form indicated CNA W had been terminated due to substantiated allegation of abuse/neglect. Interview on 9/29/22 at 2:47 p.m. with administrator A and regional nurse consultant (RNC) X revealed they: *Did not know that CNA W was previously terminated from the facility due to a substantiated allegation of abuse/neglect. *Would not have considered CNA W as a potential candidate for rehire if they knew about the previous termination. *Had not been aware of the incident between resident 71 and CNA W before 9/29/22. Interview on 10/3/22 at 3:36 p.m. with HRD H about her process for rehiring former employees revealed: *She reviewed the applicant's file in the provider's electronic human resource software program to learn why they previously left or why they were terminated from their position. *She confirmed again that she should have uploaded CNA W's termination papers from January 2020 into the program for easy access to review. *She was planning on conducting an audit of all employee files due to this incident. *She started to update the provider's do not rehire list. Interview on 10/4/22 at 11:17 a.m. with administrator A and RNC C regarding the incident revealed: *Administrator A interviewed the other staff members that worked on the evening of 9/25/22. -No other staff or residents voiced complaints about CNA W. -The other staff members were not aware that CNA W abandoned resident 71 on the toilet. *They were finishing their investigation to submit to the South Dakota Department of Health (SDDOH). *Due to learning one of their employees had previously been terminated due to abuse and neglect, they committed to improve their hiring practices by thoroughly checking potential applicant's references, looking at their employee files, and keeping their do not rehire list updated. Review of resident 71's electronic medical record revealed: *She was admitted on [DATE]. *She required extensive assistance with transfers. *Her brief interview for mental status score was 15, indicating she was cognitively intact. Review of CNA W's Corrective Action Form signed on 1/31/20 revealed: *The Facts section read, Resident filed complaint. Investigation completed. [Allegation] of abuse/neglect substantiated. [SDDOH] report completed. Last day worked 1/26/20. Review of the provider's Abuse and Neglect policy revealed: *Page one, Policy Statement: It is the policy of the facility to provide professional care and services in an environment that is free from any type of abuse, corporal punishment, misappropriation of property, exploitation, neglect, or mistreatment. *Page one, Definitions of Abuse, Neglect, Exploitation, & Abuse Coordinator. -Abuse: abuse is willful infliction of mistreatment, injury, unreasonable confinement, intimidation or punishment. Abuse assumes intent to harm, but inadvertence or careless behavior done it deliberately that results in harm may be considered abuse. *Page one continued, Types of abuse . -2. Verbal. -3. Mental . -5. Neglect . -7. Involuntary Seclusion. *Page two, Verbal: verbal abuse includes but not limited to the use of oral, written or gestured language. This definition includes communication that expresses disparaging and derogatory terms to residents within their hearing slash seeing distance. -Examples: name calling, swearing, yelling, threatening harm, trying to frighten the resident, racial slurs, etc. *Page two continued, Mental: mental abuse includes but is not limited to humiliation, harassment, threat of bodily harm, punishment, isolation (involuntary, imposed or seclusion) or deprivation to provoke fear of shame. *Page two continued, Involuntary Seclusion: Isolation of a resident against his/her will (involuntary, imposed seclusion) . -Examples: statements to threaten or actually secluding, isolating or locking a resident in their room or a room or area by themselves; leaving a resident in their room all day who does not wish to be left alone in his/her room all day. *Page three, Neglect: Neglect is the failure to provide necessary and adequate (medical, personal or psychological) care. Neglect is the failure to care for a person in a manner, which would avoid harm and pain, or the failure to react to a situation which may be harmful. Staff may be aware or should have been aware of the service the resident requires, but fails to provide that service. *Pages three and four indicated the screening process for potential applicants. There was no process mentioned for screening the facility's own personnel files for potential applicants who had worked at the facility previously. 