**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on South Dakota Department of Health (SD DOH) facility reported incident (FRI), interview, and policy review, the provider failed to ensure a contracted licensed practical nurse (LPN) (F) had followed nursing professional standards of practice for the preparation of one of one sampled resident's (1) physician-ordered medication administration delivered through a syringe driver according to the provider's policy. That failure resulted in a medication error. Findings include: 1. Review of 5/13/25 SD DOH FRI revealed: *Resident 1 was admitted on [DATE] and was receiving hospice services. *A syringe driver (a battery powered pump that delivers medications under the skin) was initiated on 5/9/25. *That pump was to continuously deliver medications for pain, anxiety, and agitation to the resident twenty-four hours a day. *On 5/12/25 at 4:30 a.m., the syringe medication was prepared by travel licensed practical nurse (LPN) F who then began its administration. *The oncoming nurse, LPN D changed the syringe at 6:30 a.m. and identified the controlled (medications at risk for addiction and abuse) medication count for morphine (controlled pain medication) was incorrect. *LPN F was then interviewed by the assistant director of nursing (ADON) (G). -LPN F reported she mixed the resident's ordered medications in the syringe, but she did not add the instructed distilled water to the syringe. *Avera pharmacy and the resident's primary care provider (PCP) were notified of the medication error. -They had no concerns of adverse outcome due to the medication error. 2. Interview on 6/10/25 at 3:15 p.m. with LPN D revealed: *She had been employed at the facility for more than ten years. *She reported using the syringe driver to administer medication to residents on a regular basis. -She reported syringe drivers were commonly used with hospice residents nearing the end of their life. *She was able to show the syringe driver kit (syringe driver and associated supplies that were stored in a plastic bin) and demonstrated its setup and function. *She stated she knew how to prepare the medication for the syringe driver by following the syringe driver procedure that was easily seen in the syringe driver kit. 3. Interview on 6/11/25 at 2:00 p.m. with director of nursing (DON) B and staff development coordinator C revealed: *Training was provided to new employees on how to operate syringe drivers. *Training was not provided to travel staff prior to working shifts. *It was the expectation of staff development coordinator C, that travel staff were educated through their employment agency. *It was DON B's expectation for LPN F to read the syringe driver procedure and ask for help if needed. *She confirmed this was a medication error. 4. Interview on 6/11/25 at 6:30 p.m. with LPN E revealed: *He worked the shift on 5/12/25 prior to LPN F taking over and he gave a shift report to her that evening. *He had never worked with LPN F before that day. *He informed LPN F when the syringe would need to be changed for resident 1, and asked if she had questions. *He asked LPN F if she was familiar with syringe drivers and how to prepare the medications, and LPN F reported to him that she was familiar with syringe driver use. *He reported education was completed as part of new employee competencies and usually at the annual skills fair. 5. Review of the provider's undated syringe driver procedure revealed: *1. Obtain initial doctor's orders *2. Assemble equipment: syringe driver, battery (9-volt), softest (needleset), 12cc (cubic centimeter) syringe, betadine [cleaning solution], alcohol wipes, transparent dressing/opsite [adhesive dressing], tape, bag, pin, sterile water, MS [morphine sulfate]/Haldol [antipsychotic medication]/Robinol [saliva and secretion reducing medication] 3.Fill syringe with MS, then sterile water, then Haldol, then Robinol if ordered to an amount to equal 10cc or 12cc. 6. Review of the providers September 2018 medication administration policy revealed: *Instructions, C, 4, If unfamiliar with the med [medication], check in the drug handbook, call the Pharmacist and/or physician for clarification or look for manufacturer guidelines if it is a recently released med.

Based on observation, interview, and record review, the provider failed to ensure the posted daily staff data: *Was displayed in a prominent area accessible to all residents and visitors. *Included the resident census. *Included the total number and the actual hours worked by registered nurses, licensed practical nurses, and certified nursing assistants per shift and the resident census. Findings include: 1. Observation on 1/30/25 at 4:42 p.m. throughout the entire building revealed the nurse staffing data was located in an inconspicuous location near the visitor screening station to the right of the front desk. The staffing data was not posted anywhere else in the building, including the locked memory care units. 2. Review of the posted staffing data for 1/30/25 revealed: *The resident census was not included. *There were three sections for each shift. Each section was divided by resident unit. *Staff names were displayed for each shift they were working. *There was no distinction between registered nurses and licensed practical nurses. *The total number of nurse staffing hours was not included for each shift. 3. Interview on 1/30/25 at 5:18 p.m. with director of nursing B revealed: *The nurse staffing data was only posted at the front desk. *She indicated that the staffing data was supposed to have been posted more prominently, such as in front of the receptionist, rather than by the visitor screening station. *She agreed that not all residents had access to the posted staffing information. *She was not aware of all the requirements for the posted nurse staffing data, such as the resident census and the total hours worked per nursing discipline. *They did not have a policy regarding the posted nurse staffing data.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and review of the Hospice and Nursing Facility Services Agreement, the provider failed to ensure an integrated plan of care had been developed and made accessible between the provider's nursing staff and hospice agency for one of one sampled resident (19) who received hospice services. Findings include: 1. Observation and interview on 1/28/25 between 11:42 a.m. and 12:08 a.m. with cosmetologist AA in the Dixie dining room revealed: *Cosmetologist AA was seated next to resident 19 at the assisted dining table. *Resident 19 had a recent weight loss, was on a pureed diet due to pocketing of food, and had recently began receiving hospice services. 2. Interview on 1/29/25 at 11:34 a.m. with licensed practical nurse (LPN) L revealed resident 19 had gallstones, no surgery was recommended, and she began receiving hospice services about two weeks ago. 3. Interview on 1/29/25 at 3:07 p.m. with registered nurse (RN) K and staff development coordinator (SDC) H at the North Oak nurses' station regarding hospice revealed: *There was only one hospice provider the facility used, and they were available by phone 24 hours a day seven days a week. *Communication of when the hospice nurse would return to complete wound care or baths was provided verbally and in the electronic medical record (EMR) system. *There was no specific binder or paper records available at that nurse's station regarding resident 19's hospice plan. 4. Review of resident 19's EMR revealed there was no documentation that a physician's order for hospice had been received. 5. Interview on 1/29/25 at 3:38 p.m. with hospice RN GG revealed: *Consent forms were kept in the resident's paper medical record. *She documented her assessments, phone number, and the date of the next visit directly in the resident's EMR. 6. Review of resident 19's current facility care plan revealed: *She had been admitted to the facility on [DATE]. *Her diagnoses included mild intellectual disabilities, osteoarthritis, anemia, heart failure, fracture of left patella, acute kidney failure, anorexia, and anxiety disorder. *A nutrition focus area indicated, Currently on hospice was revised on 1/28/25. *The nutrition goal indicated, Comfort Care Nutrition provided due to hospice. *The nutrition interventions included, 1/28/24: admitted to hospice on 1/17 [2025] due to recent diagnosis of Calculus of Gallbladder with Acute Cholylith [Cholelith (gallstones)] with back pain. General surgeon recommends comfort cares over surgical intervention. On 1/29/25 a request was made to director of nursing (DON) B for resident 19's hospice care plan and physician order. 7. Interview on 1/30/25 at 8:19 a.m. DON B regarding hospice services revealed: *On 1/29/25 she had contacted hospice for a copy of resident 19's care plan. -Hospice was to put together a care plan and review it weekly with the medical doctor. *A hospice care plan was to be kept in the front of resident 19's paper medical chart and contained the contact number and the services that hospice staff provided. *She obtained a copy of resident 19's hospice physician's order on 1/29/25. *The joint care plan had not been completed. *She expected the facility care plan to be updated with the specific hospice plan by each department when resident 19 started receiving those services. *Hospice documented their notes directly in the EMR if there were any concerns. 8. Interview on 1/30/25 at 8:52 a.m. CNA FF regarding identifying residents receiving hospice revealed: *She identified resident 19 received hospice services. *That information was provided to her by the nurse, and it was to be on the pocket care plan. *Hospice visited resident 19 one to two times a week to take her vitals and complete a bed bath. 9. The provided pocket care plan did not indicate that the resident received hospice services. 10. Interview on 1/30/25 at 4:19 p.m. with administrator A and DON B regarding resident 19's hospice care revealed: *There had been a delay in getting the hospice admitting diagnosis for resident 19. *She was admitted to hospice on 1/17/25. *During the interview DON B called the hospice provider to request a copy of the physician's order and the hospice care plan. *DON B stated she updated the facility care plan to reflect that resident 19 had been admitted to hospice and the services she received. *She expected the care plan to reflect the specific care resident 19 received. 11. Review of resident 19's 1/30/25 updated care plan revealed: *Her care plan included a focus area that was revised on 1/30/25, See the MAR/TAR, Physician orders/protocol, CNA [certified nursing assistant] flow sheets and the Short Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the exception reflecting facility standards. Administer medications as ordered. [Resident 19] was admitted to Hospice on 1/17/25. *There was no resident-centered goal, it directed to See Focus revised on 4/16/24. *There were no specific interventions, it directed to See Focus initiated on 5/9/18. 12. Review of resident 19's hospice care plan revealed: *It was dated 1/17/25. *The progressive disease process was gallbladder with acute cholylith (cholelith). *Ongoing updates will be communicated by Hospice to LTC [long-term care] and LTC will integrate changes into their care planning system. The Hospice care plan is the Plan of Treatment/485 with ongoing MD [medical doctor] orders being part of that plan. Hospice does not utilize a separate nursing plan of care [POC]. The LTC plan of care will reflect the most current POC at the LTC facility. That was marked with the responsibility code for hospice and long-term care. 14. A review of the provider's 1/8/13 Hospice and Nursing Facility Services Agreement revealed: *Joint Plan of Care . means a coordinated joint plan of care for an individual Patient for the palliation or management of the Patient's terminal illness and related conditions that (a) clearly delineates the services to be provided by Hospice and Facility; (b) is consistent with Hospice's philosophy; (c) is based on the assessment of the Patient's current medical, physical, psychological and social needs, and unique living situation; (d) reflects the participation of Hospice, Facility, the Patient and the Patient's family, as appropriate; and Euro complies with applicable federal and state laws and regulations. *Facility responsibilities included: -Participate in Development of JPOC -Coordination with Hospice Staff in implementation and update of Joint Plan of Care. *Joint Responsibilities/Mutual Promises. Development and Implementation of Plan of Care Hospice and Facility shall jointly develop and agree upon the Patient's Joint Plan of Care Hospice and Facility each shall maintain a copy of each Patient's JPOC in the respective clinical records maintained by each Party.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the provider failed to maintain resident rooms and resident common areas in a clean manner free from strong odors, sticky floors, and damage to the walls and bathroom tiles for at least seven resident rooms, at least one resident common area, and at least one shower and one tub room. Findings include: 1. Observations on 1/28/25 from 9:53 a.m. to 10:36 a.m. in the Pine Village memory care unit on the second floor revealed: *In resident room [ROOM NUMBER]: -There were gouges in the corner with exposed drywall. -Phone cords were in a tangled pile on the floor behind the resident's rocking chair. *In resident room [ROOM NUMBER]: -There were at least five vertical gouges in the wall behind the tan recliner, ranging from approximately two to six inches in size. *In resident room [ROOM NUMBER]: -Drywall was exposed on the out-[NAME] corner. -Painter's tape had been left on the baseboard. -The wall next to the bed had at least eight quarter-sized gouges, with drywall exposed. -The wall behind the light brown recliner had a gouge approximately two inches by one inch in size with exposed drywall. -There was a scrape approximately six inches above the baseboard that extended about three feet along another wall with exposed drywall. -The bathroom floor was sticky and had a strong urine odor. *In resident room [ROOM NUMBER]: -There was exposed drywall near the baseboard in a corner. *In resident room [ROOM NUMBER]: -The bathroom sink was leaking a steady flow of water, even though the faucet paddles were in the off position. *In resident room [ROOM NUMBER]: -The wall behind the bed had vertical gouges with drywall exposed. -There was a gouge on a corner of a wall with exposed drywall. -The hand sanitizer dispenser was not functioning. *In the resident day room: -At least five gouges were in the walls behind the recliners. * The above conditions remained unchanged during additional observations on 1/29/25 from 9:33 a.m. to 10:05 a.m., and on 1/30/25 at 9:05 a.m. 2. Observations on 1/29/25 at 2:21 p.m. and on 1/30/25 at 7:59 a.m. in the North Oak care unit on the third floor revealed: *In resident room [ROOM NUMBER]: -A corner of wall tile in the bathroom was chipped and had jagged edges with exposed cement. -There was a missing piece of tile located just outside the doorway to the left of the sink. -The hand sanitizer dispenser was not functioning. *Outside the doorway of resident room [ROOM NUMBER]: -There were three small gouges in the wall above the railing with exposed drywall. -There was an approximate two-foot scrape on the wall below the railing with exposed drywall. 3. Interview on 1/30/25 at 3:12 p.m. with activity aide Z about what staff would do if something was not working or needed repair revealed she stated, I would have to ask the nurse to verify or go to maintenance. 4. Interview on 1/30/25 at 3:19 p.m. with CNA W about what staff would do if something was not working or needed repair revealed she stated, I would call maintenance for a repair because its faster, but we can use a maintenance green slip and send that to maintenance. 5. Interview 1/30/25 at 3:27 p.m. with LPN R about what staff would do if something was not working or needed repair revealed he stated, I would call maintenance or use a maintenance green slip. 6. Interview on 1/30/25 at 5:19 p.m. with administrator A revealed: *He explained there was no policy for submitting maintenance requests. *He expected staff to submit a green maintenance request slip, talk with someone from the maintenance department directly, or call immediate maintenance requests over the radio.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** D. 1. Observation on 1/28/25 at 4:09 p.m. of resident 70 revealed she was in her room lying on her bed's alternating air mattress and appeared comfortable with no facial indicators of pain. Review of resident 70's EMR revealed: *She admitted to the facility on [DATE]. *Her BIMS was scored at 4 indicating severe cognitive impairment. *She had an Alzheimer's Disease diagnosis. *Her medications included: -An antipsychotic medication QUEtiapine Fumarate [antipsychotic] Oral Tablet: --25 MG [milligrams] (Quetiapine Fumarate) Give 1 tablet by mouth in the morning for hallucinations. --25 MG (Quetiapine Fumarate) Give 12.5 mg by mouth at bedtime for hallucinations. -Two controlled (medications with risk for abuse of addiction) pain medications: --oxyCODONE-Acetaminophen Oral Tablet 5-325 MG (Oxycodone w/ Acetaminophen) Give 1 tablet by mouth every 12 hours as needed for pain control. --fentaNYL Transdermal Patch 72 Hour 12 MCG/HR [mg per hour] (Fentanyl) Apply 1 patch transdermally every 72 hours for Pain and remove per schedule. -A hypnotic medication Zolpidem Tartrate Oral Tablet 10 MG (Zolpidem Tartrate) Give 1 tablet by mouth at bedtime for Insomnia. Review of resident 70's current care plan printed on 1/30/25 revealed: *Her care plan did not address her antipsychotic, opioid (pain), and hypnotic medications. *Her care plan included a focus area that was initiated on 1/8/25 See the MAR/TAR, Physician orders/protocol, pocket care plan and the Long-term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the direction of the resident and their wishes for their plan of care. Administer medications as ordered. *There was no resident centered goal, it directed to See Focus initiated on 1/8/25. *There were no specific interventions, it directed to See Focus initiated on 1/8/25. *The focus area regarding her medications did not include: -A goal regarding her high-risk medications. -Specific interventions including the medications' side effects that assisted her to meet that goal. 2. Review of resident 40's current care plan revealed: *A focus area: See the MAR/TAR, Physician orders/protocol, pocket care plans and the Long Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment if applicable. Care plans are written by exception reflecting facility standards. Administer medications as ordered. Initiated on 2/25/19. Revised on 4/25/24. -Goal: See Focus. Initiated on 2/25/19. Revised on 10/29/23. -Interventions: See Focus. Initiated on 2/25/19. *There were two separate focus areas relating to altered skin integrity due to incontinence. The interventions on one of those focus areas had not been updated since 5/13/21. *There were several interventions in other focus areas that appeared to be a copy/paste and summaries of progress notes from the resident's electronic medical record. -For example, there was an intervention under the skin focus area that read: --4/3/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions at the time were appropriate - will keep in place. --5/7/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions revised. --6/18/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions revised. --8/6/24: Interventions were assessed at a skin meeting. The care plan interventions were reviewed and interventions at the time were appropriate - will keep in place. --Initiated on 8/19/24, revised on 8/19/24. *A focus area related to a diagnosis of depression was initiated on 12/8/24. -An intervention was added on 12/8/24 that read, Administer medications as ordered. Monitor/document for side effects and effectiveness. -Review of resident 40's medication administration records from July 2024 through January 2025 revealed she had not taken any type of antidepressant or mood-altering medication. *A focus area related to pain was initiated on 7/30/20 and revised on 4/3/24. [Resident 40] has a history of taking scheduled analgesic [a category of pain-relieving medications]. Staff will monitor for s/s of generalized pain and stiffness. -An intervention was added on 2/25/19 related to pain that read, Administer analgesia as per ordered. -Review of resident 40's medication administration records from July 2024 through January 2025 revealed she had not taken any type of analgesic medication. Interview on 1/30/25 at 5:19 p.m. with administrator A and DON B revealed: *They tried to rework their resident care plan policy because of the previous recertification survey. *DON B was not aware that the interventions for depression and pain medications were still included on resident 40's care plan. *The nurse manager for the memory care units was responsible for those residents' care plans. *They had no explanation as to why the resident care plans included goals and interventions of See Focus. 