2. Interview on 9/29/22 at 11:24 a.m. with resident 73 during the resident group meeting revealed: *He sat on the toilet today for an hour before a medication aide arrived. He did not give a name. *She did not want to take the time to get the lift equipment and was going to physically help him stand up off the toilet. *He said no, but she said, 'I'm the boss, we'll do it my way.' *He refused again, and said he asked her what she was smoking, with some added offensive words. *The lift equipment was used to get him off the toilet. *Another staff person came and told him to apologize to the medication aide about his statement to her. Interview on 9/29/22 at 4:34 p.m. with licensed practical nurse (LPN) L revealed: *When asked if she was aware of an incident that morning involving resident 73, she reported he had made a statement to the medication aide about her being on drugs. *She said, He exaggerates. Interview on 10/4/22 at 11:04 a.m. with DON B and RNC X revealed they agreed the incident should have been reported and investigated as an allegation of abuse and neglect. Follow-up interview on 10/4/22 at 11:09 a.m. with LPN L revealed: *The medication aide reported resident 73's refusal to let her transfer him off the toilet. *She went with the medication aide to his room and said to both that she did not want to hear their arguments about how he should be transferred. *She then asked resident 73 how he wanted it done, and he was transferred with the lift. *She did not report the incident for further investigation because it was he said, she said situation. Interview on 10/4/22 at 11:10 a.m. with SSD D revealed she agreed the incident should have reported as an allegation of abuse so it could be investigated. Review of resident 73's electronic health record revealed: *On 8/29/21, a lift evaluation required a sit to stand lift. *The care plan noted current interventions for assistance with activities of daily living (ADL) and risk for falls related to leg impairment due to post-polio plegia: -Revised on 2/18/22, Using stand-aid for transfers. Can get on to toilet per self, needs stand-aid to get off of toilet. -Revised on 4/8/22, Use of assistive device during transfers. Stand-aid. -Revised on 8/31/22 to assist with ADL's/mobility as needed. Stand-aid and motorized w/c [wheelchair]. *On 9/3/22, the annual minimum data set (MDS) coded him as cognitively intact, without behavior symptoms, and needing weight bearing assistance of one person to transfer on and off the toilet. *There was no progress note on 9/29/22 regarding the incident. *Transferring task documentation for 9/29/22 was not documented.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation on 9/28/22 at 5:40 p.m. of CNA R during supper service in the [NAME] dining room revealed she served coffee to resident 277 without thickening the beverage. Interview at that time with CNA R about resident 277 revealed she: *Did not know resident 277 had an order for nectar thickened fluids. *Did not really know the residents on the [NAME] unit. *Had seen resident 277's wife give him thin fluids previously, so she thought he could have thin fluids. *At that time, she retrieved the coffee, thickened it, and returned it to resident 277. Interview at that time with resident 277's wife revealed she: *Wondered why CNA R served coffee to resident 277 because both she and her husband were active Seventh-Day Adventists. *Discussed that Seventh-Day Adventists practiced certain dietary restrictions, such as refraining from drinking caffeinated beverages. Please refer to tag F656, finding 6 for additional information regarding resident 277's religious dietary preferences. Review of resident 277's order summary report revealed: *He had a 9/12/22 physician's order for nectar thick fluids. 2. Interview on 9/27/22 at 2:06 p.m. with resident 55 revealed she: *Was in her room in a bariatric bed. *Stated she had gone to the hospital this summer for treatment of a UTI. *Could not remember exact date. Record review for resident 55 revealed: *She had been admitted on [DATE]. *She had a brief interview of mental status (BIMS) of 10, meaning she was moderately impaired. *Her diagnosis included: overactive bladder, indwelling catheter, UTI. *She was sent to the emergency room on 6/1/22 after a sudden change in condition. -Diagnosed with sepsis (acute), acute UTI, E. coli bacteremia and acute alteration in mental status. -Returned to the provider on 6/7/22. *Her revised care plan dated 6/9/22 revealed interventions for monitoring resident 55 for: -Risk for alteration of bowel and bladder functioning related to: --Foley catheter use. --Obesity. --Impaired mobility. --Diuretic use. --Bowel incontinence. --History of UTI. -Catheter related trauma. -Catheter care every shift and as needed. -Change Foley catheter per facility protocol or MD order. -Monitor urine/catheter output every shift. -Monitor for pain/discomfort due to catheter use. Interview on 10/04/22 at 9:09 a.m. with regional nurse consultant X and DON B regarding resident 55's UTI/sepsis hospitalization revealed: *Her change in condition was a sudden onset of slurred speech and slow response. *The physician evaluated her while doing rounds and ordered her to be transferred to the emergency department. *The provider did update the care plan after this hospital stay to provide more guidance to staff. *Staff need to do a better job with peri care and re-education. 3. Observation and interview on 9/28/22 at 9:32 a.m. with resident 40 in his room revealed: *He had been sitting in his electric wheelchair. *A catheter bag had been hanging off a garbage can and the tubing had been lying on the floor of his bathroom. *The toilet had urine remaining in the bowl, and fecal matter spattered around the back half of the toilet and the toilet seat. *Stains had been noted on his bed mattress. *The front of his electric wheelchair had a thick layer of dirt. *His ostomy bag had been hanging below his shirt on the outside of his pants. *Multiple bottles of personal hygiene products and empty boxes cluttered up his room. *He did not like people coming into his room to organize his stuff. Review of resident 40's electronic medical record revealed: *He had been admitted on [DATE]. *He had a brief interview for mental status (BIMS) of 15, meaning he was cognitively intact. *His diagnosis included: personal history of malignant neoplasm of bladder, ostomy and urinary tract infection (UTI). *His revised care plan dated 7/13/21 revealed: -He preferred to provide his own ostomy cares. -He did not follow infection protocols as he has done this for many years. *He had been diagnosed with a UTI on 8/4/22. Interview on 9/28/22 at 3:39 p.m. with administrator A regarding observations of resident 40 revealed: *She had agreed his room does need to be reorganized. *He will only allow housekeeping in his room once a month. *She had agreed the catheter tubing laying on the floor would be an infection control issue. Interview on 9/28/22 at 4:21 p.m. with DON B regarding observations of resident 40's bathroom revealed she: *Had not been aware that his catheter bag and tubing had been stored in his bathroom. *Agreed that would have been an infection control issues. *Did not find any documentation that the provider tried to re-educate resident 40 on ostomy care. 4. Review of the provider's September 2019 Catheter Care procedure revealed: *The purpose of the procedure was to prevent catheter-associated infections. *The catheter bag was to be positioned lower than the bladder to prevent urine from flowing back into the bladder. *To keep the catheter tubing and bag off the floor. *Residents who wanted to perform their own catheter care should be assessed to ensure they knew how to do it safely. *To notify the physician immediately with any signs or symptoms of urinary tract infection. Based on observation, interview, record review, and procedure review, the provider failed to: *Follow up and monitor for signs and symptoms for a urinary tract infection (UTI) resulting in hospitalization for one of one sampled resident (12). *Provide sufficient incontinence and peri care to avoid development of a UTI for one of one sampled resident (55). *Provide ongoing educational opportunities for one of one sampled resident (40) who self-cares for his ostomy. *Provide fluids that were thickened to the correct consistency based on physician's orders for one of one sampled resident (277). *Address all aspects of a resident's pain and implement interventions for one of one sampled resident (15). Findings include: 1. Observation and interview on 9/27/22 at 10:54 a.m. of resident 12 in his room while certified nursing assistants (CNA) M and FF assist him to get ready for a shower. *CNAs M and FF used the mechanical total body lift to move him from his wheelchair and into bed. *They undressed him in the bed, emptied his catheter bag, set the catheter bag on his lap, and with the mechanical lift assisted him into the shower chair. *CNA M pushed him to the east shower room in the shower chair with the catheter bag on his lap. *When she got him in the shower, she then moved the catheter bag below the bladder and attached it to the side of the shower chair. Interview on 9/27/22 at 11:32 a.m. with CNA M regarding the above observation revealed: *She had been educated to empty the catheter bag prior to transferring a resident so then the bag could be placed in their lap so it would not get pulled out. *She had agreed there could still be urine in the tubing of the bag that could go back into the bladder. *Resident 12 had a history of UTIs. Interview on 9/27/22 at 11:52 a.m. with licensed practical nurse BB regarding resident 12's catheter revealed: *She had changed the resident's catheter recently with no issues. *He was not currently on antibiotics for UTI. *Did have a history of UTIs. *Had not had an infection or hospitalization recently. *The CNAs put the catheter bag in his lap because resident 12 is nervous it will get pulled on. Review of resident 12's medical record revealed: *4/26/22 he had seen a urologist and a foley catheter was inserted. He was to have the catheter changed every 30 days. *There was an order on his treatment administration record (TAR) to change his catheter on 5/26/22. This had not been signed as completed. *A nurses note from 6/1/22 at 5:58 p.m.: Resident c/o [complaints of] Right side abdominal pain that started this morning et [and] gradually got worse thru out the day pain 6/10 per resident; writer emptied 300cc [cubic centimeter] of dark light brown urine per cath [catheter]bag. PRN [as needed] Tramadol given as ordered for pain PRN. VS [vital signs] 98.9-98-20-158/82. Will continue to monitor. *No other documentation regarding residents' abdominal