3. Interview on 1/28/25 at 10:53 a.m. with resident 45 revealed that she thought she was on an antibiotic but did not know if she took an anticoagulant (a blood thinner). Review of resident 45's EMR revealed: *She was admitted to the facility on [DATE]. *Her BIMS assessment score was 14, which indicated she was cognitively intact. *She had a diagnosis of long-term (current use) of anticoagulants. *Her medications included Eliquis [an anticoagulant] Oral Tablet 2.5 MG [milligrams] (Apixaban) Give 2.5 mg by mouth two times a day for atrial fibrillation. Review of resident 45's current care plan printed on 1/30/25 revealed: *Her care plan did not address her use of anticoagulant medications. *Her care plan included a focus area that was revised on 8/7/24, See the MAR/TAR, Physician orders/protocol, CNA flow sheets and the Short Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the exception reflecting facility standards. Administer medications as ordered. *There was no resident-centered goal; it directed to See Focus, revised on 8/15/24. *There were no specific interventions; it directed to See Focus, revised on 7/25/24. E. 1. Observation and interview on 1/28/25 at 5:05 p.m. with resident 10 revealed: *She was in her room sitting in her recliner working on a word puzzle. *She stated she was living at the facility because the doctor thought I needed more help. Review of resident 10's EMR revealed: *She had lived at the facility in the secure memory care unit since 7/31/24. *Her BIMS assessment score was 15 which indicated she was cognitively intact. *A 7/31/24 admission progress note stated . it was determined that she was unable to safely return to her own apartment d/t [due to] altered mental . Resident admitted to secured unit d/t [due to] dx [diagnosis] of dementia and history of wandering . in her own apartment building. Secured unit assessment initiated. *An 8/8/24 physician order summary stated Resident noted to have a diagnosis of Dementia, because of this condition the resident benefits from the consistent smaller therapeutic environment and the specialized care provided in a secured unit. Specific clinical indications will be reviewed by the interdisciplinary team on a quarterly and as needed basis and documented in the resident's care plan. *A 9/27/24 social service note stated She repeatedly commented on wanting to get some things from her old apartment, however she has been informed many times that it's been cleaned out by family/responsible party and her things donated. She was asked before things were dispersed what she wanted. She commented on hating it here and voiced confidently that she does not think she needs to be here. Doctor has documented her need for SNF [Skilled Nursing Facility] care. With her comments, she was asked about talking to someone about return to community and her response was well, if I can get outta here . Call placed to [first name], LTCO [long term care ombudsman]. Message left . Review of resident 10's current care plan printed on 1/29/25 revealed: *A focus area initiated on 8/8/24 indicated Resident noted to have a dx of Dementia, this resident benefits from the consistent smaller therapeutic environment and the specialized care provided in a secured unit. *There was no resident-centered goal, only the words see focus that was initiated on 8/8/24. *There were no specific interventions, only two narratives in the section for the interventions: -1/9/25 - [resident 10] she has been noted to have the following symptoms/behaviors: rejection of cares and disorientation to time. Resident's POA [power of attorney] notes that resident has intermittent periods of increased confusion. BIMS assessment completed on 1/8/25 with result of 14.0. Secured unit order received from PCP [primary care physician] on 8/7/24. [First name of resident] does not appear to be impacted by residing in a secured unit. Writer discussed secured unit placement with POA [first name] on 1/7/25, [POA's name] in agreement to with secured unit placement. [Resident 10] has been noted to benefit from the following services provided in the secure unit: specialized care, increased security to allow for independent mobility, smaller/calming environment, therapeutic activities, and consistency. Due to above information, resident will continue secured unit placement. -[Resident 10] can become very agitated and often yells/swears at staff, typically related to missing her old apartment at [Name of apartment building]. She seems to calm some when staff listen quietly and redirect her towards positive aspects. *The focus area regarding her placement on the secured memory care unit did not include: -A goal regarding her placement and adjustment to living on the secure memory unit. -Specific interventions to assist her to adjust to living on the unit. Review of the provider's revised August 2024 Care Plan, Resident-Centered and Individualized Plan of Care Policy revealed: *To ensure that each resident receives individualized, comprehensive, and person-centered care by developing and maintaining a written care plan based on their needs, preferences, and medical conditions. *Care plans should include a focus, goals and interventions for the resident. *The resident's care plan is reviewed and/or revised frequently due to changes and updates to the plan of care. *Each discipline is responsible for updating the care plan as changes to the plan of care occur. * The care plan covers focuses related to but not limited to: -Medications -Infections -Pressure injuries -Continents and Incontinence of resident -Bowel function of the resident -Fall risk and history -Dehydration and Risk of dehydration -Day-to-day activities and the assistance needed -Activities the resident enjoys doing. Based on observation, interview, record review, and policy review the provider failed to ensure resident care plans had been revised to reflect their current needs for: A. One of one sampled resident (19) who received hospice services. B. Five of five residents (6, 7,15, 19, and 41) who received a pureed diet and were included in the paid feeding assistants program. C. Five of five sampled residents (6, 25, 62, 66, and 68) who required transmission-based precautions (TBP). D. Three of three sampled residents (40, 45, and 70) who required monitoring for medications they received. E. One of one sampled resident (10) who required placement on a secure memory unit. Findings include: A. 1. Interview on 1/29/25 at 11:34 a.m. with licensed practical nurse (LPN) L regarding resident 19 revealed resident 19 had gallstones, no surgery was recommended, and she began receiving hospice services about two weeks ago. 2. Interview on 1/30/25 at 8:52 a.m. certified nursing assistant (CNA) FF regarding identifying residents who received hospice services revealed: *She identified resident 19 received hospice services. *That information was provided to her by the nurse, and it would be on the pocket care plan. *Hospice visited resident 19 one to two times a week to take her vitals and provide a bed bath. 3. Review of the provided pocket care plan did not indicate that the resident received hospice services. 4. Review of resident 19's care plan revealed: *She admitted to the facility on [DATE]. *Her diagnoses included mild intellectual disabilities, osteoarthritis, anemia, heart failure, fracture of left patella (kneecap), acute kidney failure, anorexia, and anxiety disorder. *A nutrition focus area indicated, Currently on hospice was revised on 1/28/25. *The nutrition goal indicated, Comfort Care Nutrition provided due to hospice. *The nutrition interventions included, 1/28/24: admitted to hospice on 1/17 [2025] due to recent diagnosis of Calculus of Gallbladder with Acute Cholylith [Cholelith, gallstones] with back pain. General surgeon recommends comfort cares over surgical intervention. *There were no other focus areas, goals or interventions related to resident 19's hospice care. 5. Interview on 1/30/25 at 4:19 p.m. with administrator A and director of nursing (DON) B regarding resident 19's hospice care revealed: *There had been a delay in getting the hospice admitting diagnosis for resident 19. *She was admitted to hospice on 1/17/25. *During the interview DON B called the hospice provider to request a copy of the physician's order and the hospice care plan. *DON B stated she updated the facility care plan to reflect that resident 19 had been admitted to hospice and the services she received. *She expected the care plan to reflect the specific care resident 19 received. 6. Review of resident 19's 1/30/25 updated care plan revealed: *Her care plan included a focus area, See the MAR/TAR [medication administration record/treatment administration record], Physician orders/protocol, CNA flow sheets and the Short Term Care Plan. Also, see the restorative nursing flow sheet and therapy plan of treatment in integrated therapy reports if applicable. Care plans are written by the exception reflecting facility standards. Administer medications as ordered. [Resident 19] was admitted to Hospice on 1/17/25 revised on 1/30/25. *There was no resident-centered goal, it directed to See Focus revised on 4/16/24. *There were no specific interventions, it directed to See Focus initiated on 5/9/18. B. 1. Observation and interview on 1/28/25 between 11:42 a.m. and 12:08 a.m. with cosmetologist AA in the Dixie dining room revealed: *Cosmetologist AA assisted resident 19 in eating with a spoon and assisted her in drinking from a cup with two handles and a lid. *Cosmetologist AA was trained as a hair stylist, certified to assist in the kitchen, and had completed a training program for paid feeding assistants. She was not a certified nursing assistant (CNA). 2. Observation and interview on 1/29/25 at 11:48 a.m. in the Dixie dining room revealed: *Resident 19 was assisted in eating a pureed meal by cosmetologist AA. *Resident 41 was assisted in eating a pureed meal by activities aide (AA) Y. -AA Y confirmed she worked in the activities department, was a paid feeding assistant and not a CNA. 3. Interview on 1/29/25 between 12:21 p.m. and 12:35 p.m. with staff development coordinator (SDC) H and speech therapist (ST) G regarding the paid feeding assistant program revealed: *SDC H was new in the role of staff development coordinator and oversaw the paid feeding assistant program since August 2024. *ST G stated that she determined which residents could be assisted by paid feeding assistants. *Participation in the feeding assistant program was made by the interdisciplinary team based on ST G's recommendation and it was care planned. 4. Review of the provider's 1/27/25 Feeding Assistant List revealed: *Sixteen residents were participating in the Feeding Assistant program. *Six of those residents (6, 7,15, 19, and 41) received a pureed diet. *There were no residents listed under the Requiring CNA's [CNAs] to Feed. 5. Review of resident 6's electronic medical record (EMR) revealed: *She received a pureed diet. *Her care plan indicated on 5/29/24 that she, did agree to a pureed texture for her foods. Daughter states [resident 6] can't chew the chopped-up food even now. *She does have swallowing problems occasionally. *She was screened by speech therapy in April 2024 twice for swallowing concerns. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 6. Review of resident 7's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition risks include: cognition, dysphagia [difficulty swallowing]. *Dependent assist of 1 [one] for eating. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 7. Review of resident 15's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition Risk factors include: cerebral Infarction [a stroke], dementia, hemiplegia [paralysis of one side of the body], dyshagia [dysphagia, difficulty swallowing]. *It was documented that she had some difficulties with eating when her dentures are in. *A care plan intervention included Monitor/document ability to chew and swallow. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 8. Review of resident 19's EMR revealed: *She received a pureed diet. *A 1/24/25 speech therapy screen indicated a referral was made due to the resident was pocketing solids [solid foods]. *A 1/28/25 progress note indicated the feeding assistant reported patient was a little gaggy this morning. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 9. Review of resident 41's EMR revealed: *She received a pureed diet. *She had a diagnosis of dysphagia. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 10. Interview on 1/30/25 at 8:43 a.m. with AA EE revealed: *She was an activities assistant and had completed the paid feeding assistant training. *She assisted residents with eating about once a month. *She was allowed to assist any resident who needed assistance with eating. *No one told her which residents to assist with eating. 11. Interview on 1/30/25 at 4:41 p.m. administrator A, DON B, and SDC H regarding the paid feeding assistant program revealed: *The Feeding Assistant List that was provided included all the residents within the facility who required assistance with eating. *SDC H stated that paid feeding assistants were able to assist any resident not deemed by the speech therapist, to need assistance from a CNA. *Administrator A stated that a feeding assistant could assist any resident in the facility except those who have been excluded. *At that time there were no residents who should have been excluded. *DON B stated care plans did not indicate which residents were in the paid feeding assistant program because it could change. -The care plans may include if they could not be fed by a feeding assistant, but because there was not anyone excluded, no care plans contained that information. C. 1. Observation and interview on 1/28/25 at 2:47 p.m. with resident 25 revealed: *There was a stop sign on her door and a cart outside that room contained gowns and gloves. *She wore a boot on her left foot from a recent surgery on her toe. Observation on 1/30/25 at 8:03 a.m. with resident 25 revealed: *There had not been any signage on her door that indicated she was on enhanced barrier precautions (EBP). *She stated she had one toe with a wound and a dressing on it, but the nurse had not looked at it today (1/30/25). *She stated that staff had worn gloves but not gowns when they assisted her. Interview on 1/30/25 at 2:21 p.m. with wound care nurse (WCN) I and infection preventionist (IP) C who participated by phone revealed: *Resident 25 had an open wound to her left toe. *WCN I was unsure if resident 25 was on EBP for wound care and stated she would need to consult with the infection preventionist. *WCN I called IP C at home to join the interview. *IP C stated she had removed resident 25 from EBP because she did not think a Band-Aid was a dressing that required EBP. *WCN I confirmed that resident 25 had an open wound on her left toe with a Medihoney (wound healing) dressing. *IPC stated, I would put her back on EBP with that information. Review of resident 25's EMR revealed: *A 1/24/25 weekly wound observation tool indicated resident 25 had a four millimeter (mm) by four mm unstageable wound to her left second toe with an undeterminable depth. *There was no documentation in the care plan that indicated that resident 25 required EBP. 2. Observation on 1/28/25 at 11:12 a.m. with resident 62 and certified nursing assistant (CNA) X revealed: *There were two signs on her door and a cart outside that room that contained gowns and gloves. *One sign indicated, STOP please see nurse, and the other indicated, Steps to put on PPE 1. Put on Gown and tie 2. Put on gloves. Interview on 1/30/25 at 7:49 a.m. with WCN I revealed resident 62 was on EBP for a foot wound. Interview on 1/30/25 at 8:10 a.m. with CNA U revealed: *The sign on resident 62's door indicated that staff needed to wear a gown and gloves when providing direct care, but it was okay to go in to talk to her or deliver items to her room. *Resident 62 had an infection in her leg. *There would be a sign on the resident's door, and she used a pocket care plan to know which residents required staff to wear gowns and gloves when providing their direct care. *She stated that information was also in the residents' care plans in the EMR. Interview on 1/30/25 between 8:31 a.m. and 8:40 a.m. with LPN M and WCN I revealed: *LPN M stated resident 62 was on EBP for a heel wound and staff were to wear a gown and gloves when providing her direct care. *LPN M expected the CNAs to find information on which residents required EBP on the pocket care plan. *WCN I stated that the EBP list had been updated yesterday (1/29/25) and that residents with wounds and catheters. The provided pocket care plan did not indicate that resident 62 required EBP. Review of resident 62's EMR revealed: *She was admitted on [DATE] with a diabetic ulcer (wound) on her right foot. *Her care plan indicated hx [history] of MRSA [methicillin-resistant Staphylococcus aureus] from the wound on her right foot. *The care plan indicated, CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. *There was no documentation in the care plan that indicated the staff were to use a gown or gloves with resident contact. A review of resident 62's printed medical record documents requested revealed a 10/2/24 physician's order for Contact precautions: May leave room for meals and therapy as long as wound is covered and not draining. Resident must wash hands with soap and water prior to leaving. 3. Interview on 1/28/25 at 9:53 a.m. with CNA V revealed: *The signs posted on the residents' doorways by their name badges with a stop sign indicated they were on EBP. Observation on 1/28/25 at 2:29 p.m. outside of resident 68's room revealed: *There was a sign posted outside of her door that stated, STOP, check with nurse before entering and signs that indicated the correct way to put on personal protective equipment (PPE). *There was an empty three-drawer bin in the hallway by her doorway, and a tub that contained a clear trash bag of yellow gowns beside it. Review of resident 68's EMR revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12, which indicated she had moderate cognitive impairment. *Her diagnoses included extended spectrum beta lactamase (ESBL, enzymes that breakdown some antibiotics) resistance. *A 12/20/24 active contact precaution order. *An order to clean her arterial ulcers on her right lower extremity (RLE) daily with soap and water and to cover them with an appropriate dressing. *There was no documentation that indicated she was on contact precaution or EBP in her care plan. 4. Observation and Interview on 1/28/25 at 3:02 p.m. of resident 6 in her room revealed: *There was a sign with a stop sign on it next to her name badge outside of her room. *There was a three-drawer bin with PPE supplies in it outside of her room. *She was lying in bed, with a pillow propped under her left side, and a call light button on the moveable tray table in front of her. *She stated she had a sore on her coccyx, but staff had told her it was healing. *Staff changed the pressure ulcer (PU) dressing every day. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 14 which indicated she was cognitively intact. *She had an order for a wound dressing change daily and as needed that began on 12/6/24 for her PU. *There was no documentation that indicated she was on EBP in her care plan. 5. Observation on 1/30/25 at 7:56 a.m. of resident 66's room revealed: *There was no PPE inside or outside of her room. *There was a sign by the resident's name badge on her door with a stop sign on it. Review of resident 66's EMR revealed: *She was admitted on [DATE]. *She had an active order for wound care related to her PU that began on 1/13/25. *There was no documentation that indicated she was on EBP in her care plan.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the provider failed to properly store products determined to be unsafe for cognitively impaired residents for at least 10 residents (7, 9, 15, 23, 36, 38, 40, 44, 46, and 69) on one of two memory care units. Findings Include: 1. Observations on 1/28/25 at 10:25 a.m. in resident 36's room revealed: *There was a sign posted on the mirror in the bathroom that read, Any product with 'Keep Out of Reach of Children' printed on its label needs to be kept on a closet shelf, i.e alcohol, mouthwash, [NAME] 24 [a moisturizing body cream], Baza Cleanse [a no-rinse lotion], deodorant, etc. Thanks! -Mouth Rinse, deodorant, and toothpaste were stored on a shelf in the bathroom and were accessible to the resident. *CPAP (continuous positive airway pressure) cleaning wipes were stored on top of the resident's dresser and accessible to the resident. -The container label read Keep out of reach of children. 2. Interview on 1/28/25 at 3:03 p.m. with resident 36 revealed she was pleasantly confused and was not oriented to place or situation, meaning she did not understand where she was or that she was a resident in a nursing home. 3. Interview on 1/30/25 at 9:46 a.m. with licensed practical nurse (LPN)/Nurse Manager J revealed: *The signs posted in the resident rooms were for the confused residents or for those who could not perform personal cares on their own. *The signs were placed in all resident rooms in the memory care units. *Products with the label Keep out of reach of children should have been stored away from the resident, such as the top shelf of a resident's closet, so the resident did not have access to those products. 4. Observation on 1/30/25 at 9:55 a.m. in resident 36's room revealed the CPAP cleaning wipes were still accessible on top of the dresser, and the mouthwash and toothpaste were still accessible on the shelf in the resident's bathroom. 5. Interview on 1/30/25 at 3:19 p.m. with certified nurse assistant (CNA) W revealed: *When asked how staff determined which residents on the secured memory care units should have their personal care products stored out-of-reach, she explained if a resident had dementia their products should be placed on the top shelf of their closet. -She was not aware of a policy or process to verify this practice. 6. Interview on 1/30/25 at 3:27 p.m. with LPN R revealed: *Residents were screened upon admission to the memory care unit to determine if they should have their products stored out-of-reach, when labeled with Keep out of reach of children. -Staff were to monitor for resident safety throughout each day. *If there were changes in the resident's behavior or cognition, staff were to report those changes to the nurse managers. -He was not aware of a process for determining which residents could have products accessible and which should have been placed on the top shelf of the closet. 7. Observation on 1/30/25 from 3:12 p.m. to 3:48 p.m. of the Pine Village memory care unit on the second floor revealed: *In resident rooms for residents 7, 9, 15, 23, 38, 40, 44, 46, and 69: -Products labeled Keep Out of Reach of Children were in various areas of each resident's rooms and accessible to those residents. -Products identified: mouth rinse, deodorant, Baza All-In-One Perineal Lotion, Gold Bond powder, toothpaste, Biotene mouth spray, perfume, and Head and Shoulders shampoo. 8. Review of resident 36's electronic medical record (EMR) revealed: *She was admitted on [DATE]. -The most current Minimum Data Set (MDS) dated [DATE] indicated a Brief Interview for Mental Status (BIMS) assessment score of 4, which indicated she had severe cognitive impairment. *Diagnoses included unspecified dementia, adjustment disorder with depressed mood, and unspecified mood (affective) disorder. *Her care plan included the following: -She required staff supervision with personal hygiene tasks like oral cares. -She had impaired decision-making skills, impaired memory, impaired cognitive function and thought processes related to her dementia diagnosis. *Her care plan did not include that she required personal care products like toothpaste, mouthwash, and lotion to be stored out of reach due to her cognitive impairment. 9. Review of resident 7's EMR revealed: *She was admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: -Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. --She had short-term and long-term memory issues. --She was able to recall staff names and faces. --Her daily decision-making skills were severely impaired. -She had the following diagnoses marked under section I: Non-traumatic brain dysfunction, Alzheimer's disease, dementia, anxiety disorder, depression, and manic depression. 10. Review of resident 9's EMR revealed: *He was admitted on [DATE]. *His quarterly MDS assessment dated [DATE] included the following: - Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. -He had short-term and long-term memory issues. -He was able to recall staff names and faces. -His daily decision-making skills were impaired. -He had the following diagnoses marked under section I: Dementia, Parkinson's disease, anxiety, and depression. 11. Review of resident 15's EMR revealed: *She was admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: - She had a BIMS assessment score of 7, which indicated she had severe cognitive impairment. -She had short-term and long-term memory issues. -She was unable to recall year, month or day. -Her daily decision-making skills were impaired. -She had the following diagnoses marked under section I: Dementia. 12. Review of resident 23's EMR revealed: *She was admitted on [DATE] *Her quarterly MDS assessment dated [DATE] included the following: - She had a BIMS assessment score of 4, which indicated she had severe cognitive impairment. -She had short-term and long-term memory issues. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, anxiety, and depression. 13. Review of resident 38's EMR revealed: *She was admitted on [DATE]. *Her significant change MDS assessment dated [DATE] included the following: -She had a BIMS assessment score of 11, which indicated moderate cognitive impairment -She required cueing on Section C; oriented to month and day, but unable to recall the year. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, Parkinson's disease, anxiety, and depression. 14. Review of resident 40's EMR revealed: *She was admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: -Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. -She had short-term and long-term memory issues. -She was unable to recall. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Dementia, and depression. 15. Review of resident 44's EMR revealed: *She was re-admitted on [DATE]. *Her quarterly MDS assessment dated [DATE] included the following: -Under section C for cognitive patterns, the Staff Assessment for Cognitive Patterns was utilized rather than the BIMS assessment. -She had short-term and long-term memory issues. -She was unable to recall. -Her daily decision-making skills were severely impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, anxiety, and depression. 16. Review of resident 46's EMR revealed: *She was re-admitted on [DATE]. *Her significant change MDS assessment dated [DATE] included the following: -She had short-term and long-term memory issues. -She was unable to recall. -Her daily decision-making skills were severely impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, and anxiety. 17. Review of resident 69's EMR revealed: *She was admitted on [DATE]. *Her admission MDS assessment dated [DATE] included the following: -She had a BIMS assessment score of 9, which indicated moderate cognitive impairment -She had short-term and long-term memory issues. -She had recall impairment. -Her daily decision-making skills were moderately impaired. -She had the following diagnoses marked under section I: Alzheimer's disease, dementia, anxiety, and depression. 19. Interview on 1/30/25 at 5:37 p.m. with director of nursing B revealed: *She stated, Products labeled with Keep Out of Reach of Children for every resident that was cognitively impaired were to be kept up on closet shelves. Like mouthwash, we don't want them to drink the entire bottle. *She stated, Residents more cognitively impaired are assisted in the bathroom and supervised. *She agreed that products in resident rooms on lower shelves in bathrooms, in 3-drawer bins, on window ledges or on the dressers were accessible to residents in the memory care unit. -She confirmed there was no process or policy in place to determine and what products for which residents should have been stored to ensure the environment remained as free of accident hazards as possible.

Based on observation, interview, record review, and policy review the provider failed to ensure five of five residents (6, 7,15, 19, and 41) who received a pureed diet and assessed to have complicated eating problems were not assisted to eat by paid feeding assistants. Findings include: 1. Observation and interview on 1/28/25 between 11:42 a.m. and 12:08 a.m. with cosmetologist AA in the Dixie dining room revealed: *Cosmetologist AA was seated next to resident 19 at the assisted dining table. *Cosmetologist AA was trained as a hair stylist, certified to assist in the kitchen, and had completed a training program for paid feeding assistants. She was not a certified nursing assistant (CNA). *Resident 19 had a recent weight loss, was on a pureed diet due to pocketing of food, and had recently began receiving hospice services. *Resident 19 was served a plate with mashed potatoes with gravy, pureed meat, and a dish that contained pureed pie. *Cosmetologist AA assisted resident 19 in eating with a spoon and drinking from a cup with two handles and a lid. *Cosmetologist AA asked another staff to reposition resident 19 in her wheelchair because she was leaning back. 2. Observation on 1/29/25 at 11:32 a.m. in the dining room with licensed practical nurse (LPN) L revealed LPN L administered medication to resident 19 by spoon. 3. Interview on 1/29/25 at 11:34 a.m. with LPN L and administrator A revealed: *LPN L confirmed that resident 19 took her medications crushed and was on a pureed diet. -She stated resident 19 chews and chews her food. *Speech therapist (ST) G had recommended a downgrade of resident 19's food textures and the pureed diet had been ordered by hospice. *She confirmed that cosmetologist AA assisted resident 19 in eating her meals because she had a connection with resident 19. *Administrator A confirmed that cosmetologist AA was a paid feeding assistant and not a CNA. *Staff development coordinator (SDC) H oversaw the paid feeding assistant program and was new to that role. 4. Continued observation and interview on 1/29/25 at 11:48 a.m. in the Dixie dining room revealed: *Resident 19 was assisted in eating a pureed meal by cosmetologist AA. *Resident 41 was assisted in eating a pureed meal by activities aide (AA) Y. -AA Y confirmed she worked in the activities department, was a paid feeding assistant and not a CNA. 5. Interview on 1/29/25 at 12:04 p.m. with ST G, director of nursing (DON) B, and administrator A revealed they had approached the surveyor and confirmed that ST G had downgraded resident 19's diet to pureed. 6. Interview on 1/29/25 between 12:21 p.m. and 12:35 p.m. with SDC H and ST G regarding the paid feeding assistant program revealed: *SDC H was new in the role of staff development coordinator and oversaw the paid feeding assistant program since August 2024. *The provider had transitioned from the textbook training format to the online format during that time. *She confirmed that cosmetologist AA and AA Y were paid feeding assistants and not CNAs. *She was unsure if the training covered the topic of residents with special diets, such as pureed. *ST G stated she screened residents for swallowing difficulties at admission, quarterly, with any significant changes or when the nurse requested. *ST G stated that she determined which residents could have been assisted by paid feeding assistants. *Issues related to dental problems, oral issues, the need for altered food textures, and a pureed diet were not considered complicated feeding issues. *Issues like a feeding tube, choking, pocketing food, requiring to be fed on one side of the mouth, aspiration, and the need for special strategies to swallow would have been considered complicated feeding issues. *The decision for resident participation in the feeding assistant program was made by the interdisciplinary team based on ST G's recommendation and it was care planned. 7. Review of the provider's 1/27/25 Feeding Assistant List revealed: *Sixteen residents were participating in the Feeding Assistant program. *There were no residents listed under the Requiring CNA's [CNAs] to Feed. 8. Review of resident 6's electronic medical record (EMR) revealed: *She received a pureed diet. *Her care plan indicated on 5/29/24 that she, did agree to a pureed texture for her foods. Daughter states [resident 6] can't chew the chopped-up food even now. *She does have swallowing problems occasionally. *She was screened by speech therapy twice in April 2024 for swallowing concerns. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 9. Review of resident 7's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition risks include: cognition, dysphagia [difficulty swallowing]. *Dependent assist of 1 [one] for eating. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 10. Review of resident 15's EMR revealed: *She received a pureed diet. *Her care plan revealed, Nutrition Risk factors include: cerebral Infarction [a stroke], dementia, hemiplegia [paralysis of one side of the body], dyshagia [dysphagia]. *She had some difficulties with eating when her dentures are in. *A care plan intervention included Monitor/document ability to chew and swallow. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 11. Review of resident 19's EMR revealed: *She received a pureed diet. *A 1/24/25 speech therapy screen indicated a referral was made due to pocketing solids. *A 1/28/25 progress note indicated the feeding assistant reported patient was a little gaggy this morning. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 12. Review of resident 41's EMR revealed: *She received a pureed diet. *She had a diagnosis of dysphagia. *There was no documentation in the care plan that indicated that she was assisted by a paid feeding assistant. 13. Interview on 1/30/25 at 8:43 a.m. with AA EE revealed: *She was an activities assistant and had completed the paid feeding assistant training. *She assisted residents with eating about once a month. *She was allowed to assist any resident who needed assistance with eating. *No one told her which residents to assist with eating. 14. Interview on 1/30/25 at 9:41 a.m. with AA Z revealed: *She was a paid feeding assistant. *Resident 15 was on a pureed diet, required assistance to eat, and sometimes coughed with liquids. *Resident 7 was on a pureed diet, required assistance to eat, and AA Z did not think resident 7 had any swallowing issues. 15. Interview on 1/30/25 at 3:35 p.m. with SDC H and ST G regarding the paid feeding assistant program revealed: *ST G had assessed residents 6, 7,15, 19, and 41 who had pureed diets and had deemed them safe to participate in that program because They no longer need specific strategies. *ST G stated that a paid feeding assistant could assist a resident who had pocketed regular food but did not pocket pureed food because they no longer had a problem. *Only residents with a feeding tube or who require a very specific feeding strategy would be disqualified from the paid feeding assistant program. *Residents who placed food on one side of their mouth needed to have a CNA feed them. 16. Interview on 1/30/25 at 4:41 p.m. administrator A, DON B, and SDC H regarding the paid feeding assistant program revealed: *The Feeding Assistant List that was provided included all the residents within the facility who required assistance with eating. *SDC H stated that paid feeding assistants were able to assist any resident not deemed by the speech therapist, to need assistance from a CNA. *Administrator A stated that a feeding assistant could assist any resident in the facility except those who have been excluded. *At that time there were no residents that should have been excluded. *DON B stated care plans did not indicate which residents were in the paid feeding assistant program because it could change. -The care plan may include if they could not be fed by a feeding assistant, but because there was not anyone excluded, no care plans contained that information. 17. Review of the provider's revised April 2020 Assisted Dining: The Role and Skills of Feeding Assistants textbook revealed: *Paid feeding assistants are only permitted to assist residents who have no complicated eating or drinking problems as determined by their comprehensive assessment. Examples of residents that a paid feeding assistant may assist include residents who are independent in eating and/or those who have some degree of minimal dependence, such as needing cueing or partial assistance, as long as they do not have complicated eating or drinking problems. *Important! Feeding assistants are not permitted to feed residents with dysphagia. *Residents with dysphagia have difficulty or discomfort when swallowing. *Symptoms of dysphagia include: Coughing before, during or after swallowing food, liquid or medication . Pocketing food in the side of the mouth . 18. Review of the provider's February 2010 Dining Assistants policy revealed: *Assisted dining will be provided to appropriate residents when necessary in accordance with applicable federal and state requirements regarding Feeding Assistants. *An [A] FA [feeding assistant] is to feed only those residents who have no complicated eating problems. Complicated eating problems include, but are not limited to, difficulty swallowing, recurrent lung aspirations, tube or parenteral/IV [intravenous] feedings, paralysis, trauma or facial, oral or neck surgery or any other complicating condition as, high risk for choking, depressed cough or gag reflex, needing positioning during feeding or decreased gastric motility.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the provider failed to ensure call light systems were accessible to residents in two of two observed resident shower/tub rooms, and five of eleven observed resident bathrooms (rooms 273, 278, 280, 286, and 288). Findings include: 1. Observation on 1/29/25 from 9:33 a.m. to 10:05 a.m. in the 2nd floor memory care unit revealed: *The wall-mounted call light in the bathroom of resident room [ROOM NUMBER] did not have a pull cord and was not accessible if a resident was on the floor. *The cord for the wall-mounted call light in the bathrooms of resident rooms 278, 280, 286, and 288 was wrapped around the call light box and was not accessible if a resident was on the floor. *There was no call light available in the shower room [ROOM NUMBER]. *The wall-mounted call light in the tub room did not have a pull cord and was not accessible if a resident was on the floor. 2. Interview on 1/30/25 at 3:12 p.m. with activity aide Z revealed: *The shower room was rarely used, but the toilet in that room was used for residents. *She was not aware that there was no call light available in that room. 3. Interview on 1/30/25 at 3:27 p.m. with licensed practical nurse (LPN) R revealed: *He was not aware that the shower room did not have a call light available. *The shower in the shower room was never used, but the toilet was used by residents frequently. *He said, I don't leave them alone, but I do stand outside on the other side of the door until the resident is done. *He agreed there should be functioning call lights in resident areas. *If a call light was not functioning, he would call maintenance. 4. Interview on 1/30/25 at 5:19 p.m. with administrator A revealed: *They did not have a policy regarding the minimum requirements for call lights. *He indicated he thought a call light was not necessarily needed in the shower room because a staff member would be in the room with the resident at all times. -He felt that staff would have used their radios if they needed help. *The maintenance department completed call light audits for functionality. This surveyor requested to review that documentation. That documentation was not provided by the end of the survey.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, record review, and policy review, the provider failed to ensure infection prevention and control practices were implemented for: *The maintenance and disposal of resident care items in one of one shower room. *Transmission based precautions by four of four staff (certified nursing assistant (CNA) T, CNA X, licensed practical nurse (LPN) P, and wound care nurse (WCN) I) for five of five sampled residents (62, 68, 25, 6, and 66) who had care concerns requiring personal protective equipment (PPE). *Hand hygiene and glove use by five of five staff (CNA W, LPN P, LPN DD, LPN N, and staff development coordinator (SDC) H) for four of four observed sampled residents (6, 66, 59, and 328). Findings include: 1. Observation on 1/28/25 from 9:53 a.m. to 10:36 a.m. in the shower room [ROOM NUMBER] on the Pine Village memory care unit on the second floor revealed there was: *A used nail file and a dirty hair pick with visible hair and lint sitting on top of the wall-mounted glove box to the left of the entrance. *A soiled plastic cup with a small amount of an unidentifiable dried green paste on top of the soap dispenser in the shower. 