pain until 6/3/22 at 5:10 p.m. and a nurses note indicated resident was sent to the emergency department for persistent abdominal pain that was not relieved with pain medications. *6/3/22 he was seen by Avel eCare via a two-way audiovisual telehealth system for evaluation of his abdominal pain. -Review of the note from this visit had indicated: --The pain had started the night before. --No mention of the symptoms he was having on 6/1/22. --His abdomen was distended and tender. --Plan was to transfer him to the emergency department to rule out appendicitis. Review of resident 12's 4/29/22 care plan revealed: *[Resident name] will show no signs and symptoms of urinary infection. *Change foley catheter per facility protocol or MD [medical doctor] order. Interview on 9/29/22 at 3:06 p.m. and on 10/3/22 at 3:41 p.m. with director of nursing (DON) revealed: *There had been no other documentation between 6/1/22 when the pain first presented until 6/3/22 when he was sent to the hospital. *Had expected a nurse to notify a doctor with his complaints on 6/1/22. *Had expected nurses to monitor and document in his medical record after his change on 6/1/22. *His catheter should have been changed and signed out on the TAR on 5/26/22. 6. Observation and interview on 9/27/22 at 11:27 a.m. with resident 15 revealed: *Sleeping in the wheelchair is not good, it hurts my tailbone. *He was supposed to be getting a recliner and the social service designee was working on it. *His right leg had an open area that was wrapped, and he reported he went to a wound doctor for it. *He had pain that was increasing, and he received two pills for pain, but he needed more. Review of the 7/12/22 admission Minimum Data Set (MDS) assessment for resident 15 revealed: *The pain interview assessment coded him as having occasional pain at a rating of five that limited his day-to-day activities. *He had shortness of breath when lying flat. Review of resident 15's care plan revealed: *No interventions to obtain a recliner in his room to address his preference and need for comfort. (Refer to F656, finding 1.) *Pain focus area related to his leg wound, revised on 7/14/22, with interventions of: -Resident will report complaints of pain or requests for treatment. -The medication will have the intended effect or the nurse will notify the physician if interventions are unsuccessful. Review of the September 2022 medication administration record (MAR) revealed he received: *Three Gabapentin 300 milligrams (mg) capsules at bedtime for the non-pressure chronic ulcer on his lower leg, started on 9/2/22, (a medication used to manage pain due to damaged nerves). *Two Gabapentin 300 mg capsules two times a day for chronic venous hypertension with ulcer of his lower leg, started on 9/2/22. *Two acetaminophen 325 mg tablets every 4 hours as needed for pain, not to exceed 100 mg a day, started on 7/6/22. *One hydrocodone-acetaminophen 5-325 mg tablet every 6 hours as needed for moderate pain for non-pressure chronic ulcer of lower leg, started on 7/19/22. It was administered only on 9/28/22. An additional order on the September MAR revealed: *Staff were to remind resident to elevate legs above the heart 3-4 times a day for 30-45 minutes and at night when in bed after meals and at bedtime related to generalized edema. *Documentation was present 4 times a day on 9/1/22 - 9/30/22 except for: -The 9:00 p.m. time on 9/2/22. -The 9:00 a.m. and 1:00 p.m. times on 9/26/22. Review of progress notes between 7/19/22 and 10/3/22 revealed: *No notation regarding an effort to obtain a recliner for resident 15. *A 9/2/22 progress note reported: -The order for three Gabapentin at bedtime was an increased dose. -The resident wants a different mattress - he feels like hes [sic] going to fall out of bed. Interview on 10/4/22 at 11:10 a.m. with SSD D revealed: *Resident had used a recliner at his previous long-term care location. *He did not have a bed in his room at that location. *She knew he wanted a recliner and was working on it but confirmed she had not written a progress note.

**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 resident (20) with a facility acquired pressure ulcer had received necessary care and interventions to prevent her wound from developing and worsening. Findings include: 1. Observation and interview on 9/27/22 at 4:02 p.m. with resident 20 revealed: *She had gone several weeks without a bath or a shower. *She could not recall the specific date but stated recently a staff person had assisted her into bed for the evening without changing her brief or removing her clothing. When she woke up in the morning, she was still in the same brief soiled with urine and stool and clothing. *She had been in her wheelchair since they had gotten her out of bed that morning around 10:00 a.m. *It was her normal routine to get up later in the morning around 10:00 a.m. and then be in her chair until the staff assisted her to lay down in the late afternoon or early evening. -She indicated staff usually would not check to see if she was dry, change her brief, or reposition her while she was up