2. Observation and interview on 1/28/25 at 2:47 p.m. with resident 25 revealed: *There was a stop sign on her door and a cart outside that room that contained gowns and gloves. *She wore a boot on her left foot from a recent surgery on her toe. *She was frustrated that she shared a bathroom with the female resident next door. Observation and interview on 1/30/25 at 8:03 a.m. with resident 25 revealed: *There had not been any signage on her door that indicated she was on enhanced barrier precautions (EBP). *She stated she had one toe with a wound and a dressing on it, but the nurse had not looked at it today (1/30/25). *She stated that staff had worn gloves but not gowns when they assisted her. Review of her 1/24/25 weekly wound observation tool revealed resident 25 had a four millimeter (mm) by four-mm unstageable wound to her left second toe with an undeterminable depth. Review of resident 25's care plan revealed no indication that resident 25 required EBP. Interview on 1/30/25 at 2:21 p.m. with wound care nurse (WCN) I and infection preventionist (IP) C who participated by phone revealed: *Resident 25 had an open wound to her left toe. *WCN I was unsure if resident 25 was on EBP for wound care and stated she would need to consult with the infection preventionist. *WCN I called IP C at home to join the interview. *IP C stated she had removed resident 25 from EBP because she did not think a Band-Aid was a dressing that required EBP. *WCN I confirmed that resident 25 had an open wound on her left toe with a Medihoney (wound healing) dressing. *IPC stated, I would put her back on EBP with that information. 3. Observation on 1/28/25 at 11:12 a.m. with resident 62 and certified nursing assistant (CNA) X revealed: *There were two signs on resident 62's door and a cart outside that room contained gowns and gloves. -One sign indicated, STOP please see nurse, and the other indicated, Steps to put on PPE 1. Put on Gown and tie 2. Put on gloves. *Resident 62 was in her room calling out, Please come. *CNA X entered resident 62 room and closed the door. *The surveyor then entered the room. Resident 62 was seated on the toilet and CNA X was not wearing a gown or gloves. *CNA X exited the bathroom and without completing hand hygiene, put on a pair of gloves and finished assisting resident 62. Interview on 1/30/25 at 7:49 a.m. with WCN I revealed resident 62 was on enhanced barrier precautions (EBP) for a foot wound. Interview on 1/30/25 at 8:07 a.m. with resident 62 who used a whiteboard for communication revealed: *Staff sometimes wore a gown and gloves when they assisted her, but some times she had to get to the toilet so fast that they did not. *She indicated she had to use the shared bathroom frequently, had difficulty waiting, and sometimes had to wait for the other resident to be done in the bathroom. Interview on 1/30/25 at 8:10 a.m. with CNA U regarding precautions revealed: *The sign on resident 62's door indicated that staff needed to wear a gown and gloves while providing her direct care, but it was okay to go in to talk to her or deliver items to her room. *Resident 62 had an infection in her leg. *A sign was to be on a resident's door, and she used a pocket care plan to know which residents required staff to wear gowns and gloves while providing their direct care. *She stated that information was also in the residents' care plans in the EMR. The provided pocket care plan did not indicate that resident 62 required EBP. Observation on 1/30/25 at 8:15 a.m. at the North Oak nurses' station revealed: *A sign with a list indicated what residents in that area were on EBP. -There were two residents on that list however resident 25 and resident 62 were not listed. Interview on 1/30/25 between 8:31 a.m. and 8:40 a.m. with licensed practical nurse (LPN) M and WCN I revealed: *LPN M stated resident 62 was on EBP for a heel wound and staff were to wear a gown and gloves when providing direct care. *LPN M expected to see resident 62's name on the list of residents that required EBP. *LPN M expected the CNAs to find information on which residents required EBP on the pocket care plan. *WCN I stated that the EBP list had been updated yesterday (1/29/25) and that residents with wounds and catheters that required the use of EBP were on that list. *Signs were to be on those resident room doors. *Residents who required precautions for COVID-19 or contact precautions would be listed on a separate sign. *There were no other lists or signs at that nurse's station. *There were no residents in the North Oak area on COVID-19 or contact precautions. Review of resident 62's EMR revealed: *She was admitted on [DATE] with a diabetic ulcer (wound) on her right foot. *Her care plan indicated hx [history] of MRSA [methicillin-resistant Staphylococcus aureus] from the wound on her right foot. *The care plan indicated, CONTACT ISOLATION: Wear gowns and masks when changing contaminated linens. Place soiled linens in bags marked biohazard. Bag linens and close bag tightly before taking to laundry. *There was no documentation in the care plan that indicated the staff were to use a gown or gloves with resident contact. Interview on 1/30/25 at 12:57 p.m. with LPN M regarding resident 62's MRSA culture revealed: *Resident 62's daughter stated that the last culture of that wound had been done at the hospital prior to her admission to the facility. *She would request those culture results from IP C. *She was unaware if the MRSA was and active infection. Review of resident 62's printed medical record documents requested revealed: *A 10/2/24 physician's order for Contact precautions: May leave room for meals and therapy as long as wound is covered and not draining. Resident must wash hands with soap and water prior to leaving. *A 9/25/24 wound culture of the right foot revealed Positive for MRSA. 4. Observation on 1/28/25 at 2:29 p.m. of CNA T and resident 68 revealed: *Resident 68 had a sign posted outside of her door that stated, STOP, check with nurse before entering and signs that indicated the correct way to put on PPE. *There was an empty three-drawer bin in the hallway outside the resident's room, and a tub containing a clear trash bag of yellow gowns beside it. *Resident 68 was sitting in her recliner in her room when CNA T came in without wearing a gown or gloves and told her she would be going to a doctor's appointment. *CNA T positioned resident 68's wheelchair next to the recliner and assisted her in standing and transferring to her wheelchair. *CNA T got the residents' jacket and asked if she wanted her shoes on as well, which she declined. *CNA T pushed resident out of her room in her wheelchair and down the hallway. Interview on 1/30/25 at 8:01 a.m. with LPN Q revealed: *She was unsure what type of transmission-based precautions resident 68 was on. *She thought she was on contact precautions for extended-spectrum beta-lactamase (ESBL) (bacteria that is resistant to some antibiotics) for the ulcers on her legs. Observation and Interview on 1/30/25 at 9:56 a.m. with LPN N and M regarding resident 68 revealed: *LPN N thought she was on enhanced barrier precautions (EBP) for the ulcers on her legs. *LPN M thought she was on contact precautions. *Both LPN M and N searched the resident's electronic medical record and paper chart for the resident's current transmission-based precautions type. *They concluded that resident 68 was on contact precautions due to ESBL in her urine based on a positive culture they found on 1/16/25. *LPN M stated that residents who have a wound or a catheter will have a stop sign by their name tag on their door that indicated to staff to see the nurse for their transmission-based precautions type. *LPN M stated EBP is for direct patient care, contact precautions are for all cares provided to a resident. Observation on 1/30/25 at 11:02 a.m. at resident 68's room revealed: *Resident 68 shared a room with resident 11. *Wound care nurse I entered the resident's room without putting on any PPE. *She wheeled resident 11 out of the bathroom, installed the foot pedals on her wheelchair, and wheeled her out of the room. *When asked what type of precautions was required for the residents in that room, she indicated that resident 68 was on enhanced barrier precautions (EBP). Interview on 1/30/25 at 11:04 a.m. with housekeeper HH revealed: *The color of the stop sign coincided with the level of transmission-based precautions (TBP). *The yellow stop sign coincided with contact precautions. *There was a cheat sheet on each housekeeping cart that listed the type of TBP associated with each colored stop sign, as well as a list of diseases that the residents may have, and the level of cleaning required for each disease. *At the nurse's station, there was a list of residents, the type of TBP the residents were on, and the reason for the TBP. *She confirmed that resident 68 was on contact precautions related to ESBL in her urine. *She explained that when cleaning the room shared by resident 11 and 68, she would put on a gown, gloves, and an eye protector. *The chemical she would use to clean that room was Betco brand pH7Q Dual concentrated cleaner, which killed viruses and organisms like COVID-19, Staphylococcus aureus, pseudomona, salmonella, VRE (vancomycin-resistant enterococcus) and MRSA (methicillin-resistant Staphylococcus aureus). Interview on 1/30/25 at 11:11 a.m. with LPN N revealed: *She confirmed resident 68 was on contact precautions because of what's in her urine. *If staff were entering the resident's room to help resident 11 instead of resident 68, they did not need to put on PPE. *She confirmed that both resident 11 and 68 used the same bathroom. Interview on 1/30/25 at 12:09 p.m. with infection preventionist (IP) C revealed: *Staff were to perform hand hygiene every time they removed gloves and before they put new gloves on. *She expected staff to know what precautions a resident was on based on a sheet of paper posted at the nurse's desk. *If a resident was on contact precautions, she expected staff to put on PPE (gown, gloves, goggles or face shields if there was a chance of spray back) with each entry into the resident's room. *If a resident had ESBL in their urine and was continent, then they would downgrade the precautions from contact precautions to EBP and the resident would be able to exit their room. *They would try not to room residents together when one of them was on a type of TBP and the other was not, such as the case with residents 11 and 68. *She expected staff to clean the residents' shared bathroom with the purple-top sanitizing wipes (Super Sani-Cloth brand) after each time resident 68 used the bathroom. -Usually we do not have them share a bathroom but at times it does happen. *She was aware that resident 68 currently had ESBL in her urine. -Resident 68 was continent, so they were in the process of changing her to EBP because resident 68 wished to go out of her room for meals and activities. *She confirmed that resident 11 was not on TBPs. -She indicated that staff did not need to wear a gown or gloves when assisting resident 11. Observation and interview on 1/30/25 at 12:58 p.m. with resident 68 revealed: *Staff wore yellow gowns while taking her to the bathroom. *Staff did not clean her bathroom after she used it. *No purple disinfectant wipes were found in her bathroom or within proximity of her room. Interview on 1/30/25 at 1:00 p.m. with CNA W revealed: *Housekeeping cleaned the residents' bathrooms once a day. *Staff would clean resident 68's bathroom if it was obviously soiled. Interview on 1/30/25 at 3:05 p.m. with director of nursing (DON) B revealed: *She confirmed she was aware that resident 68 had ESBL in her urine. *She confirmed that residents 11 and 68 shared a bathroom. -When asked about cleaning the residents' shared bathroom after resident 68 used it, she said, I would hope that it would be happening. *Staff were to clean their bathroom with the purple-top wipes after each time resident 68 used the bathroom. *If the purple-top wipes were not available, staff had the option to carry around a small package of sanitizing wipes. *She stated not cleaning the residents' shared bathroom put resident 11 at risk for contracting ESBL. *She expected staff to wear PPE when providing care for residents on EBP and contact precautions. Review of resident 68's electronic medical record revealed: *She was admitted on [DATE]. *She had a Brief Interview for Mental Status (BIMS) assessment score of 12 indicating she had moderate cognitive impairment. *Her diagnoses included weakness, acute kidney injury, and ESBL resistance. *Her active contact precaution order started on 12/20/24. *There was an order for staff to clean her arterial ulcers on her right lower extremity (RLE) daily with soap and water and to cover them with an appropriate dressing. *There was no documentation in her care plan that indicated she was on contact precautions or EBP. 5. Observation and Interview on 1/28/25 at 3:02 p.m. of resident 6 in her room revealed: *There was a sign with a stop sign on it next to her name badge outside of her room. *There was a three-drawer organizer with PPE supplies in it outside of her room. *She was lying in bed, with a pillow propped under her left side, and a call light button on the moveable tray table in front of her. *She stated she had a sore on her coccyx, but they had told her it was healing. *Staff were to change the pressure ulcer (PU) dressing every day. Interview on 1/29/25 at 8:35 a.m. with LPN O regarding resident 6's PU revealed: *She stated the PU has shown a lot of improvement. *It was considered a facility acquired stage 4 PU. Observation and interview on 1/30/25 at 10:44 a.m. of resident 6 while receiving a shower (after obtaining permission by the resident) in the bathroom with CNA W and staff development coordinator (SDC) H revealed: *Resident 6 was in a shower chair, CNA W and SDC H were both wearing a gown and gloves. *Once the shower was completed, both the staff members dried resident 6 with towels and covered her with blankets. *Both staff members removed their PPE (gown and gloves), but did not perform hand hygiene. *CNA W did not put on clean gloves before transporting resident 6 to her room. *SDC H and CNA W applied new gowns once inside her room. *SDC H performed hand hygiene and put on new gloves. *CNA touched the bed comforter on the residents' bed before putting on clean gloves. *Both staff members assisted resident 6 from the shower chair to her bed using a full body mechanical lift (lift and sling used to lift a person's full body). *There was a moveable tray table that had a black plastic bag that was used as a barrier for the clean wound dressing supplies. *LPN N entered the room wearing a gown, performed hand hygiene, and put on clean gloves. *LPN N then: -Removed the dirty wound dressing and discarded it. -Removed her gloves and discarded them. -Retrieved a clean package of gauze from the bedside table, opened it, and set it on the bed comforter without a barrier under it. -Performed hand hygiene and then put on clean gloves. -Retrieved the wound cleanser from the bedside table and gauze from the package on the bed comforter. -Sprayed the wound cleanser directly onto the wound and dried the wound with the gauze. -Removed her gloves, performed hand hygiene, and put on new gloves. -Applied collagen with silver to the wound bed, packed the wound with calcium alginate, and covered the wound with an adhesive dressing. -Removed her gloves and discarded them. -LPN N did not perform hand hygiene then picked up the leftover unused supplies from the resident's bedside table. Review of resident 6's EMR revealed: *She was admitted on [DATE]. *She had a BIMS assessment score of 14 which indicated she was cognitively intact. *She had an order for a wound dressing change daily and as needed started on 12/6/24 for her PU. *There was no documentation that indicated the resident was on EBP in her care plan. 6. Observation on 1/29/25 at 3:18 p.m. with LPN P during administration of resident 59's eye ointment revealed she did not perform hand hygiene before she put on her gloves before she administered that ointment or after she removed those gloves after she completed the administration of that eye ointment. 7. Observation and interview on 1/29/25 at 3:50 p.m. with CNA X, LPN P, and WCN I during resident 66's wound dressing change in her bathroom revealed: *There was a sign by the resident's name badge on her door with a stop sign on it. *There was no PPE inside or outside of resident 66's room. *CNA X was wearing gloves but no gown while assisting resident 66 in the bathroom with her toileting cares. *LPN P and WCN I both performed hand hygiene and put on gloves but no gowns. *After CNA X was finished helping resident 66, she removed and discarded her gloves, performed hand hygiene, and left the room. *While resident 66 was still in the bathroom, LPN P removed the adhesive wound covering and sprayed a disinfectant spray on the wound located on resident 66's coccyx (tailbone area). *LPN P blotted the area with a clean towel. *WCN I handed LPN P the opened wound care products that included a honey fiber pad for packing the wound and an adhesive covering. *LPN P applied the wound care products and then assisted resident 66 in pulling up her incontinence brief and pants and then transferred her to her wheelchair. *LPN P and wound care nurse I both then removed their gloves, discarded them, and performed hand hygiene. *They stated they should have worn a gown and gloves because the resident was on EBP due to her wound. *LPN P stated, I'm the one at risk so if the resident had some sort of infection, she would have put on a gown to protect herself. Review of resident 66's EMR revealed: *A 1/13/25 active order for wound care related to her PU. *There was no documentation that indicated she was on EBP in her care plan. 8. Observation on 1/30/25 at 8:04 a.m. with LPN DD revealed: *She did not perform hand hygiene before she applied gloves prior to administering a medication to be taken by mouth to resident 328. 9. Review of the provider's undated Enhanced Barrier Precautions Policy and Procedure revealed: *It is the policy of this facility to implement enhanced barrier precautions for the prevention of transmission of multidrug-resistant organisms (MDROs). *Enhanced Barrier Precautions involve gown and glove use during high-contact resident care activities for residents known to be colonized or infected with MDRO as well as those at increased risk of MDRO acquisition (e.g., residents with wounds or indwelling medical devices). *High-contact resident activities may include: Dressing, Bathing/showering, Transferring, Providing hygiene, Changing linens, Changing briefs or assisting with toileting, Device care or use: central line, urinary catheter, feeding tube, tracheostomy/ventilator, wound care: any opening requiring a dressing . *Examples of MDROs Targeted by CDC include: Methicillin-resistant Staphylococcus aureus (MRSA), ESBL-producing Enterobacterales, Vancomycin-resistant Enterococci (VRE) . *Contact precautions are recommended if the resident has acute diarrhea, draining wounds, or other sites of secretions that are unable to be covered or contained for a limited period of time during a suspected or confirmed MDRO outbreak investigation. *2. Gowns and gloves will be available immediately near or outside of the resident's room. Face protection may also be needed if performing activity with risk of splash or spray (i.e., wound irrigation, tracheostomy care). *8. Enhanced barrier precautions should be used for the duration of a resident's stay in the facility or until resolution of the wound or discontinuation of the indwelling device that placed them at a higher risk. 10. Review of the provider's revised 9/2021 Infection Prevention and Control Manual regarding Hand Hygiene policy revealed: *Hand Hygiene includes hand washing with soap and water and hand hygiene with alcohol-based hand rub (ABHR.) *Hand hygiene continues to be the primary means of preventing the transmission of infection. 11. Review of the provider's reviewed 9/2022 Contact Precautions policy revealed: *Contact Precautions will be used to prevent the healthcare acquired spread of organisms that can be transmitted by direct resident contact (hand or skin-to-skin contact that occurs when performing resident-care) or by indirect contact (touching) with environmental surfaces or contaminated resident care equipment. *Healthcare personnel caring for residents on Contact Precautions should wear a gown and gloves for all interactions that may involve contact with the resident or potentially contaminated areas in the resident's environment. 12. Review of the provider's reviewed 6/2023 Guidance for Control of Extended-Spectrum Beta-Lactamase (ESBL) policy revealed: *The purpose of this policy is to provide guidelines for prevention and control of ESBL. *Prevention -A. Appropriate resident placement -B. Gloves for all activities in resident's room -C. Gowns indicated for activities where skin or clothing will come in contact with the resident or their environment or when performing direct care -D. Dedicated equipment or adequate cleaning and disinfection of shared equipment, with particular attention to management of urinary catheters and associated equipment *Cohort symptomatic residents with ESBL in specific areas if possible. *The environment of a resident with ESBL should be cleaned thoroughly at least daily, with special attention to those items likely to be contaminated.

**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, policy review, and interview the provider failed to ensure the safety of one of one sampled resident (1) who had an unwitnessed fall and required hospitalization for injuries the next day. 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 provider's [DATE] DOH FRI for resident 1 revealed: *On [DATE] at 10:25 p.m. he had an unwitnessed fall. -His Brief Interview for Mental Status (BIMS) score was 7 which meant he had severe cognitive impairment. -He was found in the middle of his room on the floor, lying on his back. -His vital signs were taken and were within normal limits. -He was able to move all extremities. -He complained of right knee pain while on the floor. -He denied hitting his head. -He takes Warfarin (blood thinner medication). -Neuro checks were not indicated to be completed per the provider's Emergency Procedures policy. *After being assisted off the floor he complained of right hip pain. -He was given as needed acetaminophen (pain medication). *His physician was faxed about the fall. *His family was notified of the fall. *On [DATE] at 9:00 a.m. a nurse assessed him and found him to have fixed pupils, and not acting like himself. -His vitals were taken, and his blood pressure was low at 92/52. -He was sent to the emergency room (ER) for evaluation. *He was admitted to the hospital for: - A fractured right hip. - A subarachnoid hemorrhage (bleeding in the brain). -A critical Troponin level (indicative of a heart attack). *He returned to the facility on [DATE] at 1:20 p.m. -He was admitted to a hospice program. -His code status was changed to Do Not Resuscitate (no CPR). *He passed away on [DATE] at 3:15 p.m. 2. Interview on [DATE] at 4:45 p.m. with administrator A and director of nursing B revealed: *Residents were categorized as fall risk based on past fall history. *No fall risk assessments were done for residents before [DATE]. *There was no Fall Policy and Procedures Policy before [DATE]. *Per provider's Emergency Procedures policy if resident hit head Neuro checks would be completed. The provider's implemented actions to ensure the deficient practice does not reoccur was confirmed on [DATE] after record review revealed: *The provider followed their quality assurance process and education was provided, to all nursing care staff. -The nursing staff had been educated on their Emergency Procedures Policy update, Abuse and Neglect Policy, Reporting Requirements Policy and the new Fall Policy and Procedures for Long Term Care Facility. -Neuro checks are now to be completed for all unwitnessed falls. -Nurses are now to document in the nurse's notes for 72 hours post fall. -New Fall Risk Assessments were completed on all residents on [DATE], and they are to be completed upon admission and periodically after that, especially after a significant change in a resident's condition. -Updating of the resident's care plan is to be completed following assessment completion. -Audits on care plans and pocket care plans were started and completed on [DATE], [DATE], and [DATE]. These will be reviewed during QAPI (Quality Assurance and Performance Improvement) meetings. *Record review of other resident falls after [DATE] showed they were following their new and updated policies. *Observations and staff interviews revealed the staff understood the education provided and the revised processes. Based on the above information, non-compliance at F689 occurred on [DATE], and based on the provider's implemented corrective action for the deficient practice confirmed on [DATE], the non-compliance is considered past non-compliance.

Based on interview, record review, and policy review, the provider failed to ensure an allegation of neglect made by one of one sampled resident (1), was reported to the South Dakota Department of Health (SDDOH) within twenty-four hours from the time that the provider was made aware of the allegation. Findings include: 1. Interview on 3/21/24 at 8:14 a.m. with resident 1 revealed the following: *She was left in a mechanical lift sling on the toilet in her bathroom for at least two to three hours. *She stated, I cried, prayed, tried to holler, but no one heard me. I could hear them (staff members) laughing and talking. -The lift sling was pressing into her leg and really hurt, and her leg was still hurting her on the day of the interview. -She thought it was Monday (3/18/24), as the staff members were getting everyone ready for BINGO. Interview on 3/21/24 at 8:35 a.m. with director of nursing (DON) B revealed the following: *On 3/18/24 resident 1 had made an allegation of being left in a mechanical lift sling while in her bathroom. -She had reported it to administrator (ADM) A and thought he had talked to resident 1. -She had instructed registered nurse (RN) R to do a skin check and make a note in resident 1's EMR. -She had not initiated an investigation into the allegation. -She had not reported the event to the SDDOH. Interview on 3/21/24 at 8:49 a.m. with ADM A and DON B regarding the allegation of resident 1 revealed the following, ADM A: *Was notified on Tuesday (3/19/24), after the noon meal, about the incident and he had: -Talked to resident 1 and she had told him that she did not want to yell for help because her heart was beating too fast. -Confirmed her call light was working. -Reviewed the call light log, and her call light had not been on any extended length of time. -Not completed a thorough investigation into that allegation -Not considered the incident a reportable event to the SDDOH. Continued interview on 3/21/24 at 10:15 a.m. with ADM A and DON B regarding the allegation from resident 1 revealed the following: *He clarified the allegation had occurred 3/18/24. *He confirmed that on 3/18/24 from 12:36 p.m. to 2:17 p.m. resident 1 had been left in the mechanical lift sling on the toilet in her bathroom. -That information was based on his review of the facility's recording cameras and interviews conducted with staff on 3/21/24. Review of the provider's revised 12/2019 Abuse/Neglect/Exploitation of Residents revealed the following: *Policy: Residents must not be subjected to verbal, sexual, physical and mental abuse, corporal punishment, involuntary punishment, involuntary seclusion or misappropriation of property by anyone, including, but not limited to facility staff, other residents, consultants, volunteers, staff of other agencies, family members, legal guardians, friends or other individuals. *Responsibility: All staff -IV. Identification: Any injury or event is communicated to at least one member of the QAPI team followed by investigation if abuse/neglect is suspected. Alleged or suspected violations involving any mistreatment, neglect, or abuse including injuries of unknown source, will be reported to your immediate supervisor and to other officials in accordance with State law. -V. Investigation: DON/Designee will review events of suspected abuse/neglect. -VII. Reporting/Response: The DON or Designee will report results of investigation to State Department of Health and other official in accordance with the law. Reporting is done per State Department of Health requirements. Refer to F600.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, electronic medical record review (EMR), and policy review, the provider failed to ensure staff interactions and services were provided in a manner that maintained a sense of dignity and respect for the following: *One of one sampled resident (3) by maintaining privacy during personal care. *Two of two sampled resident (2 and 1) resident in honoring their preference for wake time. *Two of two sampled residents (2 and 13) by using their proper name. *One of nine sampled residents (3) who needed a call light to call for assistance. Findings include: 1. Observation on 3/21/24 at 6:45 a.m. of resident 3 revealed: *He was yelling help me and motioning with his hands for assistance. *He stated his scrotum was itching and he needed a salve put on it. *He had his hand inside his incontinent brief and appeared to be scratching at his scrotum. *Licensed practical nurse (LPN) L entered his room and without closing his window curtain before completing the care she: -Provided his perineal care. -Applied salve to his scrotum. Interview on 3/21/24 at 7:25 a.m. with LPN L confirmed she did not pull the window curtain before providing perineal care to resident 3. Interview on 4/4/24 at 9:01 a.m. with licensed social worker (LSW) K confirmed it was not appropriate to leave window-curtains or doors open when providing personal cares to residents. -Privacy was to have been provided by all staff members when providing personal care to residents. Review of the provider's August 2023 A.M. Care policy revealed there was no guidance on providing privacy when completing resident care. Review of the provider's August 2022 Oral Cares/hygiene policy revealed staff members were to close the privacy curtain when providing care to residents. -There was no reference to the window curtain. 2. Observation and interview on 3/20/24 at 7:40 a.m. with resident 2 and nurse aide (NA) E revealed the following: *NA E was assisting getting resident 2 up for the day. *Resident 2 kept repeating she did not want to get up, and I was sleeping so good. 3. Observation and interview on 3/21/24 at 8:02 a.m. with resident 1 revealed she: *Was seated in her recliner. *Stated, They got me up at 5:30 a.m. this morning, never in my life have I gotten up at 5:30. Maybe 6:00 [a.m.] but never 5:30. -Was unsure as to why the staff had woken her up at 5:30 a.m. -They did not turn on the lights while getting me up or when I was in the bathroom brushing my teeth and washing my face. I have to tell them to set up the things so I can brush my teeth. They always have different staff; I have to tell them where everything is at. Review of resident 1's EMR revealed the following: *She was admitted on [DATE]. *Her 1/17/24 Brief Interview on Mental Status (BIMS) score was an 11, indicating she had mild cognitive impairment. *Her diagnoses included: hemiplegia affecting her right side, scoliosis, anxiety disorder, history of poliomyelitis, urge incontinence, macular degeneration, mild cognitive impairment, and hearing loss. *Review of resident 1's 3/21/24 care plan revealed the following: -She liked to be in control of a situation. -She was very specific regarding the times she wants her cares completed, she has at times voiced concern with waiting for staff to complete care for other res [residents]. -She is usually alert & [and] orientated but may get details mixed up or forget at times & require reminders/cueing. She has a diagnosis of dementia with anxiety. Sudden changes or new situations may exacerbate altered cognition. 4. Observation and interview on 3/20/24 at 7:40 a.m. with resident 2 and NA E revealed the following: *NA E called the resident honey, sweet pea, and sweetheart, while providing morning care. *CNA Q entered the room at approximately 8:04 a.m. and then called resident 2 mama and honey, while providing morning care and stated, what you feeling today girl? while looking in the closet for a shirt. Review of resident 2's 3/20/24 care plan revealed there was no documentation of her preferred name to have been used by the staff. 5. Observation on 3/21/24 at 8:50 a.m. of resident 13 and NA E revealed the following: *NA E called resident 13 honey and sweetheart, during morning cares. Review of resident 13's 3/21/24 care plan revealed there was no documentation of her preferred name to have been used by staff. 6. Interview on 3/21/24 at 8:55 a.m. with NA E and CNA Q revealed: *They were aware they should not call residents sweetheart, honey, or mama. -They both stated it was hard to stop calling residents by those names. *They agreed they were to use a resident's proper name unless the resident preferred an alternate name. Interview on 4/4/24 at 9:01 a.m. with licensed social worker (LSW) K revealed: *She stated, as a rule, it is not allowed for staff to call residents sweetheart, mama, honey, and sweet pea, it should be kept respectful, and they should use their names. *If a resident wanted staff to use something other than their proper name it was recorded on their care plan. 7. Observation on 4/3/24 at 8:20 a.m. of resident 3 revealed his call light was draped over the side of a rolling bedside table that was not within his reach. Observation on 4/3/24 at 11:03 a.m. of resident 3 revealed: *He was seated in wheelchair. -There was a bedside rolling table behind him with a call light push button on it. -The corded call light was draped over the side of the bedside table approximately 3 feet behind him. *Resident 3 required the use of a full-body mechanical lift and one staff member to transfer. *He was unable to reach either of the call lights. Interview on 4/3/24 at 11:30 a.m. with CNA Q revealed the following, she: *Confirmed he did not have access to a call light at this time. *Confirmed resident 3 was able to use both the corded call light and the push call light button. -She did not go into his room and ensure his call light was within his reach. Review of the provider's 8/23 A.M. Care policy revealed the following: *11. Place call light within easy reach of resident and instruct resident to push call light for assistance as needed. 8. Interview on 4/4/24 at 9:03 a.m. with LSW K regarding resident rights revealed the following: *Staff education related to resident rights and dignity was provided by online training, nurse's meetings, and departmental meetings. *Resident preferences were recorded on the baseline care plan upon admission. -That included the resident's preference for wake times and times to go to bed. Interview on 4/4/24 at 11:33 a.m. with administrator (ADM) A, director of nursing (DON) B, and assistant director of nursing (ADON) C revealed: *They were working on a new software program that would ask residents what their preferences were for when to get up and when to go to bed. -The program was to start of April 2024. -Preferences for those residents who were admitted before the implementation of baseline care plans were not known. --They were not certain when the baseline care plans had been implemented but thought it was a couple of years ago. *DON B stated, We ask the residents do you want to get up? Some [residents] get up early and some don't. Sometimes if they are wet and need to be changed, we ask if they care to get washed up and dressed at that time. Previously we used agency staff, and we identified early risers in the building for them.