in her wheelchair. *In the evening when she was ready to lay down, at times it took up to two hours for staff to come assist her. She was often told 'just a minute' and then no one would come back to assist her. *After she was assisted into bed for the evening, the staff would usually come in between 9:00 p.m. and 10:00 p.m. to ensure her brief was dry, and then she did not get checked again until between 4:00 a.m. and 5:00 a.m. *Staff did not reposition her at night. *She did have a sore on her bottom and the nurses would put cream on it. Observation and interview on 9/28/22 at 3:39 p.m. with resident 20 revealed: *Staff had come in to change her soiled brief around 5:00 a.m. and then was not checked or changed again until she was assisted into her wheelchair for the day around 10:00 a.m. *She had not been changed or moved since they put her into the wheelchair. *She did not know if her brief was soiled or not. Observation on 9/28/22 at 10:51 a.m. of resident 20 in her bed laying on her side while certified nursing assistants (CNA) N and AA performed perineal cares revealed: *Her coccyx was reddened with pinpoint open areas to her lower back on her coccyx. *Licensed practical nurse had come into the room with Calmoseptine cream and instructed CNA AA to apply a thin layer to the reddened open area. Review of resident 20's 7/16/22 significant change MDS revealed: *Her BIMS was 13, indicating her cognition was intact. *She was dependent on two staff for bed mobility, transfers, dressing, toilet use, personal hygiene, and bathing. *She was dependent on one staff for locomotion. *She could not walk and used a wheelchair. *She was always incontinent of bowel and bladder. *She was at risk for developing a pressure ulcer. *She did not currently have a pressure ulcer. *She did have moisture associated skin damage (MASD). *There had been a pressure reducing device for her chair and her bed. Review of resident 20's medical record revealed: *She had been admitted on [DATE]. *She had been admitted with a stage II pressure ulcer to her right buttock that was healed on 7/29/22. *An order to apply Calmoseptine ointment to buttocks twice a day due to incontinence of bowel and bladder. *6/19/22 at 12:11 p.m. a progress note indicated: small of back with a indented are [area] with redness surrounding the indention no visible open are [area] applied zinc oxide. -It had not indicated whether the physician was notified. *She had been hospitalized from [DATE] through 7/12/22. *She had returned from the hospital with fractures to both legs and an elbow. *Wound summary documentation indicated: -She had a stage I pressure ulcer on her low back: --6/22/22, measuring 4 centimeters (cm) x 5 cm. --7/8/22, measuring 3.8 x 4 cm. --7/22/22 and 7/29/22, measuring 2.5 cm x 1 cm. --8/19/22, measuring 2.2 cm x 1 cm. -On 9/19/22 the pressure ulcer was documented as healed. *On 7/12/22 in her readmission user defined assessment (UDA) had indicated she had no: -History of a pressure ulcer. -Existing pressure ulcer. *One 7/12/22 she had refused a skin assessment upon readmission due to complaints of pain. *The first skin assessment was completed on 7/25/22 and stated she had a red groin. *Her skin assessment on: -8/2/22 stated she had an alteration in skin integrity but did not indicate what it was or where it was located. -8/9/22 and 8/16/22 she had redness under breasts, left inner thigh, groin folds, and coccyx. -8/23/22 the skin on her coccyx was pink and irritated. Calmoseptine cream was applied. -8/30/22 her groin is red. -9/6/22 stated she had an alteration in skin integrity but did not indicate what it was or where it was located. -9/14/22 stated she had an alteration in skin integrity but did not indicate what it was or where it was located. *No documentation of how often she was being repositioned. Review of resident 20's bathing documentation between 8/1/22 through 9/28/22 revealed she had: *Received a bath on 9/1/22 and 9/5/22. *Refused a bath on 9/22/22. -There had been no documentation of why or if another time had been set up to make up the missed bath. Review of resident 20's revised 7/21/22 care plan revealed: *She had an actual impairment in skin integrity r/t CKD [related to chronic kidney disease]. *It had not indicated what the skin impairment was or where it was located. *Had a goal for her wound to not develop infection. *Apply wound treatment as ordered by the physician. *Encourage good nutrition and hydration in order to promote healthier skin. *Keep skin clean and dry. Use lotion to dry skin. *Monitor/document location, size and treatment of skin injury. Report abnormalities, failure to heal, signs and symptoms of infection, maceration etc. to MD [medical doctor]. *Pressure reduction mattress and w/c [wheelchair] cushion. This was initiated on 2/25/22. *Turn and reposition as needed. *It had not indicated she was at risk for pressure ulcers or that she currently had a pressure ulcer. Interview on 9/28/22 at 3:54 p.m. with CNA AA regarding resident 20 revealed: *She usually worked a twelve hour day shift. *When she was working, they would get