Based on observation, interview, record review, and policy review the provider failed to ensure oral care was consistently performed and accurately documented for nine of nine sampled residents (16, 17, 18, 19, 20, 2, 3, 4, and 5). Findings include: 1. Observation on 3/20/24 at 7:17 a.m. of morning care for resident 16 provided by certified nurse aide (CNA) N revealed that oral care was not completed before placing her dentures in her mouth. 2. Observation on 3/20/24 at 7:30 a.m. of morning care for resident 17 provided by CNA N revealed that oral care was not performed before to placing her dentures in her mouth. 3. Observation on 3/20/24 at 7:45 a.m. of morning care for resident 18 provided by CNA N revealed: *The resident's dentures were not in the denture cup container and CNA N stated, They must still be in her mouth. *It was confirmed by CNA N that the resident's dentures were still in the resident's mouth. *When asked if the resident had slept with her dentures in, CNA N stated that the resident will sometimes refuse to let staff remove her dentures and that her dentures had been left in her mouth all night. *The dentures were not removed during morning care and oral care was not completed. *CNA N was unable to determine how long the resident's dentures had been left in her mouth without any oral care. 4. Observation and interview on 3/20/24 at 9:00 a.m. with CNA O and CNA N who were assisting resident 19 to bed revealed: *When asked when do residents get their teeth brushed, CNA O stated that the staff would have brushed the resident's teeth when they got up for the day or after breakfast depending on the staff. *When asked if resident 19 had his teeth brushed that morning, CNA O stated that she did not know. *When she went to look for resident 19's toothbrush, she could not find a toothbrush for him in his room and stated that she would normally use a disposable toothette for his oral care. *When asked if the resident had his teeth or wore dentures, CNA O was not aware if the resident had his teeth or wore dentures. *CNA N could not locate the resident's toothbrush and stated that she would use a disposable toothette. 5. Interview on 3/20/24 at 10:20 a.m. with licensed practical nurse (LPN)/nurse manager P revealed: *She would normally use a disposable toothette and water when completing oral care for resident 20. *She would not use resident 20's toothbrush due to the resident grinding her teeth and she was afraid that the resident would swallow the mouth rinse solution. *When asked if resident ever got her teeth brushed, she said sometimes. *She stated that oral care was usually completed when the resident got up for the day or after breakfast. 6. Observation on 3/20/2024 from 7:30 a.m. to 10:30 a.m. on the Pine Village unit revealed: *Every toothbrush that was examined was dry and appeared to have not been used that morning. *Residents who had the 4 ounce (oz) mouth rinse bottles in their rooms were all dated 12/6 and appeared to be full.7. Observation on 3/20/24 at 7:40 a.m. of morning care for resident 2 provided by nurse aide (NA) E revealed her dentures were in her mouth and no oral care was provided. Observation on 3/20/24 at 9:56 a.m. of resident 2's bathroom revealed the following: *Her toothbrush was dry and was lying in the emesis basin. *There was a 4 oz. size bottle of mouthwash dated 1/11/24 that contained approximately 3 ounces of mouthwash. Observation on 4/3/23 at 8:10 a.m. of resident 2 and her bathroom revealed her dentures were in her mouth and her toothbrush bristles were dry and hard. Review of resident 2's EMR revealed the following: *Her BIMS score was a 9, meaning she had mild cognitive impairment. *Her care plan revealed she: -Wore a full set of dentures. -Needed total assistance of one staff member with her personal care and oral hygiene. Interview on 3/20/24 at 10:05 a.m. with NA E regarding oral care for resident 2 revealed: *Oral care was usually completed by whomever assisted the resident when getting up in the morning. *Resident 2 already her dentures in that morning before she assisted her in getting up. -The dentures should have been removed from resident 2's mouth last night before bed. --Sometimes the day shift removed the dentures. *The night shift had not notified her that resident 2's oral care had been completed. *She confirmed she had not completed oral cares on any residents she assisted that morning. 8. Observation and interview on 3/20/24 at 9:55 a.m. with resident 4 revealed the following: *She had a partial denture that the staff brushed and then she would brush her own bottom teeth. *Her oral care had not been performed that morning. *She stated, They had been done the evening before, but they are not always done daily. *At 10:25 a.m. her partial denture remained in her cup in the bathroom. Interview on 3/21/24 at 11:16 a.m. with resident 4 revealed: *Last night she slept with dentures in her mouth. -Her oral care was provided last evening. *No oral care was completed by staff that morning. Review of resident 4's EMR morning care documentation for resident 4 revealed *Her 3/11/24 BIMS score was a 14, that meant her cognition was intact. *Her physician orders included that her oral cares be completed twice a day. 9. Observation on 3/20/24 at 10:00 a.m. of resident 5 revealed her toothbrush was dry and had hard firm bristles. 10. Observation on 3/20/24 at 10:21 a.m. resident 3 revealed a battery-operated toothbrush in his bathroom that was dry with hard bristles and appeared to have been unused. Review of resident 3's EMR revealed the following he required total assistance of a staff member for personal hygiene. 11. Interview on 3/20/24 at 3:30 p.m. with director of nursing (DON) B and the assistant director of nursing (ADON) C regarding resident's oral care revealed that the expectation was that oral care would have been completed every morning with every resident during morning care, but that it was still at the resident's discretion on when that would have been completed. 12. Review of the provider's 4/2023 Care Plan, Resident-Centered Facility Standards of Care Policy revealed: *Staff would provide resident oral cares daily and as needed. *Staff would monitor oral mucosa and integrity. Review of the provider's 8/22 Oral Hygiene policy revealed the following: *Policy: -Residents will be assisted with oral hygiene with a.m. and p.m. care and as necessary. The mouth will be cleansed for personal hygiene and to lessen the occurrence of mouth infections. Oral Hygiene will be provided when the resident able to assist or per the resident's preferences. *Responsibility: -RN/LPN - Assess oral health of residents regularly, monitor oral care procedure done by NA. -CNA Assist residents with oral hygiene twice daily and as necessary. Observe for problems and report same to nurse. *Care of residents with dentures: -2. Request resident to remove dentures and place them in an emesis basin or denture cup. 4. Place dentures in cup with fresh solution of an effervescent denture tablet and cool water or plan water during p.m. care. Clean denture cup after a.m. care. -5. Clean inside of mouth thoroughly with mouthwash diluted with 4 parts of water to 1 part of mouthwash and rinse with water. May use toothettes to clean soft tissues.

Based on observation, interview, record review, and policy review, the provider failed to ensure one of one sampled resident (18) had received notification of a bed hold notice upon transferring out of the facility. Findings include: 1. Observation and interview on 10/3/23 at 10:27 a.m. revealed she: *Was seated in her recliner watching television. She was alert and oriented to person, place and time. *Was aware that she had been transferred to the hospital several times for fluid retention which had resulted in shortness of breath and an altered mental status. *Stated she was sick, I do not remember if I had been informed about a bed hold. Review of resident 18's electronic medical record and paper chart revealed: *She had been transferred to the hospital on 1/23/23, 8/5/23, and 9/11/23. *There was no documentation found that her family had been notified of any bed hold notices for her transfers out of the facility. *8/17/23 Minimum Data Set significant change assessment revealed her Brief Interview for Mental Status score was 14; which indicated her cognitive status was intact. Interview on 10/05/23 at 2:45 with licensed practical nurse X revealed the bed hold notice document might have been located in front of her paper chart or behind her room door. Interview on 10/5/23 at 3:00 p.m. with assistant director of nursing C revealed the bed hold notice would have been sent with the residents transfer paperwork to the hospital. Social services would have documented in the resident's progress notes when the resident and/or the resident's representative was notified of the bed hold policy. No follow up was done to get the signed bed hold documents returned to the facility. Interview on 10/05/23 at 3:24 p.m. with social service designee W revealed the nurses should have sent the bed hold notice with the transfer paperwork for resident 18. Social services would then document the conversation of the bed hold notification with the resident and/or resident's representative in the resident's progress notes. Review of the provider's May 2018 Bed- Hold Policy and readmission After Exceeding Bed -Hold Days revealed: *A Resident's bed will be reserved upon request in the event he or she is hospitalized with the understanding that the charge for holding the bed. *There was no further information in the policy that specified who would have been responsible for the bed hold notification.

Based on record review, observation, and interview the provider failed to ensure two of two sampled residents (7 and 50) were assessed accurately for weight (wt) loss and accurate Minimum Data Set (MDS) coding. Findings include: 1. Record review of the long term care survey process MDS indicator revealed: *Resident 7 was triggered for wt loss. *That indicator would have been triggered from the last accepted MDS assessment. Observation and interview on 10/3/23 at 9:05 a.m. with resident 7 while sitting in her recliner revealed: *She has had some weight loss recently. *She does not have any problems with chewing or swallowing food. *Review of the resident 7's electronic medical record (EMR) on 10/3/23 regarding wt loss revealed the following documentation: *On 7/5/23 a weight of 168 pounds using the bath. *On 7/17/23 a weight of 145 pounds using the bath scale had been documented that was a -13.69% wt loss. *On 8/1/23 resident 7's quarterly MDS was accepted with the weight of 145 pounds recorded. *On 9/6/2023 a weight of 171 pounds using the bath scale. *On 9/27/2023 a weight of 145.5 pounds using the bath scale had been documented that was a -14.91% loss. *She had been weighed weekly. Interview on 10/5/23 at 2:30 p.m. with licensed practical nurse (LPN) M regarding resident wt loss revealed: *She would re-weigh the resident if there was a significant change in the wt. *If the wt was found to have been correct after the re-weigh then she would: -Send a notification to the physician regarding the weight change. -Send a notification to the dietary manager. -Watch for any new orders or recommendations. *LPN M had reviewed resident 7's documented weight on 9/6/23 through 9/27/23. *She agreed that was a significant weight change. *She had not been able to find a progress note regarding the weight change. Interview on 10/5/23 at 2:49 p.m. with assistant director of nursing (ADON) C regarding significant wt loss for a resident revealed: *Staff should have re-weighed the resident upon discovering the wt loss. *Her expectation would have been that a progress note should have been made by the nurse acknowledging the wt loss. *She would expect the physician and dietary to have been notified. *A copy of the fax that would have been sent to the physician with notification of the wt loss should have been in the resident's paper chart. Interview on 10/6/23 11:16 a.m. with registered dietitian (RD) D, administrator A, director of nursing (DON) B regarding resident 7's wt loss revealed: *RD D felt that her clinical judgement of the resident's wt variances had not needed to have been documented. *She had known that resident 7's wt variance was not correct due to her dietary intake, but had not documented that information in a progress note or communicated that to the nursing staff. *Administrator A felt that documentation of RD D's reviews of resident's wt variances was necessary. 2. Observation and attempted interview on 10/5/23 at 2:42 p.m. with resident 50 while certified nursing assistant (CNA) I assisted him to the restroom revealed: *He was seated in a Broda (specialized wheelchair) chair. *He was non-verbal and was unable to answer questions. *He had on sweatpants and a shirt that appeared to be loose on him. Review of resident 50's EMR revealed his: *Brief interview of mental status score had not been determined, as he was unable to complete the interview. -A staff interview on 9/11/23 had been completed that determined he had severe cognitive impairment. *Weight (wt) record revealed the following documentation: -On 4/26/23 as 198.6 pounds. -On 8/20/23 as 195.8 pounds. -On 8/25/23 as 183.8 pounds. -On 9/9/23 as 180.8 pounds. -On 9/16/23 as 180.4 pounds. -On 9/23/23 as 179.6 pounds. -On 9/30/23 as 179.4 pounds. *From 8/20/23 to 9/30/23 he had a wt loss of 8.38% Interview and record review on 10/5/23 at 3:06 p.m. with LPN K regarding resident 50's wt loss revealed: -She thought he had lost wt, Just by looking at him. *His EMR noted that he had lost about 20 pounds since April 2023. *She had not reported his wt loss to the physician or the registered dietitian (RD). On 10/6/23 at 1:00 p.m. RD D provided documentation that resident 50 had been reweighed on 10/6/23 at 10:39 a.m. and his weight was 179.4 lbs. Interview and resident assessment instrument (RAI) manual review on 10/6/23 at 3:32 p.m. with DON B regarding coding for wt on the resident's Minimum Data Set (MDS) revealed: *Resident 50's wt on his 9/12/23 MDS was recorded as 196 pounds. *His most recent wt in the last 30 days for the 9/12/23 MDS should have been recorded as 181 pounds, that was a 15-pound discrepancy. *She agreed the MDS was coded incorrectly. *She had no training on how to complete the MDS. *RD D would have been the one to complete the wt section on the MDS. Interview with RD D and on 10/6/23 at 3:55 p.m. regarding coding for resident's wt on the MDS revealed she: *Had completed the wt section on resident 50's 9/12/23 MDS. *Agreed resident 50's wt on that MDS had not been coded correctly. *Was unsure as to why she had used the 196 pounds as his wt. *Stated she followed the resident assessment instrument manual instructions for completion of the MDS. *Agreed using the 196 pounds as his wt was not following the instructions of the RAI for completing the MDS. -The instructions included using the most recent wt closest to the assessment reference date. -The assessment reference date for that MDS was 9/12/23. -She agreed she should have used his wt that was recorded from 9/9/23 of 180.8 pounds rounded up to 181 pounds as the RAI manual had instructed. Interview with administrator A on 10/6/23 at 4:00 p.m. revealed his expectations was for staff members to follow the instructions in the RAI manual for completion of the resident's MDS. Review of the provider's undated Weight Change Summary Report policy revealed: *A significant wt change report is sent to care conference members and printed to the nurses' stations at least monthly. *Significant changes are defined as 5% or more in one month and 10% or more in 6 months. 7.5% in 3 months is also considered a significant change but is not coded on the MDS as such. *Information is requested from the care conference team regarding possible underlying causes of wt changes as well as possible interventions. *Interventions may include (but not limited to): -Reweighing the resident. -Interviewing the resident or direct care-givers. -Reviewing the medical records, labs, history. -Referrals to appropriate care team members. -Reviewing food intake records. -Referral to the quality of life committee. -Nutritional supplementation. -Reviewing the care plan. Review of the provider's undated documentation of resident's nutritional care policy revealed: *Policy: -Documentation of resident's nutritional care is the responsibility of the Dietary Professional (Registered/Licensed Dietitian). --Nutritional Assessments are completed per state and federal guidelines. The Assessment may include (but not limited to) information on wt status, acute and chronic health conditions, medications, labs, diet, preferences, dental status and interventions appropriate to nutritional status. --Initial Plan of Care is completed within 7 days after completion of the MDS. --A new Nutritional Assessment and Plan of Care is completed each time a resident is re-admitted (or per MDS criteria), and as deemed necessary by the facility or the Registered and/or Licensed Dietitian.

Based on observation, interview and record review the provider failed to ensure two of two sampled residents (7 and 50) had physician involvement associated with weight loss. Findings include: 1. Record review of the long term care survey process MDS indicator revealed: *Resident 7 was triggered for wt loss. *That indicator would have been triggered from the last accepted MDS assessment. Observation and interview on 10/3/23 at 9:05 a.m. with resident 7 while sitting in her recliner revealed: *She has had some weight loss recently. *She does not have any problems with chewing or swallowing food. *Review of the resident 7's electronic medical record (EMR) on 10/3/23 regarding wt loss revealed the following documentation: *On 7/5/23 a weight of 168 pounds using the bath. *On 7/17/23 a weight of 145 pounds using the bath scale had been documented that was a -13.69% wt loss. *On 8/1/23 resident 7's quarterly MDS was accepted with the weight of 145 pounds recorded. *On 9/6/2023 a weight of 171 pounds using the bath scale. *On 9/27/2023 a weight of 145.5 pounds using the bath scale had been documented that was a -14.91% loss. *She had been weighed weekly. Interview on 10/5/23 at 2:30 p.m. with licensed practical nurse (LPN) M regarding resident wt loss revealed: *She would re-weigh the resident if there was a significant change in the wt. *If the wt was found to have been correct after the re-weigh then she would: -Send a notification to the physician regarding the weight change. -Send a notification to the dietary manager. -Watch for any new orders or recommendations. *LPN M had reviewed resident 7's documented weight on 9/6/23 through 9/27/23. *She agreed that was a significant weight change. *She had not been able to find a progress note regarding the weight change. Interview on 10/5/23 at 2:49 p.m. with assistant director of nursing (ADON) C regarding significant wt loss for a resident revealed: *Staff should have re-weighed the resident upon discovering the wt loss. *Her expectation would have been that a progress note should have been made by the nurse acknowledging the wt loss. *She would expect the physician and dietary to have been notified. *A copy of the fax that would have been sent to the physician with notification of the wt loss should have been in the resident's paper chart. Interview on 10/6/23 11:16 a.m. with registered dietitian (RD) D, administrator A, director of nursing (DON) B regarding resident 7's wt loss revealed: *RD D felt that her clinical judgement of the resident's wt variances had not needed to have been documented. *She had known that resident 7's wt variance was not correct due to her dietary intake, but had not documented that information in a progress note or communicated that to the nursing staff. *Administrator A felt that documentation of RD D's reviews of resident's wt variances was necessary. *Request was made on 10/4/23 to DON B for a copy of the notification sent to resident 7's physician regarding her weight loss. -She had not been able to produce a the document prior to exit. Resident #7 2. Observation and Interview on 10/05/23 2:42 p.m. of resident 50 with certified nursing assistant I revealed he: *Had smiled and did not respond to questions. *Required the use of a mechanical sit-to-stand lift to transfer. -Had difficulty placing his hands on the bars of the lift. Review of resident 50's EMR regarding weight loss revealed: *His weights had been documented: -On 4/26/23 as 198.6 pounds. -On 8/20/23 as 195.8 pounds. -On 9/9/23 as 180.8 pounds. -On 9/16/23 as 180.4 pounds. -On 9/23/23 as 179.6 pounds. -On 9/30/23 as 179.4 pounds. *From 8/20/23 to 9/30/23 he had a weight loss of 8.38% Review of resident 50's EMR revealed that on 9/12/2023 there had been a nutrition note RD D that revealed: *His diagnoses included: Alzheimer's disease, urinary tract infection, abdominal pain, cystitis, urinary retention, edema, constipation, and dementia. *His medications had included: senna, MiraLAX, and furosemide. *He was on a regular diet and had eaten 50-100% of his meals. *He had eaten his meals in the memory care unit with encouragement and assistance as needed. *He was able to make needs known at most times. *He had one dish of ice cream daily. *His weight was recorded as 180 pounds. *His body mass index was a score of 29, meaning he was overweight. *History of weights included that he weighed 184 pounds 30 days ago and 203 pounds 90 days ago. -His weight was down 11.4% in 90 days. *He had gained weight in the last year and was coming back down to his usual body weight range. *RD would continue to monitor. *There was no documentation to support his physician had been notified of his weight loss. Interview on 10/05/23 at 3:05 p.m. with CNA I regarding weighing of residents revealed: *They were weighed on their bath days. *That weight was documented in each resident's electronic medical record. *Residents were reweighed on that same day if there was a variance. -When the variance was accurate, she would have notified the nurse. Interview on 10/05/23 at 3:06 p.m. with LPN K regarding resident 50's weight loss revealed: *She thought he had lost weight, Just by looking at him. *His medical record noted that he had lost approximately 20 pounds since April 2023. *His weight since the beginning of August 2023 had varied. *She had not reported his weight loss to anyone. Interview with RD on 10/6/23 at 3:55 p.m. regarding weight loss of resident 50 revealed she: *Was aware resident 50 had a significant weight loss. *Was not concerned about this weight loss as he was overweight. *Had not notified the physician of his weight loss. Review of the provider's undated weight policy revealed: *A significant weight change report is sent to care conference members and printed to the nurses' stations at least monthly. *Significant changes are defined as 5% or more in one month and 10% or more in 6 months. 7.5% in 3 months is also considered a significant change, but is not coded on the MDS as such. *Information is requested from the care conference team regarding possible underlying causes of weight changes as well as possible interventions. *Interventions may include (but not limited to): -Reweighing the resident. -Interviewing the resident or direct care-givers. -Reviewing the medical records, labs, history. -Referrals to appropriate care team members. -Reviewing food intake records. -Referral to the quality of life committee. -Nutritional supplementation. -Reviewing the care plan.

Based on observation, interview, and policy review the provider failed to ensure two of two mechanical lifts and body slings were properly disinfected between resident use on two of two observed occasions. Findings include: 1. Observation and interview on 10/5/23 at 2:42 p.m. with certified nursing assistant (CNA) I and resident 50 revealed: *Resident 50 was in his room, sitting in a Broda (specialized wheelchair) chair. *She transferred resident 50 from his Broda chair to the restroom using a sit-to-stand mechanical lift. -After he used the restroom, she transferred him back to his Broda chair. --She then removed the sit-to-stand mechanical lift and body sling from the room and placed it in the hallway. -CNA I had not disinfected the mechanical lift or body sling. --She confirmed several residents used the same sit-to-stand mechanical lifts and the same body slings. --She was aware that she was supposed to disinfect the equipment by using Sani-wipes. --She was not aware where those Sani-wipes were kept. --She had only been employed for about a month. Interview on 10/5/23 at 3:03 p.m. with licensed practical nurse (LPN) K regarding disinfecting of the sit-to stand mechanical lifts and the body slings revealed: *She confirmed several residents used the same sit-to-stand mechanical lifts and the same body slings. -The equipment should have been disinfected after each resident use by using the disinfectant Sani-wipes. *She agreed the body slings were cloth which made them an uncleanable surface. Observation on 10/5/23 3:36 p.m. revealed four sit-to-stand mechanical lifts sitting in the hallway with a transfer body sling draped over each of them. Continued interview on 10/5/23 at 3:38 p.m. with LPN K revealed: *Sani-wipes were stored in the locked medication room. -Nurses and medication aides were the only staff who could access them in the locked medication room. -Sani-wipes used to have been kept on carts in the hallways. --They had been removed because the residents had taken them and used them as handwipes. -She confirmed CNA I had not requested Sani-wipes to disinfect the sit-to-stand mechanical lift and the body sling after assisting resident 50. Interview on 10/6/23 at 4:16 p.m. with director of nursing (DON) B and administrator A regarding the disinfecting of lifts revealed: *Their process for disinfecting the mechanical lifts and the body slings had been to: -Use a purple topped container containing Sani-wipes (which is a germicidal wipe) to wipe the equipment down after each resident use. -Body slings for sit-to-stand mechanical lifts were shared between residents -When the slings became visibly dirty, they would have been sent to the laundry department to have been washed. -Harness body slings used with full body mechanical lifts were not shared between residents. -Sani-wipes were kept in the nurses' carts, dirty utility rooms, locked cupboards, and locked medication rooms on the memory care units. -They had not known the Sani-wipes were not readily available to the nursing assistants. -In the past, they had completed audits on the disinfecting of equipment after resident use. --The last audit had been completed in May 2023 with one staff that was provided real-time education for not disinfecting the equipment. -They had been aware the body slings were shared between residents and would have only washed them when visibly dirty. *DON B agreed not disinfecting shared equipment between resident use was an infection control issue. 2. Observation on 10/5/23 at 4:06 p.m. with CNA V and resident 67 during a transfer revealed: *Resident 67 was in her room sitting in her recliner. *CNA V transferred resident 67 from the recliner to her bed using a sit-to-stand mechanical lift. *She positioned the resident in bed. *CNA V then wheeled the mechanical lift into the hallway next to the wall. *She had not sanitized the mechanical lift. *She returned to the nurse's station. 3. Review of the provider's revised July 2022 Resident Care Equipment and Articles for Handling, Processing and Transport policy revealed: *Purpose -Reusable equipment is to be cleaned between resident use and reprocessed appropriately .The facility protects indirect transmission through decontamination (i.e., cleaning, sanitizing, or disinfecting of an object to render it safe for handling. *Policy -2. The employee should disinfect reusable equipment between resident uses or before transport using a disinfectant.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 5. Observation and interview on 10/3/23 at 3:15 p.m. with resident 29 revealed he: *Was sitting in his recliner watching T.V. *Required toilet assistance. *Denied having any treatments for skin problems. Interview on 10/5/23 at 2:30 p.m. with licensed practical nurse (LPN) M regarding resident 29's toileting schedule revealed: *He would have been assisted to the toilet at these times: -Upon waking up and before going to breakfast. -After breakfast and before lunch. -After lunch and before activities. -After activities and before supper. -After supper. -Any time that he had requested to use the toilet. *She had not indicated that resident 29 had any problems with his skin. Interview 10/6/23 9:35 a.m. with LPN N regarding resident 29's skin revealed: *She stated that at times he would have redness on his buttocks. *Staff would have applied an ointment to his buttock, * He does not have any chronic skin issue with redness. Review of resident 29's EMR revealed: *He was admitted on [DATE] and had not been diagnosed with MASD (moisture associate skin disorder) or urinary incontinence. *On 1/6/23, day of admission the skin observation record indicated skin was dry. *On 3/23/23 and 6/22/23 he had dry skin. *On 9/22/23, the record indicated he had bruising to bilateral eye, skin tears to the right eye and right forehead, abrasion to his left knee, but no documentation that indicated he had MASD. *On 3/27/23 and 9/22/23 bowel and bladder screening record indicated he was determined a candidate for bladder retraining. *On the 6/22/23 screening, it was determined he was a candidate for scheduled toileting. Interview on 10/5/23 at 4:30 p.m. with DON B and ADON C regarding bowel and bladder assessments and skin record observations revealed: *That assessment was used for the MDS. *It was not a nursing care tool. Review of resident 29's care plan revised on 4/5/23 revealed: *Resident 29 is at risk for altered skin integrity related to her {sic} needing assist with his bed mobility and having MASD to his coccyx/gluteal folds. *Resident 29 has complaint of, depending on how he sits, having pain to his bottom. * He is currently being treated for MASD to his coccyx. Interview 10/6/23 4:49 p.m. with MDS coordinator U, administrator A, and DON B regarding updating resident 29's care plan to his current needs revealed: *MDS coordinator U would have updated the care plan with the quarterly MDS, and if someone would have informed her for the need update or revise the care plan. *DON B stated that staff were still performing interventions, but agreed that was not an active problem and that the resident was at risk for MASD. *Administrator A agreed that the resident care plans should reflect the current care needs of the resident. Review of the provider's April 2020 Care Plan, Resident-Centered Facility Standards of Care revealed: *The following are standards of nursing care that should be provided by certified nursing assistants, staff nurses, director of nursing and nursing home administrator in the nursing home setting: -Provide an accurate assessment and individualized care plan for each resident. -Recognize abnormal changes in body function and the importance of reporting such changes to the physician. -Ensure appropriate and safe transfers, positioning and turning. *At [NAME] Living Center long term care plans are developed by an interdisciplinary team (IDT) with input and participation of CNA's, the resident, family and/or legal representative (when available) .Care plans are written by exception and include measurable outcomes and identify interventions that are specific to the individual resident with defined time frames or parameters . *The care plan is reviewed and/or revisited after each assessment and PRN [as needed]. The short-term care plan is reviewed during this time and long term issues are carried forward to the long term care plan as applicable. *Each discipline is responsible for updating the care plan as changes occur between assessments and scheduled care conferences updates may occur via short-term care plan or PCC care plan. Care plan changes may be made by Nurses (with the input of C.NAs as indicated), Social Workers, Therapy ., Activity Director, Activity Coordinator (Reflections and Activity Aides, Dietary Director and Dietary Managers. Communication between the IDT, residents and families is ongoing and occurs as needed. 3. Observation and interview on 10/5/23 at 2:42 p.m. of resident 50 with CNA I revealed he: *Smiled and had not responded to questions. *Was not wearing glasses. -CNA I was not sure where his glasses were. *Had been seated in a rocking wheelchair. *Had a Foley catheter drainage bag hanging from the bottom bar of his wheelchair. *Had required the use of a mechanical sit-to-stand mechanical lift for transfers. -CNA I assisted him from his wheelchair to a sit-to-stand mechanical lift. --There was no other staff member present to assist CNA I. --The resident had difficulty placing his hands around bars of the sit-to-stand lift. --He was able to hang onto the bars once CNA I placed his hands on those bars. --CNA I then assisted the resident into the bathroom. --Upon returning him from the bathroom CNA I: ---Returned him to his wheelchair. ---CNA I washed her hands and, ---Moved the sit-to-stand mechanical lift and body sling into the hallway. ----CNA I had not disinfected the sit-to-stand mechanical lift or the body sling. Review of resident 50's EMR revealed: *He was admitted on [DATE]. *His BIMS score had not been determined, as he was unable to complete the interview. -A staff interview on 9/11/23 had been completed that determined he had severe cognitive impairment. *His diagnoses included: Alzheimer's disease, dementia with agitation, history of urinary tract infections, and obstructive and reflux uropathy (which occurs when urine cannot drain through the urinary tract). Review of resident 50's 10/5/23 care plan in his EMR revealed: *There was an initiated 6/28/23 focus that included, Risk factors include: cognition, lactose intolerance,B12 anemia [intolerance, B12, and anemia]. --The 6/28/23 goal for that focus was, No weight goal during hospice. ---He had been discharged from hospice on 2/28/23. *A revised 9/28/22 intervention for toilet use that included, has an indwelling catheter. He needs 2 staff assist with toileting [toileting]. *A revised 4/5/22 focus of, has an indwelling Catheter: He has a diagnosis of BPH with urinary obstruction. -An initiated 2/1/21 intervention for that focus that included, Monitor and document intake and output as per facility policy. *A revised 12/13/23 focus that included, Unable to assess [residents name] vision due to advanced dementia. When asked, he stared blankly at the sheet with no response at all. -The revised 6/1/23 goal that included, will show no decline in visual function through the review date. --The 2/9/21 intervention that included, remind to wear glasses when up. Ensure [residents name] is wearing glasses which are clean, free from scratches, and in good repair. Report any damage to nurse. Interview on 10/05/23 at 3:03 p.m. with LPN K regarding resident 50 revealed: *He had worn glasses. -He stopped wearing them at least a year ago. --She was not aware as to why he quit wearing them. *Regarding his weight loss: -Their process was: -Complete an assessment to determine if the weight was related to: --A fluid gain or loss. --Eating less food. -To have documented that the dietitian and the physician were notified. *She thought he had lost weight, Just by looking at him. *His EMR noted that he had lost about 20 pounds since April, 2023. *His weight since the beginning of August, 2023 had varied. -He was assisted by a staff member when eating his meals. -He would sometimes grab foods that were finger foods. -He had normally eaten 75 to 100 percent of his food. *She had not reported his weight loss. Interview on 10/06/23 at 8:16 a.m. with administrator A and DON B regarding resident 50's care plan revealed: *DON B stated he had been on hospice from 9/8/22 through, she believed 12/27/22. -The care plan should have been updated with his MDS completed after the date of his discharge from hospice. -He had glasses but had not worn them for at least six months. --DON B confirmed he had taken them off his face and thrown them on the floor the last five to six times when staff attempted to have him wear them. ---That was at least two months ago. *MDS coordinator U would have been responsible to update the care plan. -DON B and ADON C would have been able to update the care plan. -They agreed the care plan: --Should have been updated to include that the resident no longer wore his glasses. --Stated in two different sections that he was on hospice and he was not on hospice. ---They had not felt that the discrepancy in his care plan was a concern. Interview on 10/06/23 at 8:38 a.m. with administrator A, DON B, ADON C, and RD D revealed regarding resident 50's weight loss: *RD D had not felt that his weight loss was a concern. -She stated his weight was above his admission weight which had been 164 pounds. -He had gained weight after his admission. --He had been admitted to hospice for a period of time. Interview on 10/6/23 at 4:31 p.m. with administrator A, DON B, MDS coordinator U regarding resident 50's Foley catheter output on his care plan revealed: *DON B agreed the care plan included to follow the provider's policy for recording of urinary output from the Foley catheter. -Agreed the provider's policy referred to in the care plan, for catheter intake and output did not include how to measure or record output from a Foley catheter. Continued interview on 10/6/23 at 4:49 p.m. with Administrator A, and DON B, and MDS coordinator U regarding resident care plans revealed: *Care plans were updated when the MDS was completed. *Nurses would communicate to the MDS coordinator if there were changes in the resident's care. *They would have expected the care plan to accurately reflect the current care the resident was receiving. 4. Observation and interview on 10/03/23 at 9:34 a.m. with resident 41 revealed: *She was seated in her recliner with pillows positioning her to sit upright. *She stated her room, is noisy at night. -She thought the noise had come from the bed and occurred about every fifteen minutes. --The bed had an electronic low air loss mattress on it and had been making a loud humming noise. -She stated, A man brought in and slapped it on the bed and left. -She had always slept in the chair, stated I never sleep in the bed. --Staff would reposition her with pillows. Review of resident 41's EMR revealed: *She was admitted on [DATE]. *Her BIMS score was a 14, meaning she was cognitively intact. *Her revised 9/23/23 care plan included that she required the following: -Required one staff member to assist in turning and repositioning her in bed. -Needed her bed in the low position at night. -Used a low air loss mattress on her bed for pressure ulcer prevention. Based on observation, interview, record review, and policy review, the provider failed to follow, revise, and update care plans for five of twelve sampled residents (28, 29, 41, 50, and 67) to reflect their current care needs. Findings include: 1. Observation and interview on 10/03/23 at 4:35 p.m. with resident 28 in her room revealed: *The resident was in her room seated in her wheelchair. *Her room was dark with the door opened a few inches. *During the interview she was observed to have a flat affect (restricted or nonexistent expression of emotion). *She thought she had moved into the facility about six months ago. *The reason she was admitted was because she had a fall at home that resulted in a broken hip. *She was at the facility for rehabilitation but had not made enough progress in her therapy to return to her home. *It was a hard transition for her that resulted in increased anxiety and depression. *She wanted to return to her home. Review of resident 28's electronic medical record (EMR) revealed she: *Had a Brief Interview for Mental Status score of 14 that indicated her cognition was intact. *She had a history of mental health issues. *Her diagnoses included the following: -Anxiety disorder. -Depression. -Adjustment disorder with mixed disturbance of emotions and conduct. -Agoraphobia (a type of anxiety disorder) with panic disorder. -Insomnia. *There had been a 9/14/23 progress note from social services that resident 28 had stated she wanted to die. *On 9/18/2023 social services charted the following: -Note text: quarterly charting for ARD [Assessment Reference Date] date of 9-12-2023. [resident name] did her own interview questions. Her BIM'S score was 14 as she needed a cue on one of the words. PHQ-9 was higher as she is spending her time in her room due to Covid in facility. She did tell me she felt she would be better off dead though she did say she wouldn't hurt herself. I did fax over to her doctor and he noted it and no further orders received. We will monitor for changes. During our conversation she did initiate a little more than usual. She is on psychotropic meds. Her daughter visits often. *She was followed by a psychiatrist on a regular basis to address her mental health needs and had been seen since she had admitted to the facility. Interview on 10/04/23 at 9:15 a.m. with licensed practical nurse (LPN) F regarding resident 28 revealed: *The resident received medication to address her mental health issues. *She had always known her to have had a flat affect. *She had been seen and followed up by her psychiatrist and physician after the 9/14/23 suicidal statement. *The resident had a difficult time with the transition when she admitted and had been depressed. *If the resident made statements about wanting to die it would have been reported to her physician. *She was not sure if her history of suicidal ideation had been included on her care plan or if there had been a task for the CNAs to have documented concerns regarding her current mental health status. Interview on 10/05/23 at 3:04 p.m. with CNA V regarding resident 28 revealed: *The tasks for residents were assigned onto a [NAME] system for the CNAs to complete for those residents that they provided care to. *She thought the assignments were made according to the resident's care plan. *There had been a task to report if she had been angry but nothing that related to sadness or anxiety. *When the resident first admitted she had been more needy and lonely and tended to use her call light often. *Now she participated in activities on a regular basis and seemed more satisfied with her current living arrangements. Review of resident 28's revised 9/12/23 comprehensive care plan revealed: *It had included the following: -She received psychotropic medications and staff were to have monitored for side effects, including suicidal ideation. -Interventions on how to assist her when she refused care or had displayed verbal or physical aggression. -Her interests for group and individual activities she enjoyed. *It had not included information about her personal history that she had made suicidal statements or instructions for staff on what behavior changes to have observed that would alert the staff that she might have been experiencing an emotional crisis. Interview on 10/06/23 at 8:22 a.m. with agency CNA R regarding resident 28 revealed: *The following interventions were included for tasks to chart on for the resident including: -Frequent crying, repeats movement, yelling/screaming, kicking and hitting, pushing, grabbing, pinching, scratching, spitting, biting, wandering, abusive language, threatening behavior, sexually inappropriate, rejection of care. *There was no interventions related to her moods such as sadness, loneliness, or anxiety. *She never known the resident to make statements that she wanted to die or that it was in her history, but thought it would have been important information for the staff to have been aware of. 2. Review of resident 67's EMR revealed: *She was admitted on [DATE] for rehabilitation for a stroke. *During rehabilitation she suffered further mini strokes (TIAs) that caused her to decline further. *She had right-sided weakness with no physical ability to move or use her right arm or the right leg. *She was able to eat independently but due to her decline in May 2023 they had added an intervention for staff to assist her with eating meals. *She was placed on hospice care on 7/17/23. Observation on 10/4/23 at 8:20 a.m. with resident 67 in her room revealed: *She had been in her room seated in her recliner with her breakfast tray in front of her on the bedside stand. *She had been eating and drinking out of a cup using her left hand. *Staff were not assisting the resident to eat. Observation on 10/6/23 at 8:50 a.m. with resident 67 in her room revealed: *The resident had been seated in her recliner with her bedside stand in front of her. *A CNA brought in her breakfast tray and set it up for her and then left the room. *She had not made an attempt to assist the resident with eating. *The resident then ate her food using her left hand. Interview on 10/3/23 at 9:20 a.m. with LPN F regarding resident 67 revealed: *She was on hospice services since 7/17/23. *The hospice staff would come in to assist her with care. *The resident insisted on feeding herself and the CNAs respected her wishes. *She was evaluated by speech therapy for her swallowing function. *They tried to change the texture of her food to have made it easier for her to eat but she refused to eat anything but regular textured foods. *She had been very independent. *She would let staff know her needs by pushing things on the floor if she was displeased. *Her family had been very involved in her care. *She was not aware if the care plan included her wanting to eat on her own but the CNAs were aware and would let her eat independently. Review of her current care plan revealed she was to have a one person assist with her meals. *That had not been observed. *Her care plan had not been updated to reflect her current care needs.