resident 20 up into her wheelchair around 10:00 a.m. or when she called for assistance. -This was the first time she had been changed or repositioned on the day shift. *Resident 20 would then stay in her wheelchair until she was ready to get into bed for the evening. *They did not check to ensure she was dry during the time she was in her wheelchair or reposition her. *Resident 20 was always incontinent of bowel and bladder and did not use the toilet. *Resident 20 did have a sore on her bottom. Interview on 9/28/22 with LPN BB regarding resident 20 revealed: *Resident 20 did have a pressure ulcer to her coccyx area and the nurses were putting cream on it. *She had thought all wounds in the building were measured weekly. *Had not been aware staff did not ensure resident 20's brief was clean and dry while she was up out of bed in her wheelchair. Interview on 9/29/22 at 4:11 p.m. with regional nurse consultant X revealed: *There was not a nurse designated as the wound nurse. *Director of nursing and Minimum Data Set nurse shared the role. *All pressure ulcers were to be measured weekly. Interview on 10/3/22 at 4:00 p.m. with director of nursing B regarding resident 20's pressure ulcer revealed: *Interventions put into place were an air mattress, wheelchair cushion, keep skin clean and dry, and to turn and reposition as needed. *She thought the resident should have been repositioned every two hours. *She had not been aware resident 20 was not checked to ensure she was clean and dry while up in her wheelchair. *She had expected the staff at night to ensure she was clean and dry. *The pressure ulcer and her risk of developing a pressure ulcer should have been included in the care plan. *Resident 20's skin impairment was probably not related to her chronic kidney disease but from not being repositioned and being clean and dry. *They had not had a dedicated wound nurse, so the measurements of wounds were not getting done weekly. Review of the provider's April 2021 Skin Program revealed: *To provide care and services to prevent pressure injury development, to promote the healing of pressure injuries/wounds that are present and prevent development of additional pressure injuries/wounds. *A skin assessment should have been completed at time of readmission. *When a pressure ulcer was identified it was to be reassessed weekly, and provider was to be updated if not improving within two or three weeks. *7. Nursing personnel will develop a plan of care (POC) with interventions consistent with resident and family preferences, goals and abilities, to create an environment to the resident's adherence to the pressure injury prevention/treatment plan. *POC to include: Impaired mobility, Pressure relief, Nutritional status and interventions, Incontinence, Skin condition checks, Treatment, Pain, Infection, Education of resident and family, Possible causes for pressure injury and what interventions have been put into place to prevent. *Skin checks to be completed at least weekly by a Licensed Nurse. Review of the provider's September 2019 Care Planning policy revealed each resident's care plan should be updated to reflect their current needs.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 3. Interview on 9/27/22 at 4:21 p.m. with resident 61 revealed she: *Had been sitting in her wheelchair in her room. *Had to wait a long time to use the bathroom. *Had some accidents because she has to wait for someone to transfer her. Record review for resident 61 revealed she: *Was admitted on [DATE]. *Had a diagnosis of unspecified urine incontinence. *Was assessed on the Minimum Data Set (MDS) dated [DATE] as one person physical assist with transfers. 4. Interview on 9/28/22 at 9:07 a.m. with resident 40 revealed he: *Had been sitting in his electric wheelchair in his room. *Had to wait 30 minutes in the morning for help sometimes. *Stated staff take other residents to the dining room to eat and then do not come back to help him. Record review for resident 40 revealed he: *Was admitted on [DATE]. *Had a diagnosis of malignant neoplasm of bladder and a Urostomy. *Was assessed on the MDS dated [DATE] as one person physical assist with transfers. Based on observation, interview, record review, policy review, and facility assessment review, the provider failed to ensure sufficient nursing staff were available to provide nursing services to meet residents' needs safely and in a manner that promoted each resident's rights and physical, mental, and psychosocial well-being for 79 residents. Findings include: 1. Interview on 9/27/22 at 4:02 p.m. with a resident who did not want to be identified revealed: *She did not get a bath regularly. *She had false teeth, staff did not usually brush them, they just put them in a denture cup at night with a denture cleaning tablet, rinse them off in the morning and give them back to her. *Hates the weekends because staff is always short and feels there is no one there to care for her. *Sometimes in the evening when she is ready to get into bed, she has to wait up to two hours for assistance. -She states usually because it takes two staff to transfer her and there is not always two available to help. *She stated the staff will tell her just a minute but then never come back. *Has been put to bed at night soiled and not changed until the next morning. 2. Interview on 9/27/22 at 4:53 p.m. with resident 45 revealed: *At times he has to go without a shower because there is not enough staff to assist him with the task. *He stated This [the provider] is a business and its about meeting the business standards, not taking care of people. *He did not think management listened to what the residents wanted or needed. 5. Interview on 9/27/22 at 3:15 p.m. with certified nursing assistant (CNA) M, who was assigned to give baths that day, revealed: *She did not know where she would be assigned until she arrived that morning, but she was okay with giving the residents baths, because she knew they would get done. *She had been full-time but worked just part-time now because of the concerns she had identified with poor quality of care, including: -Perineal care not getting done correctly leading to a high frequency of urinary tract infections. -Oral care not getting done at all. -Not all of residents were getting routine baths or showers. -Not using two staff when total lifts were used. *She was trying to get as many baths done as she could to get some of the missed residents done. *The tub room was a mess when she first walked into it that morning with soiled towels all over the place. *She named several residents who have had negative experiences related to staffing concerns. 6. Interview on 9/28/22 at 3:51 p.m. with CNAs S and V revealed: *CNA V had been working here for a few weeks, but CNA S started just on Monday, 9/26/22; both were already CNAs when they started. *CNA V reported she had received a little orientation when she started, but CNA S said she had received none. *They were assigned to work two halls together, blue [rooms 218-230, 20 residents as of 9/27/22] and red [209-217, 15 residents as of 9/27/22], but sometimes there was only one CNA for the blue wing. *No help was provided from other staff or nurses. *They did not know who leadership was. *There was no rounding between shifts with the off-going CNAs. *They try hard to do all personal cares. *The bath CNA doesn't do any baths outside of scheduled baths. *The CNAs have to pick up the water cups from each room and return with fresh water during the shift. CNA V reported there was no system for doing that when she first started so she started putting tape on the mugs so she could tell when fresh water was last delivered to each room. *Snack carts had to be done by CNAs if it was going to be done. *They had not had time yet to pass fresh water or snacks. Review of the employee files for CNAs S and V revealed: *CNA V started on 9/15/22 and there was a completed orientation checklist in her file. *CNA S started on 9/26/22 but there was not a completed orientation checklist in her file. Interview on 10/4/22 at 1:15 p.m. with human resource director (HRD) H revealed: *CNA S had not received orientation because she started working before she [HRD H] knew she was starting. *CNA V resigned effective immediately last week. 7. Interview on 9/28/22 at 4:16 p.m. with CNA N, while standing at the nurses desk with no residents in the area, revealed: *She had worked as a CNA here for a year. *The CNAs rotate wing assignments, and it took her two weeks to get to know every resident. *She was assigned as bath CNA that day, but they usually don't know who is assigned until they come on duty. She was the bath CNA maybe once a week out of three to four days. *The day shift CNAs will do walking rounds with the night CNAs if the night CNAs get here on time. *The CNAs do not get report from the nurses. *Regarding the bath schedule: -There is a schedule in the tub room. -The CNAs fill out a bath sheet to report the bath being done and any concerns observed during the skin check. -If scheduled bath is not done, a second CNA may see if the resident is willing to get a bath that day. -If the bath is not done, it may be done on another day if there is time and the bath CNA is aware of who was not done. -Sometimes, the nurse will write a note in the bath book. -We document the bath task in POC [point of care]. *Radios don't help with communication between staff. There was either not enough or they are not charged. *The CNAs are not able to hear call lights from one end to the next. *Most Hoyer [total] lifts are on blue [wing], and the CNAs have to pool together to get two person transfers done. *Mealtimes can be a challenge for assisting all the residents. -Today during lunch, there wasn't enough. Several people, including leadership, left while the surveyors were gone for lunch. -Supper is hardest for having enough staff to assist with the mealtime because we are changing shifts at 6:00 [p.m.] At the end of the interview with CNA N on 9/28/22 at 4:20 p.m., LPN L, who was charting while seated at the nurses desk, spoke up and reported there was never enough staff. She said, Management has asked the CNAs several times what would help, and nothing has changed. 