Based on observation, interview, and record review, the provider failed to ensure orientation had been completed for six of six sampled temporary staff, including four certified nursing assistants (CNAs) (O, P, Q, and R) and two licensed practical nurses (LPNs) (S and T) prior to working directly with residents. Findings include: 1. Observation and interview on 10/3/23 at 10:20 a.m. with LPN M on the third-floor memory care unit regarding staffing revealed the provider used nurses and CNAs from staffing agencies at times to staff five nursing units on the day, evening, and night shifts. Interview on 10/4/23 at 11:00 a.m. with an anonymous employee from a staffing agency regarding her orientation revealed: *This was the third shift she had worked the past three days. *She was oriented to the time keeping system, but had received no formal orientation regarding the care of residents. Review of the provider's daily nursing schedules from 10/3/23 through 10/6/23 revealed each day's schedule had: *Two to four CNAs scheduled each day on either the day or evening shifts that included: -Seven different CNAs. -Three different staffing agencies. *One to two LPNs scheduled each day on either the day and/or the evening or the night shift that included: -Four different LPNs. -Two different staffing agencies. Interview on 10/06/23 at 5:46 p.m. with administrator A, director of nursing (DON) B, and assistant DON C revealed: *The provider utilized CNAs, LPNs, and registered nurses (RNs) from several different staffing agencies on a regular basis that included: -Short term assignments of 2 to 3 shifts. -Month-to-month contracts. -Long-term contracts of three months or longer. *When discussing how they ensure those staff were competent and had the knowledge and skills necessary to care for the residents: -Administrator A stated each individual agency staff member was required to wear an identification badge from that agency which displayed a photo, name, and position of that individual. -Administrator A stated Our expectation is they are ready to go. -DON B stated it was the agency employee's responsibility to get the required training to maintain their certification or license. *In reviewing how the agency staff were provided orientation to the facility DON B revealed each agency staff member was: -Sent to the nursing unit they were assigned to. -Introduced to the staff on the unit. -Given a tour of the unit and floor they were assigned. -Provided with a one-page pocket care plan. *Administrator A and DON B further revealed: -No individual personnel files were kept for agency staff members. -No orientation of agency staff was documented or retained. On 10/6/23 at 10:15 a.m. a request was made to DON B for: *The policy for agency staff orientation and training. *Agency personnel files including registry verification and orientation/training for: -CNAs O, P, Q, and R. -LPNs S and T. On 10/06/23 at 5:08 p.m. documentation was received from the provider that included: *A one-page Registration Verification for active CNA registration for the following: -CNA O dated 10/2/23. -CNA P dated 10/19/22. -CNA Q dated 10/6/23. -CNA R dated 10/6/23. *A two-page QuickConfirm License Verification Report for active LPN licensure for the following: -LPN S dated 9/21/23. -LPN T dated 9/28/23, *LPN T's Basic Life Support certification from the American Heart Association. *No other documentation for the above agency staff was provided. *No policy for agency staff orientation/training was provided. Review of the provider's Employee List that included contracted agency staff revealed: *Nine RNs were listed as Contract from four staffing agencies, none of whom worked during the time of the survey. *Thirteen LPNS were listed as Contract from four staffing agencies and two LPNs S and T were identified and worked during the time of the survey. *Seventy-one CNAs were listed as Contract from seven staffing agencies and four CNAs O, P, Q, and R were identified and working during the time of the survey.

Based on observation, record review, interview, and policy review, the provider failed to ensure proper sanitary conditions were followed for 72 of 72 residents who received meals from three of three kitchens; that failure had the potential to affect all 72 residents for foodborne illnesses. Specifically, the provider failed to monitor the temperatures for three of three mechanical dishwashers with incomplete temperature sanitizing logs. Findings include: 1. Observation and interview on 10/3/23 at 8:06 a.m. with food service supervisor E during the initial tour of the first floor main kitchen revealed: *A mechanical dishwasher that used a high temperature sanitizing process. *The August 2023 dishwasher temperature log that had been posted on the wall across from the dishwasher. -That temperature log sheet had mostly blank areas, with very few temperature entries. *Food service supervisor E agreed the temperatures had not been consistently taken by the dietary staff. *There had been a chemical sanitizing dishwasher on both the second and third floors where they had served meals for the residents. *The dietary department had several open positions. *They had been actively trying to recruit to fill those positions. *The facility had offered incentives to dietary staff for open shifts that were available. *Open shifts had been filled without a problem due to those incentives. Further review of the August 2023 main kitchen mechanical dishwasher temperature log revealed: *There were columns for breakfast, lunch, and dinner and also included a column for wash and rinse cycle temperatures. -The columns for the breakfast and dinner meals were blank. -There had been eight out of thirty-one entries made for the lunch meal that included the wash and rinse cycle temperatures. -The bottom of the log sheet had September 2023 with handwritten documented entries for nine out of thirty days for the lunch meals. *There had not been an October 2023 temperature log sheet posted in the dish room. *Minimum temperature standards for the wash cycle for the dishes was to have been 150 degrees Fahrenheit (F), and 180 degrees F for the final rinse cycle. *The above entries had been in the appropriate temperature ranges for that high-heat mechanical dishwasher. *There had been no temperature log sheets posted for the dietary staff to document for the second and third-floor dishwasher rooms. *A request was made for the temperature log sheets for the second and third-floor chemical sanitizer dishwashers and no documentation was provided. -The last temperature logs provided for the second and third-floor chemical sanitized dishwashers was July 2023. Interview on 10/6/23 at 12:41 p.m. with food service supervisor E revealed: *She had been the food service supervisor for 4 years, but had been employed by the facility for 22 years. *She had not completed the required training to become a certified dietary manager. *She had started the education before but had not been able to continue with it because of staffing issues. *None of the staff were Serv Safe certified. *Her Serv Safe certification had expired in February 2023. *She confirmed the temperature logs for all three of their mechanical dishwashers were not completed consistently according to the policy. *The lack of documentation surprised her. *The chemical-sanitized dishwashers were just replaced a few months prior and staff were documenting taking dishwasher temperatures appropriately at that time. *Blank copies of the temperature log sheets had been available for use in each kitchen and should have been posted by the dietary staff and documented at each mealtime. *It was her expectation that dietary staff working in the dish rooms would complete the temping of the dishwashers for each meal that was served to the residents. *She agreed that if dietary staff had not temped the dishwashers for proper sanitization temperatures, it would have placed all of the residents at risk for foodborne illnesses. Interview on 10/06/23 at 3:20 p.m. with registered dietician D regarding dishwasher machine temping revealed: *The dietary staff were supposed to complete dishwasher temps after breakfast, dinner, and supper meals and record those temperatures on a log sheet posted in the dish rooms. *She agreed that if temping had not been completed, it could have been an infection control concern for all of the residents. Review of the provider's undated Dish Machine Temperature Log Policy and Procedure revealed: *Policy: Dietary staff will monitor and record dish machine temperatures to assure proper sanitizing of dishes. *Procedure: -1. Dietary staff will record dish machine temperatures after breakfast, dinner, and supper meal times in temperature log provided. -2. Dietary staff will make sure dish machine is temping before using. -3. Notify maintenance, [staff name and staff name]. Then [company name who serviced dishwashers and company name who supplied sanitizing chemicals] will be notified. -4. Use of other dish machine will be utilized until correct temps are reached on dish machine.

Based on observation, interview, document review, and policy review, the provider failed to ensure: *Two of three dishwasher ventilation ducts were maintained in a clean manner. *One of one food vending machine was cleaned. Findings include: 1. Observation on 9/21/22 from 2:44 p.m. through 3:12 p.m. in the dietary department revealed the ventilation ducts above the dishwashers on the first and third floor kitchens were covered with dust and an unidentified black substance, which had the potential to fall from the duct onto clean dishes. Interview on 9/22/22 at 11:43 a.m. with maintenance supervisor C regarding the dishwasher ventilation ducts revealed: *He was not aware of the condition of the dishwasher ventilation ducts. *All the ventilation ducts throughout the building were cleaned on an annual basis. *A contracted ventilation duct cleaning service had cleaned the ventilation ducts on 2/6/22. *He agreed that the dishwasher ventilation ducts needed to be cleaned. 2. Observation on 9/21/22 at 3:02 p.m. of the rotating vending machine on Main Street of the facility revealed: *There were spots of white-colored fuzzy mold and black-colored mold and/or mildew throughout the inside and outside of the rotating vending machine. *Two plastic containers of hard boiled eggs were on the bottom shelf. -Both containers were broken due to being too large for the shelf space. -One of the hard boiled eggs was cracked and sitting directly on the shelf. *On the top shelf, there was a container of yogurt with spots of mold in the shelf space to the right of the yogurt. Interview on 9/21/22 at 3:12 p.m. with food service supervisor D and assistant cook E regarding the rotating vending machine on Main Street revealed: *The morning shift employees were responsible for cleaning the rotating vending machine and rotating the food items in it. *The dietary department staff had not cleaned the rotating vending machine often because it took too long. *The rotating vending machine was mostly used by staff, but residents also had access to purchase food from it. *They did not: -Know when it had been cleaned last. -Have a cleaning schedule for the rotating vending machine. -Have documentation when it had been cleaned last. Review of the provider's undated Sanitation of Dietary Department policy revealed: *Procedure: -1. The Dietary Manager shall record all cleaning and sanitation tasks for the department. -2. Tasks shall be designated to be the responsibility of specific positions in the department. -3. All tasks shall be addressed as to the frequency of cleaning. -4. The method of procedures to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. -5. A cleaning schedule shall be posted weekly for all cleaning tasks, and employees will initial tasks as completed. Review of the dietary department's weekly Cleaning List revealed there was no task item to clean the rotating vending machine.

Based on observation, interview, and policy review, the provider failed to ensure positioning devices had a safety assessment completed for two of four sampled residents (1 and 10). Findings include: 1. Observation and interview with resident 10 on 9/20/22 at 4:41 p.m. in her room revealed she: *Had positioning rails on the top half of her bed on both the left and right sides. *Had asked for them to be installed. *Used them to reposition herself in bed. 2. Observation and interview with resident 1 on 9/21/22 at 9:04 a.m. in her room revealed she had: *Positioning rails on the top half of her bed on both the left and right sides. *The positioning rails as long as she could remember. *Used them all the time to reposition herself in bed. Interview on 9/21/22 at 2:41 p.m. with maintenance supervisor C regarding repositioning devices revealed: *Nursing staff would create a work order for maintenance to put a positioning rail on a resident bed. *The nursing department completed the quarterly assessments for the positioning rails. *The assistive devices were ordered from the same company that manufactured the bed. *He was not aware a safety assessment needed to be completed for positioning rails. Interview on 9/21/22 at 3:43 p.m. with director of nursing B regarding repositioning devices revealed: *If a resident needed/requested an assistive device a maintenance requisition was filled out. *The nursing department completed an assistive device assessment/evaluation quarterly for residents who used them. *She was not aware of any safety assessment that needed to be completed. Interviews on 9/22/22 at 8:36 a.m. and at 10:40 a.m. with administrator A regarding repositioning devices revealed: *He would check with the therapy department about a safety assessment. *The nursing department completed a quarterly assessment for the positioning rails. *He agreed the quarterly nursing assessment was different from the safety assessment that should have been completed by maintenance. Review of the provider's April 2016 Assist Bar policy revealed: *Assist bar(s) may be utilized to assist residents with bed mobility and positioning if certain parameters are followed. .Responsibility: RN/LPN/NA -Instructions: --1. An assessment on the resident must be done prior to installing assist bars. a. Assess for safety use and need for positioning and bed mobility assistance. --2. Notify the resident and/or family of the risk of entrapment, as indicated. --3. If the resident is assessed to be safe, the need for assistance exists and the resident/family has been informed of the risk(s), call the attending physician for an order.