8. Interview on 9/29/22 at 10:00 a.m. with 7 residents (9, 34, 36, 50, 52, 63, and 73) interviewed during the resident group meeting agreed: *They did not know who to go to when reporting a grievance. There had been so many changes in the last two months that they don't know what is happening. *The provider did not have sufficient staff to ensure care was provided in a timely manner: -They reported they have had to wait too long for call lights to be answered. -Staff get pulled away when providing care with a resident, sometimes several times, to help with other situations. -At times, there will be two staff when using a mechanical lift but usually only one. -The CNAs stand at the desk or in the hallway talking and laughing with each other while call lights are going off. -Resident 34 had reported that [when CNAs were not responding to call lights] to the nurse, but no changes in behavior have been seen. -Resident 73 reported he sat on toilet today for an hour before a medication aide arrived and then she did not want to take the time to get the sit-to-stand lift. When he refused, she said, I'm the boss, we'll do it my way. (Refer to F600, finding 2.). -Resident 63 reported staff will not transfer me more than once a day so, when he wanted to attend morning and afternoon activities, he had to choose so he could get off his wheelchair during the day. -Residents 9, 34, and 63 all agreed they have had to help other residents get over a doorway threshold when stuck because there were no staff around to help. Then they get told they were not supposed to help other residents but do not get an explanation for why. -This should be our home, but it isn't. -They treat us as just a reason to get a paycheck. *They got fresh ice water when they ask for it, but it is not routinely distributed. *They had not seen a snack cart and had never been offered snacks at bedtime. 9. Review of the Facility Assessment revealed it was dated 5/24/21 and was based on an average daily census of 52 residents. *The facility census on the 9/27/22 Resident List Report had 79 residents total, with:. -20 residents on Unit: 218-230 Blue (Center). -16 resident on Unit: East-Wing [rooms 301-312]. -15 residents on Unit: 209-217 Red (Center) -12 residents on Unit: 201-208 Yellow (Center). -16 residents on Unit: [NAME] Wing [rooms 100-115]. *Comparative Review of the staffing numbers posted on the dry erase board in the conference room and the August and September 2022 nursing schedules revealed: *The current census was listed on the board as 80, 18 [short stay] residents. The goal census was 80, 20. *The CNA numbers on the board listed eight CNAs, without specifying which shift, assigned as: -CNAs Blue x [times] 2. -East x 2. -Red/Yellow [both wings] x 1. -Bath aid x 1. -[NAME] x 1. -[NAME]/Red x 1. *The August and September 2022 schedules revealed: -On 9/6/22 and 9/7/22, there was only one CNA. -On 9/13/22, there were only three CNAs. -On 8/28/22 - 9/1/22, 9/3/22, 9/11/22, and 9/26/22 [8 days], there were only four CNAs. -There were 13 days with only five CNAs, 17 days with only six CNAs, and 8 days with only seven CNAs. -Only 11 days were covered by eight or more CNAs, most of those days in August. -Only 2 days in September (9/28 and 9/30) had 8 CNAs on the schedule. *The nurse and certified medication aide (CMA) numbers on the board showed 3 and 2 respectively, each day, while the August and September 2022 schedules revealed shortages: -For nurses, three days in August and four days in September. There was only one nurse on 9/17/22. -For CMAs, seven days in August and four days in September. 10. Interview on 10/04/22 at 1:25 p.m. with administrator (ADM) A and regional nurse consultant X regarding staffing revealed: *They have trialed several changes in staffing from eight hour shifts to twelve hours shifts. The change to twelve hours started the end of July. *Residents have been interviewed about staffing concerns. *Staff have been interviewed to see where they felt the high acuity cares were in the building. *ADM A acknowledged that she had not had a chance to update the Facility Assessment to reflect current acuities. *Staff need to use the walkies [radios] to communicate with each other. *Staff have not been willing to cross-over to help each other and will only work on their assigned hallway. We are trying to change the culture. *Bath assignments were trialed two ways: -Had the CNAs give the baths assigned on their hallways each day instead of having an assigned bath aid. -After conducting a bath Ad Hoc quality improvement audit and discovered that baths did not get done that way, we now assign a bath aide every day to give all the baths. *We are working to hold some nurses accountable to make correct decisions about reassigning staff. *We are making progress moving away from having contract staff; we were at 80% [percent] contract staff and now it is 50/50 [50% contract to 50% hired}. 11. Refer also to F600, F677, F685, F686, F689, F692, and F809 for findings that demonstrate the impact that insufficient staffing had on unmet resident needs.